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N-Acetylcysteine Regenerates In Vivo Mercaptoalbumin. Antioxidants (Basel) 2022; 11:antiox11091758. [PMID: 36139832 PMCID: PMC9495570 DOI: 10.3390/antiox11091758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/02/2022] [Accepted: 09/03/2022] [Indexed: 11/18/2022] Open
Abstract
Human serum albumin (HSA) represents the most abundant plasma protein, with relevant antioxidant activity due to the presence of the sulfhydryl group on cysteine at position 34 (Cys34), the latter being one of the major target sites for redox-dependent modifications leading to the formation of mixed disulfide linkages with low molecular weight thiols. Thiolated forms of HSA (Thio-HSA) may be useful as markers of an unbalanced redox state and as a potential therapeutic target. Indeed, we have previously reported that albumin Cys34 can be regenerated in vitro by N-Acetylcysteine (NAC) through a thiol-disulfide breaking mechanism, with a full recovery of the HSA antioxidant and antiplatelet activities. With this case study, we aimed to assess the ability of NAC to regenerate native mercaptoalbumin (HSA-SH) and the plasma antioxidant capacity in subjects with redox unbalance, after oral and intravenous administration. A placebo-controlled crossover study, single-blinded, was performed on six hypertensive subjects, randomized into two groups, on a one-to-one basis with NAC (600 mg/die) or a placebo, orally and intravenously administered. Albumin isoforms, HSA-SH, Thio-HSA, and glutathione levels were evaluated by means of mass spectrometry. The plasma antioxidant activity was assessed by a fluorimetric assay. NAC, orally administered, significantly decreased the Thio-HSA levels in comparison with the pre-treatment conditions (T0), reaching the maximal effect after 60 min (−24.7 ± 8%). The Thio-HSA reduction was accompanied by a concomitant increase in the native HSA-SH levels (+6.4 ± 2%). After intravenous administration of NAC, a significant decrease of the Thio-HSA with respect to the pre-treatment conditions (T0) was observed, with a maximal effect after 30 min (−68.9 ± 10.6%) and remaining significant even after 6 h. Conversely, no effect on the albumin isoforms was detected with either the orally or the intravenously administered placebo treatments. Furthermore, the total antioxidant activity of the plasma significantly increased after NAC infusion with respect to the placebo (p = 0.0089). Interestingly, we did not observe any difference in terms of total glutathione corrected for hemoglobin, ruling out any effect of NAC on the intracellular glutathione and supporting its role as a disulfide-breaking agent. This case study confirms the in vitro experiments and demonstrates for the first time that NAC is able to regenerate mercaptoalbumin in vivo, allowing us to hypothesize that the recovery of Cys34 content can modulate in vivo oxidative stress and, hopefully, have an effect in oxidative-based diseases.
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Connors NJ, Mazer-Amirshahi M, Motov S, Kim HK. Relative addictive potential of opioid analgesic agents. Pain Manag 2020; 11:201-215. [PMID: 33300384 DOI: 10.2217/pmt-2020-0048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Opioid overdoses and deaths continue to be a problem in the USA with a significant portion related to prescribed opioid analgesic agents. The role of pharmacogentic factors in opioid addiction is an active area of research. While all opioid analgesic agents have some addictive potential, it is clear that there are some with greater addictive potential. Oxycodone is the most widely abused opioid analgesic and it appears to predispose to chronic use with high likability by users. Fentanyl and hydromorphone are both very lipophilic allowing rapid penetration into the CNS, but are not rated as highly as other agents. Providers should consider the risk of addiction with the opioids they prescribe and give those with a lower addictive potential.
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Affiliation(s)
- Nicholas J Connors
- HCA Healthcare, Trident Medical Center, Charleston, SC 29406, USA.,Palmetto Poison Center, Columbia, SC 29201, USA
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY 11219, USA
| | - Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Poe FL, Corn J. N-Acetylcysteine: A potential therapeutic agent for SARS-CoV-2. Med Hypotheses 2020; 143:109862. [PMID: 32504923 PMCID: PMC7261085 DOI: 10.1016/j.mehy.2020.109862] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/07/2020] [Accepted: 05/21/2020] [Indexed: 02/08/2023]
Abstract
COVID-19, a respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), continues to spread across the globe. Predisposing factors such as age, diabetes, cardiovascular disease, and lowered immune function increase the risk of disease severity. T cell exhaustion, high viral load, and high levels of TNF-ɑ, IL1β, IL6, IL10 have been associated with severe SARS-CoV-2. Cytokine and antigen overstimulation are potentially responsible for poor humoral response to the virus. Lower cellular redox status, which leads to pro-inflammatory states mediated by TNF-ɑ is also potentially implicated. In vivo, in vitro, and human clinical trials have demonstrated N-acetylcysteine (NAC) as an effective method of improving redox status, especially when under oxidative stress. In human clinical trials, NAC has been used to replenish glutathione stores and increase the proliferative response of T cells. NAC has also been shown to inhibit the NLRP3 inflammasome pathway (IL1β and IL18) in vitro, and decrease plasma TNF-ɑ in human clinical trials. Mediation of the viral load could occur through NAC's ability to increase cellular redox status via maximizing the rate limiting step of glutathione synthesis, and thereby potentially decreasing the effects of virally induced oxidative stress and cell death. We hypothesize that NAC could act as a potential therapeutic agent in the treatment of COVID-19 through a variety of potential mechanisms, including increasing glutathione, improving T cell response, and modulating inflammation. In this article, we present evidence to support the use of NAC as a potential therapeutic agent in the treatment of COVID-19.
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Affiliation(s)
- Francis L Poe
- Whole Systems Research Institute, 1020 SW Taylor St Ste. 340, Portland, OR 97239, United States.
| | - Joshua Corn
- Whole Systems Research Institute, 1020 SW Taylor St Ste. 340, Portland, OR 97239, United States
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N-Acetyl-Cysteine Regenerates Albumin Cys34 by a Thiol-Disulfide Breaking Mechanism: An Explanation of Its Extracellular Antioxidant Activity. Antioxidants (Basel) 2020; 9:antiox9050367. [PMID: 32354002 PMCID: PMC7278672 DOI: 10.3390/antiox9050367] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 12/20/2022] Open
Abstract
In the present paper, the extracellular antioxidant activity of N-acetyl-cysteine (NAC) is explained by considering its ability to regenerate the free form of albumin Cys34 by breaking the disulfide bond of the cysteinylated form (HSA-Cys). NAC’s capability to regenerate albumin Cys34 (HSA-SH) was studied by MS intact protein analysis in human plasma and in a concentration range of NAC easily achievable after oral and i.v. administration (5–50 µg/mL). NAC dose-dependently broke the HSA-Cys bond to form the dimer NAC-Cys thus regenerating Cys34, whose reduced state was maintained for at least 120 min. Cys was faster in restoring Cys34, according to the reaction constant determined with the glutathione disulfide (GSSG) reaction, but after 60 min the mixed disulfide HSA-Cys turned back due to the reaction of the dimer Cys-Cys with Cys34. The explanation for the different rate exchanges between Cys-Cys and Cys-NAC with Cys34 was given by molecular modeling studies. Finally, the Cys34 regenerating effect of NAC was related to its ability to improve the total antioxidant capacity of plasma (TRAP assay). The results well indicate that NAC greatly increases the plasma antioxidant activity and this effect is not reached by a direct effect but through the regenerating effect of Cys34.
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Aldini G, Altomare A, Baron G, Vistoli G, Carini M, Borsani L, Sergio F. N-Acetylcysteine as an antioxidant and disulphide breaking agent: the reasons why. Free Radic Res 2018; 52:751-762. [PMID: 29742938 DOI: 10.1080/10715762.2018.1468564] [Citation(s) in RCA: 426] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The main molecular mechanisms explaining the well-established antioxidant and reducing activity of N-acetylcysteine (NAC), the N-acetyl derivative of the natural amino acid l-cysteine, are summarised and critically reviewed. The antioxidant effect is due to the ability of NAC to act as a reduced glutathione (GSH) precursor; GSH is a well-known direct antioxidant and a substrate of several antioxidant enzymes. Moreover, in some conditions where a significant depletion of endogenous Cys and GSH occurs, NAC can act as a direct antioxidant for some oxidant species such as NO2 and HOX. The antioxidant activity of NAC could also be due to its effect in breaking thiolated proteins, thus releasing free thiols as well as reduced proteins, which in some cases, such as for mercaptoalbumin, have important direct antioxidant activity. As well as being involved in the antioxidant mechanism, the disulphide breaking activity of NAC also explains its mucolytic activity which is due to its effect in reducing heavily cross-linked mucus glycoproteins. Chemical features explaining the efficient disulphide breaking activity of NAC are also explained.
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Affiliation(s)
- Giancarlo Aldini
- a Department of Pharmaceutical Sciences , Università degli Studi di Milano , Milan , Italy
| | - Alessandra Altomare
- a Department of Pharmaceutical Sciences , Università degli Studi di Milano , Milan , Italy
| | - Giovanna Baron
- a Department of Pharmaceutical Sciences , Università degli Studi di Milano , Milan , Italy
| | - Giulio Vistoli
- a Department of Pharmaceutical Sciences , Università degli Studi di Milano , Milan , Italy
| | - Marina Carini
- a Department of Pharmaceutical Sciences , Università degli Studi di Milano , Milan , Italy
| | - Luisa Borsani
- b Global Medical Information, Zambon S.p.A. , Bresso , Italy
| | - Francesco Sergio
- c Global Respiratory Medical Affairs, Zambon S.p.A. , Bresso , Italy
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Lopez-Lopez V, Ros J, Ferreras D, Sanmartin J, Martinez M, Pons Miñano JA, Sanchez-Bueno F, Robles-Campos R, Ramirez-Romero P, Parrilla-Paricio P. Molecular Adsorbent Recirculating System Treatment Can Reduce Blood Levels of N-Acetylcysteine in Patients With Acetaminophen Overdose: Case Reports. Transplant Proc 2018; 50:687-689. [PMID: 29579890 DOI: 10.1016/j.transproceed.2017.09.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 09/21/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acetaminophen poisoning continues to be a major cause of liver failure that can lead to liver transplantation. N-acetylcysteine (NAC) is the cornerstone of treatment. Some authors use a Molecular Adsorbent Recirculating System (MARS) system in acetaminophen poisoning. It is reported that the MARS system eliminates acetaminophen more efficiently than conventional dialysis. It is theoretically possible that treatment with MARS administered after NAC will increase the effectiveness of treatment. CASE REPORTS The first patient, a woman of 14 years old, presented blood levels of 112 mg/dL 12 hours after ingestion of 15 g of acetaminophen. Treatment with NAC was initiated. At 17 and 23 hours after ingestion, blood levels were 23.5 μg/mL and 5.9 μg/mL, respectively. The second patient, a woman of 28 years old, presented blood levels of 115 mg/dL 4 hours after ingestion of 40 g of acetaminophen. Treatment with NAC was initiated. At 14 and 23 hours after ingestion, blood levels were 15.8 μg/mL and <2 μg/mL, respectively. In both patients, we performed MARS after completing treatment with NAC, and after the first session, blood levels were below the lower limit of detection (≤2 μg/mL). DISCUSSION The correct timing of MARS to avoid interactions with the administered dose of NAC in acetaminophen overdose is essential so as to not impair the effectiveness of this treatment. These considerations in the management of this entity help in the resolution of liver failure, thus avoiding the need for a liver transplant.
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Affiliation(s)
- V Lopez-Lopez
- Department of Surgery, Liver Transplant Unit, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain.
| | - J Ros
- Intensive Care Unit, Liver Transplant Unit, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - D Ferreras
- Department of Surgery, Liver Transplant Unit, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - J Sanmartin
- Intensive Care Unit, Liver Transplant Unit, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - M Martinez
- Intensive Care Unit, Liver Transplant Unit, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - J A Pons Miñano
- Department of Hepatology, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - F Sanchez-Bueno
- Department of Surgery, Liver Transplant Unit, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - R Robles-Campos
- Department of Surgery, Liver Transplant Unit, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - P Ramirez-Romero
- Department of Surgery, Liver Transplant Unit, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - P Parrilla-Paricio
- Department of Surgery, Liver Transplant Unit, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
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Fernández-Rivero ME, Del Pozo JL, Valentín A, de Diego AM, Pemán J, Cantón E. Activity of Amphotericin B and Anidulafungin Combined with Rifampicin, Clarithromycin, Ethylenediaminetetraacetic Acid, N-Acetylcysteine, and Farnesol against Candida tropicalis Biofilms. J Fungi (Basel) 2017; 3:jof3010016. [PMID: 29371534 PMCID: PMC5715971 DOI: 10.3390/jof3010016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 03/09/2017] [Accepted: 03/13/2017] [Indexed: 11/29/2022] Open
Abstract
We evaluated the activity of (1) amphotericin-B (AMB), combined with rifampicin (RIF), clarithromycin (CLA), N-acetylcysteine (NAC), ethylenediaminetetraacetic acid (EDTA), and farnesol (FAR) (1000, 1000, 1000, 4000, and 30,000 mg/L, and 300 µM, respectively), against Candida tropicalis biofilms formed on polytetrafluoroethylene (PTFE) and (2) anidulafungin (ANF) combined with the same compounds at 8, 10, 5, 40, and 30 mg/L, and 30 µM, respectively, against biofilms formed on titanium. Biofilm growth kinetics were performed in a CDC Biofilm Reactor (CBR). PTFE or titanium disks were removed from the CBR at 24, 48, 72, and 96 h to determine the Log10CFU/cm2. Killing kinetics were performed by adding the drugs to 24-h-mature biofilms (time 0). Disks were removed after 24, 48, and 72 h of drug exposure to determine Log10CFU/cm2. Viable cells in biofilms were 4.73 and 4.29 Log10CFU/cm2 on PTFE and titanium, respectively. Maximum Log10 decreases in CFU/cm2 depend on the combination and were: 3.53 (AMB + EDTA), 2.65 (AMB + RIF), 3.07 (AMB + NAC), 2.52 (AMB + CLA), 1.49 (AMB + FAR), 2.26 (ANF + EDTA), 2.45 (ANF + RIF), 2.47 (ANF + NAC), 1.52 (ANF + CLA), and 0.44 (ANF + FAR). In conclusion, EDTA, NAC, RIF, and CLA improve the activity of AMB and ANF against biofilms developed on both surfaces, which could be an effective strategy against C. tropicalis biofilm-related infections.
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Affiliation(s)
- Marcelo Ernesto Fernández-Rivero
- Departamento de Microbiología, Universidad de Navarra, 31008 Pamplona, Spain.
- Laboratorio de Biofilms Microbianos, Clínica Universidad de Navarra, 31008 Pamplona, Spain.
- Grupo de Infección Grave, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain.
| | - José L Del Pozo
- Departamento de Microbiología, Universidad de Navarra, 31008 Pamplona, Spain.
- Laboratorio de Biofilms Microbianos, Clínica Universidad de Navarra, 31008 Pamplona, Spain.
- Grupo de Infección Grave, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain.
- Área de Enfermedades Infecciosas, Clínica Universidad de Navarra, 31008 Pamplona, Spain.
| | - Amparo Valentín
- Grupo de Infección Grave, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain.
- Servicio de Microbiología Clínica, Hospital Universitario La Fe, 46026 Valencia, Spain.
| | - Araceli Molina de Diego
- Grupo de Infección Grave, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain.
- Servicio de Microbiología Clínica, Hospital Universitario La Fe, 46026 Valencia, Spain.
| | - Javier Pemán
- Grupo de Infección Grave, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain.
- Servicio de Microbiología Clínica, Hospital Universitario La Fe, 46026 Valencia, Spain.
| | - Emilia Cantón
- Grupo de Infección Grave, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain.
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Ghannoum M, Kazim S, Grunbaum AM, Villeneuve E, Gosselin S. Massive acetaminophen overdose: effect of hemodialysis on acetaminophen and acetylcysteine kinetics. Clin Toxicol (Phila) 2016; 54:519-22. [PMID: 27118496 DOI: 10.1080/15563650.2016.1175006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
CONTEXT Early onset acidosis from mitochondrial toxicity can be observed in massive acetaminophen poisoning prior to the development of hepatotoxicity. In this context, the efficacy of acetylcysteine to reverse mitochondrial toxicity remains unclear and hemodialysis may offer prompt correction of acidosis. Unfortunately, toxicokinetics of acetaminophen and acetylcysteine during extracorporeal treatments hemodialysis have seldom been described. CASE DETAILS An 18-year-old woman presented to the emergency department 60 minutes after ingestion of 100 g of acetaminophen, and unknown amounts of ibuprofen and ethanol. Initial assessment revealed an agitated patient. Her mental status worsened and she required intubation for airway protection. Investigations showed metabolic acidosis with lactate peaking at 8.6 mmol/L. Liver and coagulation profiles remained normal. Acetaminophen concentration peaked at 981 μg/ml (6496 μmol/L). Pending hemodialysis, the patient received 100 g of activated charcoal and an acetylcysteine infusion at 150 mg/kg over 1 hour, followed by 12.5 mg/kg/h for 4 hours. During hemodialysis, the infusion was maintained at 12.5 mg/kg/h to compensate for expected removal before it was decreased to 6.25 mg/kg for 20 hours after hemodialysis. The patient rapidly improved during hemodialysis and was discharged 48 hours post-admission. TOXICOKINETICS The acetaminophen elimination half-life was 5.2 hours prior to hemodialysis, 1.9-hours during hemodialysis and 3.6 hours post hemodialysis. The acetaminophen and acetylcysteine clearances by A-V gradient during hemodialysis were 160.4 ml/min and 190.3 ml/min, respectively. Hemodialysis removed a total of 20.6 g of acetaminophen and 17.9 g of acetylcysteine. CONCLUSION This study confirms the high dialyzability of both acetaminophen and acetylcysteine. Hemodialysis appears to be a beneficial therapeutic option in cases of massive acetaminophen ingestion with coma and lactic acidosis. Additionally, these results suggest that the infusion rate of acetylcysteine must be more than double during hemodialysis to compensate for its ongoing removal and provide similar plasma concentrations to the usual acetylcysteine regimen.
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Affiliation(s)
- Marc Ghannoum
- a Nephrology Department , Verdun Hospital , Montréal , Québec , Canada
| | - Sara Kazim
- b Department of Emergency Medicine, McGill University Health Centre , Montréal , Québec , Canada
| | - Ami M Grunbaum
- c Division of Medical Biochemistry, Department of Medicine , McGill University Health Centre , Montréal , Québec , Canada
| | - Eric Villeneuve
- d Department of Pharmacy, McGill University Health Centre , Montréal , Québec , Canada
| | - Sophie Gosselin
- b Department of Emergency Medicine, McGill University Health Centre , Montréal , Québec , Canada ;,e Centre Antipoison Du Québec , Montréal , Québec , Canada
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Hernandez SH, Howland M, Schiano TD, Hoffman RS. The pharmacokinetics and extracorporeal removal of N-acetylcysteine during renal replacement therapies. Clin Toxicol (Phila) 2015; 53:941-9. [PMID: 26484583 DOI: 10.3109/15563650.2015.1100305] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Acetaminophen-induced fulminant hepatic failure is associated with acute kidney injury, metabolic acidosis, and fluid and electrolyte imbalances, requiring treatment with renal replacement therapies. Although antidote, acetylcysteine, is potentially extracted by renal replacement therapies, pharmacokinetic data are lacking to guide potential dosing alterations. We aimed to determine the extracorporeal removal of acetylcysteine by various renal replacement therapies. METHODS Simultaneous urine, plasma and effluent specimens were serially collected to measure acetylcysteine concentrations in up to three stages: before, during and upon termination of renal replacement therapy. Alterations in pharmacokinetics were determined by applying standard pharmacokinetic equations. RESULTS Over 2 years, 10 critically ill patients in fulminant hepatic failure requiring renal replacement therapy coincident with acetylcysteine were consecutively enrolled. All 10 patients required continuous venovenous hemofiltration (n = 10) and 2 of the 10 also required hemodialysis (n = 2). There was a significant alteration in the pharmacokinetics of acetylcysteine during hemodialysis; the area under the curve (AUC) decreased 41%, the mean extraction ratio was 51%, the mean hemodialytic clearance was 114.01 ml/kg/h, and a mean 166.75 mg/h was recovered in the effluent or 41% of the hourly dose. Alteration in the pharmacokinetics of acetylcysteine during continuous venovenous hemofiltration did not appear to be significant: the AUC decreased 13%, the mean clearance was 31.77 ml/kg/h and a mean 62.12 mg/h was recovered in the effluent or 14% of the hourly dose. CONCLUSIONS There was no significant extraction of acetylcysteine from continuous venovenous hemofiltration. In contrast, there was significant extracorporeal removal of acetylcysteine during hemodialysis. A reasonable dose adjustment may be to double the IV infusion rate or possibly supplement with oral acetylcysteine during hemodialysis.
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Affiliation(s)
- Stephanie H Hernandez
- a Division of Medical Toxicology, Department of Emergency Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Maryann Howland
- b St. John's University College of Pharmacy and Health Sciences , Queens , NY , USA.,c New York City Poison Control Center, New York City Department of Health , New York , NY , USA.,d Division of Medical Toxicology, Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA
| | - Thomas D Schiano
- e Division of Liver Diseases, Department of Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Robert S Hoffman
- c New York City Poison Control Center, New York City Department of Health , New York , NY , USA.,d Division of Medical Toxicology, Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA
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Sivilotti MLA, Juurlink DN, Garland JS, Lenga I, Poley R, Hanly LN, Thompson M. Antidote removal during haemodialysis for massive acetaminophen overdose. Clin Toxicol (Phila) 2013; 51:855-63. [PMID: 24134534 DOI: 10.3109/15563650.2013.844824] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Haemodialysis is sometimes used for patients with massive acetaminophen overdose when signs of "mitochondrial paralysis" (lactic acidosis, altered mental status, hypothermia and hyperglycaemia) are present. The role of haemodialysis is debated, in part because the evidence base is weak and the endogenous clearance of acetaminophen is high. There is also concern because the antidote acetylcysteine is also dialyzable. We prospectively measured serum acetylcysteine concentrations during haemodialysis in three such cases. CASE DETAILS Three adults each presented comatose and acidemic 10 to ~18 h after ingesting > 1000mg/kg of acetaminophen. Two were hypothermic and hyperglycaemic. Serum lactate concentrations ranged from 7 mM to 12.5 mM. All three were intubated, and initial acetaminophen concentrations were as high as 5980 μM (900 μg/mL). An intravenous loading dose of 150 mg/kg acetylcysteine was initiated between 10.8 and ~18 h post ingestion, and additional doses were empirically administered during haemodialysis to compensate for possible antidote removal. A single run of 3-4 h of haemodialysis removed 10-20 g of acetaminophen (48-80% of remaining body burden), reduced serum acetaminophen concentrations by 56-84% (total clearance 3.4-7.8 mL/kg/min), accelerated native acetaminophen clearance (mean elimination half-life 580 min pre-dialysis, 120 min during and 340 min post-dialysis) and corrected acidemia. Extraction ratios of acetylcysteine across the dialysis circuit ranged from 73% to 87% (dialysance 3.0 to 5.3 mL/kg/min). All three patients recovered fully, and none developed coagulopathy or other signs of liver failure. DISCUSSION When massive acetaminophen ingestion is accompanied by coma and lactic acidosis, emergency haemodialysis can result in rapid biochemical improvement. As expected, haemodialysis more than doubles the clearance of both acetaminophen and acetylcysteine. Because acetylcysteine dosing is largely empirical, we recommend doubling the dose during haemodialysis, with an additional half-load when dialysis exceeds 6 h.
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Affiliation(s)
- M L A Sivilotti
- Department of Emergency Medicine, Queen's University , Kingston, ON , Canada
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Whillier S, Raftos JE, Chapman B, Kuchel PW. Role ofN-acetylcysteine and cystine in glutathione synthesis in human erythrocytes. Redox Rep 2013; 14:115-24. [DOI: 10.1179/135100009x392539] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Bryczkowski C, Geib AJ. Combined butalbital/acetaminophen/caffeine overdose: case files of the Robert Wood Johnson Medical School Toxicology Service. J Med Toxicol 2013; 8:424-31. [PMID: 23011802 DOI: 10.1007/s13181-012-0261-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Christopher Bryczkowski
- Department of Emergency Medicine, Robert Wood Johnson Medical School, 125 Paterson St., MEB 104, New Brunswick, NJ 08903, USA
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Mansouri MD, Hull RA, Stager CE, Cadle RM, Darouiche RO. In vitro activity and durability of a combination of an antibiofilm and an antibiotic against vascular catheter colonization. Antimicrob Agents Chemother 2013; 57:621-5. [PMID: 23114776 PMCID: PMC3535979 DOI: 10.1128/aac.01646-12] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 10/20/2012] [Indexed: 01/27/2023] Open
Abstract
Catheter-associated infections can cause severe complications and even death. Effective antimicrobial modification of catheters that can prevent device colonization has the potential of preventing clinical infection. We studied in vitro the antimicrobial activities of central venous catheters impregnated with N-acetylcysteine (NAC), an antibiofilm agent, and a broad-spectrum antibiotic against a range of important clinical pathogens. NAC-levofloxacin-impregnated (NACLEV) catheters were also evaluated for their antiadherence activity. NACLEV catheters produced the most active and durable antimicrobial effect against both Gram-positive and Gram-negative isolates and significantly reduced colonization (P < 0.0001) by all tested pathogens compared to control catheters. These in vitro results suggest that this antimicrobial combination can potentially be used to combat catheter colonization and catheter-associated infection.
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Perna AF, Violetti E, Lanza D, Sepe I, Bellinghieri G, Savica V, Santoro D, Satta E, Cirillo G, Lupo A, Abaterusso C, Raiola I, Raiola P, Coppola S, Di Iorio B, Tirino G, Cirillo M, Ingrosso D, De Santo NG. Therapy of hyperhomocysteinemia in hemodialysis patients: effects of folates and N-acetylcysteine. J Ren Nutr 2012; 22:507-514.e1. [PMID: 22226754 DOI: 10.1053/j.jrn.2011.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 09/04/2011] [Accepted: 10/09/2011] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Uremia represents a state where hyperhomocysteinemia is resistant to folate therapy, thus undermining intervention trials' efficacy. N-acetylcysteine (NAC), an antioxidant, in addition to folates (5-methyltetrahydrofolate, MTHF), was tested in a population of hemodialysis patients. DESIGN The study is an open, parallel, intervention study. SETTING Ambulatory chronic hemodialysis patients. SUBJECTS Clinically stable chronic hemodialysis patients, on hemodialysis since more than 3 months, undergoing a folate washout. Control group on standard therapy (n = 50). INTERVENTION One group was treated with intravenous MTHF (MTHF group, n = 48). A second group was represented by patients treated with MTHF, and, during the course of 10 hemodialysis sessions, NAC was administered intravenous (MTHF + NAC group, n = 47). MAIN OUTCOME MEASURE Plasma homocysteine measured before and after dialysis at the first and the last treatment. RESULTS At the end of the study, there was a significant decrease in predialysis plasma homocysteine levels in the MTHF group and MTHF + NAC group, compared with the control group, but no significant difference between the MTHF group and MTHF + NAC group. A significant decrease in postdialysis plasma homocysteine levels in MTHF + NAC group (10.27 ± 0.94 μmol/L, 95% confidence interval: 8.37-12.17) compared with the MTHF group (16.23 ± 0.83, 95% confidence interval: 14.55-17.90) was present. In the MTHF + NAC group, 64% of patients reached a postdialysis homocysteine level <12 μmol/L, compared with 19% in the MTHF group and 16% in the control group. CONCLUSIONS NAC therapy induces a significant additional decrease in homocysteine removal during dialysis. The advantage is limited to the time of administration.
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Affiliation(s)
- Alessandra F Perna
- First Division of Nephrology, Department of Cardio-thoracic and Respiratory Sciences, Second University of Medicine, Naples, Italy.
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Perna AF, Sepe I, Lanza D, Pollastro RM, De Santo NG, Ingrosso D. Hyperhomocysteinemia in Chronic Renal Failure: Alternative Therapeutic Strategies. J Ren Nutr 2012; 22:191-4. [DOI: 10.1053/j.jrn.2011.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 10/13/2011] [Indexed: 11/11/2022] Open
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Liu YM, Liu Y, Lu C, Jia JY, Liu GY, Weng LP, Wang JY, Li GX, Wang W, Li SJ, Yu C. Relative bioavailability of generic and branded acetylcysteine effervescent tablets: A single-dose, open-label, randomized-sequence, two-period crossover study in fasting healthy Chinese male volunteers. Clin Ther 2011; 32:2097-105. [PMID: 21118745 DOI: 10.1016/j.clinthera.2010.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Acetylcysteine may be used as a muco- lytic agent for the treatment of chronic bronchitis, chronic obstructive pulmonary disease, and other pulmonary diseases complicated by the production of viscous mucus. However, little is known of its pharmacokinetic properties when given orally in healthy volunteers, particularly in a Chinese Han population. This study was conducted to provide support for the marketing of a generic product in China. OBJECTIVE The purpose of this study was to compare the pharmacokinetics and relative bioavailability of a generic test formulation and a branded reference formulation of acetylcysteine in fasting healthy Chinese male volunteers. METHODS A single-dose, open-label, randomized-sequence, 2-period crossover design with a 7-day washout period between doses was used in this study. Healthy Chinese male nonsmokers aged 18 to 40 years with a body mass index (BMI) of 19 to 25 kg/m(2) were selected. Eligible volunteers were randomly assigned to receive acetylcysteine 600 mg PO as either the test formulation (3 tablets of 200 mg each) or reference formulation (1 tablet of 600 mg) under fasting conditions. A total of 15 serial blood samples were collected over a 24-hour interval, and total plasma acetylcysteine concentrations were analyzed by a validated liquid chromatography-isotopic dilution mass spectrometry method. Pharmacokinetic parameters (C(max), T(max), t(½) AUC(0-t), and AUC(0-∞) were calculated and analyzed statistically. The 2 formulations were considered bioequivalent if the 90% CIs of the log-transformed ratios (test/reference) of C(max) and AUC were within the predetermined bioequivalence ranges (70%-143% for C(max); 80%-125% for AUC), as established by the State Food and Drug Administration of China. Tolerability was determined by vital signs, clinical laboratory tests, 12-lead ECGs, physical examinations, and interviews with the subjects about adverse events (AEs). RESULTS A total of 24 healthy Chinese Han male volunteers were enrolled in and completed the study (mean [SD] age, 25.0 [2.4] years; height, 173.0 [5.6] cm; weight, 65.9 [6.4] kg; BMI, 22.0 [1.7] kg/m(2)). No formulation, period, or sequence effects were observed. The 90% CIs for the log-transformed C(max), AUC(0-t), and AUC(0-∞) were 89.7% to 103.8%, 86.7% to 101.7%, and 87.7% to 102.4%, respectively, which met the predetermined criteria for assuming bioequivalence. Two subjects (8.3%) experienced 2 mild AEs (increase in total bile acid and prolongation of the QT interval), which were not considered to be related to study drug administration. CONCLUSIONS This single-dose study of acetylcysteine 600 mg PO found that the 3 tablets of the generic test formulation and 1 tablet of the branded reference formulation met the regulatory criteria for assuming bioequivalence in these fasting healthy Chinese male volunteers. Both formulations were generally well tolerated.
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Affiliation(s)
- Yan-Mei Liu
- Phase I Clinical Research Unit, Shanghai Xuhui Central Hospital, Shanghai, China.
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Nolin TD, Ouseph R, Himmelfarb J, McMenamin ME, Ward RA. Multiple-dose pharmacokinetics and pharmacodynamics of N-acetylcysteine in patients with end-stage renal disease. Clin J Am Soc Nephrol 2010; 5:1588-94. [PMID: 20538838 DOI: 10.2215/cjn.00210110] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES ESRD is associated with systemic oxidative stress, an important nontraditional risk factor for the development of cardiovascular disease. Since interventions aimed at reducing oxidative stress may be beneficial, we examined the pharmacokinetics and pharmacodynamics of the widely used antioxidant N-acetylcysteine (NAC) after oral administration in patients with ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Twenty-four ESRD patients were randomly assigned to receive 600 or 1200 mg of sustained-release NAC orally every 12 hours for 14 days. Seven healthy control subjects received NAC 600 mg in the same manner. Blood samples were obtained on days 1 and 15 for determination of NAC pharmacokinetics and pharmacodynamics. RESULTS Significant dose-related increases in NAC plasma concentrations were observed in ESRD patients with no change in total clearance; a doubling of the dose resulted in a 2-fold increase in NAC area under the plasma concentration-time curve (AUC). However, NAC clearance was reduced by 90% in ESRD, leading to a 7-fold larger AUC and 13-fold longer half-life compared with healthy control subjects. NAC administration resulted in a significant reduction in total homocysteine plasma concentrations in ESRD and healthy subjects, but had no effect on several other oxidative stress markers. CONCLUSIONS These findings indicate that the total clearance of oral NAC is significantly reduced in ESRD patients, leading to marked increases in systemic exposure, and suggest that NAC may have a limited role in the chronic treatment of oxidative stress-related illness.
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Affiliation(s)
- Thomas D Nolin
- University of Pittsburgh School of Pharmacy, Department of Pharmacy & Therapeutics, Pittsburgh, PA 15261, USA.
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Guijarro LG, Mate J, Gisbert JP, Perez-Calle JL, Marín-Jimenez I, Arriaza E, Olleros T, Delgado M, Castillejo MS, Prieto-Merino D, Lara VG, Peña AS. N-acetyl-L-cysteine combined with mesalamine in the treatment of ulcerative colitis: Randomized, placebo-controlled pilot study. World J Gastroenterol 2008; 14:2851-7. [PMID: 18473409 PMCID: PMC2710726 DOI: 10.3748/wjg.14.2851] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effectiveness and safety of oral N-acetyl-L-cysteine (NAC) co-administration with mesalamine in ulcerative colitis (UC) patients.
METHODS: Thirty seven patients with mild to moderate UC were randomized to receive a four-wk course of oral mesalamine (2.4 g/d) plus N-acetyl-L-cysteine (0.8 g/d) (group A) or mesalamine plus placebo (group B). Patients were monitored using the Modified Truelove-Witts Severity Index (MTWSI). The primary endpoint was clinical remission (MTWSI ≤ 2) at 4 wk. Secondary endpoints were clinical response (defined as a reduction from baseline in the MTWSI of ≥ 2 points) and drug safety. The serum TNF-α, interleukin-6, interleukin-8 and MCP-1 were evaluated at baseline and at 4 wk of treatment.
RESULTS: Analysis per-protocol criteria showed clinical remission rates of 63% and 50% after 4 wk treatment with mesalamine plus N-acetyl-L-cysteine (group A) and mesalamine plus placebo (group B) respectively (OR = 1.71; 95% CI: 0.46 to 6.36; P = 0.19; NNT = 7.7). Analysis of variance (ANOVA) of data indicated a significant reduction of MTWSI in group A (P = 0.046) with respect to basal condition without significant changes in the group B (P = 0.735) during treatment. Clinical responses were 66% (group A) vs 44% (group B) after 4 wk of treatment (OR = 2.5; 95% CI: 0.64 to 9.65; P = 0.11; NNT = 4.5). Clinical improvement in group A correlated with a decrease of IL-8 and MCP-1. Rates of adverse events did not differ significantly between both groups.
CONCLUSION: In group A (oral NAC combined with mesalamine) contrarily to group B (mesalamine alone), the clinical improvement correlates with a decrease of chemokines such as MCP-1 and IL-8. NAC addition not produced any side effects.
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Borkham-Kamphorst E, Meurer SK, Gressner AM, Weiskirchen R. Disruption of intermolecular disulfide bonds in PDGF-BB dimers by N-acetyl-L-cysteine does not prevent PDGF signaling in cultured hepatic stellate cells. Biochem Biophys Res Commun 2005; 338:1711-8. [PMID: 16289037 DOI: 10.1016/j.bbrc.2005.10.139] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Accepted: 10/22/2005] [Indexed: 12/16/2022]
Abstract
Oxidative stress is important in the pathogenesis of liver fibrosis through its induction of hepatic stellate cell (HSC) proliferation and enhancement of collagen synthesis. Reactive oxygen species have been found to be essential second messengers in the signaling of both major fibrotic growth factors, platelet-derived growth factor (PDGF) and transforming growth factor-beta (TGF-beta), in cultured HSC and liver fibrosis. The non-toxic aminothiol N-acetyl-L-cysteine (NAC) inhibits cellular activation and attenuates experimental fibrosis in liver. Prior reports show that NAC is capable of reducing the effects of TGF-beta in biological systems, in cultured endothelial cells, and HSC through its direct reducing activity upon TGF-beta molecules. We here analyzed the effects of NAC on PDGF integrity, receptor binding, and downstream signaling in culture-activated HSC. We found that NAC dose-dependently induces disintegration of PDGF in vitro. However, even high doses (>20mM) were not sufficient to prevent the phosphorylation of the PDGF receptor type beta, extracellular signal-regulated kinase, or protein kinase B (PKB/Akt). Therefore, we conclude that the PDGF monomer is still active. The described antifibrotic effects are therefore mainly attributable to the structural impairment of TGF-beta signaling components reported previously.
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