(931) Safety and Efficacy of a Novel Two-Bag Dosing Regimen of N-Acetylcysteine for Acetaminophen Toxicity

Introduction: Acetaminophen (APAP) toxicity is the leading cause of acute liver failure in the United States. N-acetylcysteine (NAC) is the treatment of choice to prevent hepatic injury in APAP overdose. The traditional three-bag dosing regimen for NAC is complex and associated with errors in medication dosing and administration, which can result in treatment delays, adverse medication reactions, and treatment failures. This study was conducted to evaluate the impact of a novel two-bag dosing regimen of NAC on the incidence of medication errors and adverse events compared to the traditional three-bag dosing regimen in patients treated for APAP toxicity.

Methods: A retrospective cohort was performed including patients that received intravenous NAC either dosed traditionally or dosed per the health system’s novel two-bag dosing protocol for the treatment of APAP toxicity. Patients were excluded if they had a known ingestion of an extended-release APAP product, received treatment at a hospital outside of the health system, or had a treatment course that intentionally deviated from the standard protocol. Primary outcomes of interest were incidence of medication errors and incidence of treatment emergent adverse events in each of the two groups. Secondary outcomes included incidence of acute liver injury, need for extended NAC treatment, length of hospitalization, and discharge disposition.

Results: Of the patients reviewed, 53 received the two-bag dosing regimen, and 51 received the traditional three-bag regimen. Adverse effects occurred less commonly in the two-bag group compared to the three-bag group (32.1% vs 52.9%; p=0.0313). Medication errors also occurred less frequently in the two-bag group (7.5% vs 58.8%; p< 0.0001). There were no statistically significant differences in secondary outcomes.

Conclusions: The novel two-bag dosing regimen of NAC (200 mg/kg infused over 4 hours followed by 200 mg/kg infused over 16 hours) results in significantly fewer treatment-emergent adverse events and medication errors when compared to the traditional dosing regimen. This novel regimen improves safety and presents a viable alternative to traditional dosing of NAC for APAP toxicity.