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APAP OD Treatment

Lecture 6

QuestionAnswer
Treatment Plan Emergency stabilization , Decontamination (don’t worry about it b/c of antidote) , Antidote , Enhancing elimination , Liver transplant
APAP Treatments (3) Emergency stabilization , Decontamination , Acetylcysteine (^-acetylcysteine, NAC, Mucomyst , Acetadote )
Acetylcysteine (NAC) Available Forms Acetadote – IV , Mucomyst – Inhalation/Oral (generic)
Muco myst Inhalation/Oral (generic)
Acetadote IV
NAC MOA My notes Precursor for glutathione synthesis , Substitute for glutathione , Substrate for sulfation , Direct hepato protective
When NAC most effective within first 8 hours
Acetylcysteine Effectiveness Equally effective if given within the first 8 hours , Effectiveness decreases after 8 hours , ? Effective > 24 hours , Some benefit late in fulminant hepatic fail
NAC Indications Acute overdose [APAP] above treatment line Elevated AST/ALT or [APAP] if time unknown , Chronic overdose High risk based on symptoms and/or [APAP], AST/ALT
NAC Indications Acute OD - time known [APAP]
NAC Indications Acute OD - time unknown Increased AST/ALT (>50IU/L) Increased (APAP] (> lOmcg/mL)
NAC Indications Chronic OD High-risk , Symptoms , [APAP] . AST/ALT
NAC Oral dose Load followed by maintenance
NAC Oral dose Load 140 mg/kg load
NAC Oral dose Maintenance 70 mg/kg q4 hours for 17 doses
NAC Oral administration Dilute to 5% solution to avoid gastric irritation
Oral Acetylcysteine (NAC) Notes Dose 140 mg/kg load M 70 mg/kg q4 hours X 17 Shorter course may be used
Oral Acetylcysteine (NAC) Notes Administration Dilute to 5% solution to avoid gastric irritation Cold, sweet, acidic beverage to disguise taste - FRESCA™ NG/NJ Smaller more frequent doses
NAC Oral SEs Primarily GI
IV Acetylcysteine (NAC) Adults Loading Dose 150 mg/kg in 200mL D5W over 60 min
IV Acetylcysteine (NAC) Adults Loading Dose J Maintenance Dose 50 mg/kg in 500mL D5W over 4 hours 4 , 100 mg/kg in 100mL D5W over 16 hours
IV Acetylcysteine (NAC) Children 20kg, < 40 kg Decrease fluid volume by 50% < 20 kg Fluid adjusted by body weight (see ???)
NAC Pediatric considerations Risk for anaphylactoid reactions , Higher risk in asthamtics , Hyponatremia in children if pediatric fluid guidelines not adhered
NAC Monitoring therapy Check AST/ALT and [APAP] at end of infusion or oral therapy Continue therapy if detectable APAP or AST/AST increasing
Ensuring Optimal NAC Therapy Obtain APAP, AST & ALT concentrations at end of infusion
Ensuring Optimal NAC Therapy Continue NAC if detectable APAP or rising AST/ALT (16-hour bag)
Ensuring Optimal NAC Therapy At risk for longer duration of therapy: Late presenters , , Supra-therapeutic or unknown ingestion , , Diphenhydramine
APAP Liver transplant Kings College criteria pH < 7.3
APAP Liver transplant Kings College criteria lactate > 3 mmol/L
APAP Liver transplant Kings College criteria INR >6.5
APAP Liver transplant Kings College criteria Scr >3.39mg/dL
APAP Liver transplant Kings College criteria encephalopathy Grade III or higher
Created by: pberriochoa