Acetylcysteine
Clinical data | |
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Pronunciation | /əˌsiːtəlˈsɪstiːn/ and similar (/əˌsɛtəl-, ˌæsɪtəl-, -tiːn/) |
Trade names | ACC 200, Acetadote, Fluimucil, Mucomyst, others |
Other names | N-acetylcysteine; N-acetyl-L-cysteine; NALC; NAC |
AHFS/Drugs.com | Monograph |
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inhalation | |
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Pharmacokinetic data | |
Bioavailability | 10% (Oral)[6] |
Protein binding | 50 to 83%[7] |
Metabolism | Liver[7] |
Elimination half-life | 5.6 hours[5] |
Excretion | Kidney (30%),[7] faecal (3%) |
Identifiers | |
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JSmol) | |
Specific rotation | +5° (c = 3% in water)[9] |
Melting point | 109 to 110 °C (228 to 230 °F) [9] |
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Acetylcysteine, also known as N-acetylcysteine (NAC), is a
Common side effects include nausea and vomiting when taken by mouth.
Acetylcysteine was initially patented in 1960 and came into medical use in 1968.
The sulfur-containing amino acids cysteine and methionine are more easily oxidized than the other amino acids.[19][20]
Uses
Medical uses
Paracetamol overdose
Intravenous and oral formulations of acetylcysteine are available for the treatment of
In the treatment of paracetamol (acetaminophen) overdose, acetylcysteine acts to maintain or replenish depleted glutathione reserves in the liver and enhance non-toxic metabolism of acetaminophen.[22] These actions serve to protect liver cells from NAPQI toxicity. It is most effective in preventing or lessening hepatic injury when administered within 8–10 hours after overdose.[22] Research suggests that the rate of liver toxicity is approximately 3% when acetylcysteine is administered within 10 hours of overdose.[21]
Although IV and oral acetylcysteine are equally effective for this indication, oral administration is generally poorly tolerated due to the higher dosing required to overcome its low oral bioavailability,[23] its foul taste and odour, and a higher incidence of adverse effects when taken by mouth, particularly nausea and vomiting. Prior pharmacokinetic studies of acetylcysteine did not consider acetylation as a reason for the low bioavailability of acetylcysteine.[24] Oral acetylcysteine is identical in bioavailability to cysteine precursors.[24] However, 3% to 6% of people given intravenous acetylcysteine show a severe, anaphylaxis-like allergic reaction, which may include extreme breathing difficulty (due to bronchospasm), a decrease in blood pressure, rash, angioedema, and sometimes also nausea and vomiting.[25] Repeated doses of intravenous acetylcysteine will cause these allergic reactions to progressively worsen in these people.
Several studies have found this anaphylaxis-like reaction to occur more often in people given intravenous acetylcysteine despite serum levels of paracetamol not high enough to be considered toxic.[26][27][28][29]
Lungs
Inhaled acetylcysteine has been used for
Acetylcysteine is used in the treatment of obstructive lung disease as an adjuvant treatment.[32][33][34]
Other uses
Acetylcysteine has been used to complex palladium, to help it dissolve in water. This helps to remove palladium from drugs or precursors synthesized by palladium-catalyzed coupling reactions.[35] N-acetylcysteine can be used to protect the liver.[36]
Microbiological use
Acetylcysteine can be used in Petroff's method of liquefaction and decontamination of
Acetylcysteine has
Side effects
The most commonly reported adverse effects for IV formulations of acetylcysteine are rash,
Adverse effects for inhalational formulations of acetylcysteine include nausea, vomiting, stomatitis, fever, rhinorrhea, drowsiness, clamminess, chest tightness, and bronchoconstriction. Although infrequent, bronchospasm has been reported to occur unpredictably in some patients.[40]
Adverse effects for oral formulations of acetylcysteine have been reported to include nausea, vomiting, rash, and fever.[40]
Large doses in a mouse model showed that acetylcysteine could potentially cause damage to the
The implications of these findings for long-term treatment with acetylcysteine have not yet been investigated. The dose used by Palmer and colleagues was dramatically higher than that used in humans, the equivalent of about 20 grams per day.
Although N-acetylcysteine prevented liver damage in mice when taken before alcohol, when taken four hours after alcohol it made liver damage worse in a dose-dependent fashion.[43]
Pharmacology
Pharmacodynamics
Acetylcysteine serves as a
- Glutathione, along with excitatory amino acid receptor, and which may constitute glutathione receptors, potentially making it a neurotransmitter.[47]As such, since N-acetylcysteine is a prodrug of glutathione, it may modulate all of the aforementioned receptors as well.
- Glutathione also modulates the NMDA receptor by acting at the redox site.[48][49]
L-cysteine also serves as a precursor to
Pharmacokinetics
Acetylcysteine is extensively liver metabolized, CYP450 minimal, urine excretion is 22–30% with a half-life of 5.6 hours in adults and 11 hours in newborns.
Chemistry
Acetylcysteine is the N-
N-acetyl-L-cysteine is soluble in water and alcohol, and practically insoluble in chloroform and ether.[53]
It is a white to white with light yellow cast powder, and has a
Society and culture
Acetylcysteine was first studied as a drug in 1963. Amazon removed acetylcysteine for sale in the US in 2021, due to claims by the FDA of it being classified as a drug rather than a supplement.[54][55][56][57] In April 2022, the FDA released draft guidance on FDA's policy regarding products labeled as dietary supplements that contain N-acetyl-L-cysteine.[58] Amazon subsequently re-listed NAC products as of August 2022.[59]
Research
While many antioxidants have been researched to treat a large number of diseases by reducing the negative effect of oxidative stress, acetylcysteine is one of the few that has yielded promising results, and is currently already approved for the treatment of paracetamol overdose.[60]
- In mouse Duchenne's muscular dystrophy, treatment with 1–2% acetylcysteine in drinking water significantly reduces muscle damage and improves strength.[60]
- It is being studied in conditions such as autism, where cysteine and related sulfur amino acids may be depleted due to multifactorial dysfunction of methylation pathways involved in methionine catabolism.[61]
- Animal studies have also demonstrated its efficacy in reducing the damage associated with moderate traumatic brain or spinal injury, and also ischaemia-induced brain injury. In particular, it has been demonstrated to reduce neuronal losses and to improve cognitive and neurological outcomes associated with these traumatic events.[62]
- It has been suggested that acetylcysteine may help people with salicylates, although there is no evidence that it is of benefit.[63]
- Small studies have shown acetylcysteine to be of benefit to people with Sjögren's syndrome.[65]
- It has been shown that N-acetylcysteine may protect the human cochlea from subclinical hearing loss caused by loud noises such as impulse noise.[66] In animal models, it reduced age-related hearing loss.
- It has been shown effective in the treatment of
- Addiction to certain addictive drugs (including adjunct therapy for the treatment of addiction to cocaine, nicotine, alcohol, and other drugs.[69]
- It has been tested for the reduction of hangover symptoms, though the overall results indicate very limited efficacy.[70][71]
- A double-blind placebo controlled trial of 262 patients has shown NAC treatment was well-tolerated and resulted in a significant decrease in the frequency of influenza-like episodes, severity, and length of time confined to bed.[72]
Kidney and bladder
Evidence for the benefit of acetylcysteine to prevent
Acetylcysteine has been used for
Psychiatry
Acetylcysteine has been studied for major psychiatric disorders,[75][52][48][62] including bipolar disorder,[75] major depressive disorder, and schizophrenia.[52][48]
Tentative evidence exists for N-acetylcysteine also in the treatment of
It is also being studied for use as a treatment of body-focused repetitive behavior.[82][83]
Addiction
Evidence to date does not support the efficacy for N-acetylcysteine in treating
Bipolar disorder
In
COVID-19
Acetylcysteine is being considered as a possible treatment for COVID-19.[85][86][87]
A combination of guanfacine and N-acetylcysteine has been found to lift the "brain fog" of eight patients with long COVID, according to researchers.[88]
A combination of glycine and N-acetylcysteine is suspected to have potential to safely replenish depleted glutathione levels in COVID-19 patients.[89]
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