Assessment of the Clinical Use of Intravenous and Oral N-Acetylcysteine in the Treatment of Acute Acetaminophen Poisoning in Children: A Retrospective Review

Background: N-acetylcysteine (NAG) is the most effective therapy for acetaminophen (APAP) toxicity and is currently available for oral and intravenous (IV) administration. Although both routes are effective, use of the IV formulation has been increasing since becoming available in the United States in 2004, raising questions about cost/benefit comparisons between the 2 formulations. Decreased length of treatment and hospital stay have been used to justify the use of IV NAG; however, some patients may receive extended therapy of either NAG regimen. Objective: This retrospective review assessed the clinical use of oral and IV NAG in pediatric patients with APAP intoxication from June 1, 2004 through May 31, 2008. Methods: Electronic medical charts for patients aged 21 years were identified with International Classification of Diseases, Ninth Revision (ICD-9) codes for APAP overdose. Descriptive statistics were used to describe the overall patient population and route of NAG administration. The primary outcome variable was the length of treatment with IV and oral NAG therapy. Results: A total of 62 charts for patients with APAP toxicity were reviewed; 37 patients (60%) received IV NAG and 25 patients (40%) received oral NAG. The average lengths of treatment and stay for IV dosing were 23.5 hours (range, 17.6-54.9 hours) and 1.6 days (range, 1-3 days), respectively; those for oral dosing were 69.5 hours (range, 33-133 hours) and 1.95 days (range, 1-5 days), respectively. Of 16 patients who received oral NAG and were admitted for <3 days, 14 were transferred to an inpatient psychiatric unit and completed the 72-hour therapy. A total of 3 patients received extended NAG dosing-2 with IV dosing and 1 with oral dosing. Conclusions: Based on our review, the majority of patients received recommended dosing of NAG therapy; however, 3 patients received extended NAG therapy. Patient-specific factors should be considered when assessing whether NAG therapy should be extended and if one route of administration may be preferred. ClinicalTrials.gov identifier: NCT00725179. (Clin Ther. 2011;33:1322-1330) (C) 2011 Elsevier HS Journals, Inc. All rights reserved.