‘Pearls’ of wisdom about NAC administration
Pearls’ of wisdom about NAC administration
Tolerance most improved using IV formulation
A certain soft drink has led the way in tests for masking the taste and smell of oral N-acetylcysteine (NAC) in treating acetaminophen poisoning, according to a pharmacist who directs a poison control center. To ensure the best tolerance, however, use the intravenous (IV) formulation rather than the oral one.
Barbara Insley Crouch, PharmD, MSPH, director of the Utah Poison Control Center and professor of the department of pharmacotherapy at the University of Utah in Salt Lake City, talked about her findings at the American Society of Health-System Pharmacists Midyear Clinical Meeting in December. Her presentation, "Getting the Knack of NAC Administration," was part of the "Clinical Pearls" section.
"We know [N-acetylcysteine] to be effective if given within the first eight hours after acetaminophen ingestion," she says. N-acetylcysteine has been available for a while in 10% and 20% solutions for oral administration, but a 20% IV formulation has been marketed recently under the trade name Acetadote.
Nausea is a common complaint in patients who overdose, and it’s also a common complaint along with vomiting for N-acetylcysteine administration. N-acetylcysteine smells like rotten eggs and is irritating to the gastrointestinal tract. Therefore, it is necessary to dilute the oral formulation to a final concentration of 5% to improve tolerance, Crouch says. "It is also important to dilute it with something that will mask the taste and the smell."
The question of the proper diluent is often raised. Several drug references recommend juice or cola. Crouch told of pharmacy students who are enrolled in a clinical toxicology class. As part of an antidote lab, the students are required to taste N-acetylcysteine with various diluents. "Consistently over a five-year period of time, they have chosen Fresca as being significantly better than Coca-Cola, chocolate milk, water, and cranberry juice at masking both the smell and taste of N-acetylcysteine."
This year, switches were made in the lab and tomato juice was added to the choices. The tomato juice was found to better mask the smell but not the taste. "We also added Diet Coke this year and apple juice. However, Fresca still prevails as the beverage of choice in masking the smell and taste of N-acetylcysteine," Crouch says.
"There are benefits to improve the tolerance to oral N-acetylcysteine," she continues. Instead of giving one dose every four hours, you can divide the dose up and give smaller doses more frequently.
Or you can try other options such as putting N-acetylcysteine down an NG tube, which will mask the drug’s taste. Still, to avoid the bad taste and smell of N-acetylcysteine, use the IV formulation. "[That] is the best way to improve tolerance," Crouch says.
A certain soft drink has led the way in tests for masking the taste and smell of oral N-acetylcysteine (NAC) in treating acetaminophen poisoning, according to a pharmacist who directs a poison control center. To ensure the best tolerance, however, use the intravenous (IV) formulation rather than the oral one.Subscribe Now for Access
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