Intravenous N-acetylcysteine in pediatric patients with nonacetaminophen acute liver failure: a placebo-controlled clinical trial

ACG Clinical Guideline: the diagnosis and management of idiosyncratic drug-induced liver injury

Idiosyncratic drug-induced liver injury (DILI) is a rare adverse drug reaction and it can lead to jaundice, liver failure, or even death. Antimicrobials and herbal and dietary supplements are among the most common therapeutic classes to cause DILI in the Western world. DILI is a diagnosis of exclusion and thus careful history taking and thorough work-up for competing etiologies are essential for its timely diagnosis. In this ACG Clinical Guideline, the authors present an evidence-based approach to diagnosis and management of DILI with special emphasis on DILI due to herbal and dietary supplements and DILI occurring in individuals with underlying liver disease.

Intravenous acetylcysteine for indications other than acetaminophen overdose

PURPOSE

The use of intravenous acetylcysteine for off-label indications, specifically non-acetaminophen-induced acute liver failure (NAI-ALF), severe alcoholic hepatitis, and contrast-induced nephropathy (CIN), is reviewed.

SUMMARY

I.V. acetylcysteine is most often used as an antidote for acetaminophen overdose due to its ability to increase levels of glutathione; however, it is also used to treat NAI-ALF and severe alcoholic hepatitis and to prevent CIN. Although the i.v. and oral formulations of acetylcysteine have been evaluated for these indications, most studies have examined the i.v. form. I.V. acetylcysteine is used in the treatment of NAI-ALF to improve oxygenation to the liver. One large randomized trial of 173 adults with NAI-ALF from any etiology and of any grade encephalopathy demonstrated overall improvement in transplant-free survival, particularly for patients with low-grade encephalopathy, though overall survival was not improved. When used to treat severe alcoholic hepatitis, i.v. acetylcysteine serves as an antioxidant and glutathione source. A trial of 174 patients with severe alcoholic hepatitis revealed that patients had 28-day survival benefit when treated with acetylcysteine; improvement in patients with hepatorenal syndrome was also noted. When used for the prevention of CIN, i.v. acetylcysteine provides antioxidants and vasodilation. The benefit for this indication is limited to surrogate markers such as serum creatinine and in patients with multiple risk factors for the development of CIN.

CONCLUSION

Data regarding the use of i.v. acetylcysteine for the treatment of NAI-ALF and severe alcoholic hepatitis and in the prevention of CIN are inconclusive, though some evidence supports its use in certain populations.