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Prescott LF. Paracetamol (acetaminophen) poisoning: The early years. Br J Clin Pharmacol 2024; 90:127-134. [PMID: 37683599 DOI: 10.1111/bcp.15903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 09/10/2023] Open
Abstract
Paracetamol (acetaminophen) was marketed in the 1950s as a nonprescription analgesic/antipyretic without any preclinical toxicity studies. It became used increasingly for self-poisoning, particularly in the UK and was belatedly found to cause acute liver damage, which could be fatal. Management of poisoned patients was difficult as maximum abnormalities of liver function were delayed for 3 days or more after an overdose. There was no treatment and the mechanism of hepatotoxicity was not known. The paracetamol half-life was prolonged with liver damage occurring when it exceeded 4 h and the Rumack-Matthew nomogram was an important advance that allowed stratification of patients into separate zones of risk. It is used to guide prognosis and treatment and its predictive value could be increased by combining it with the paracetamol half-life. The problems of a sheep farmer in Australia in the early 1970s led to the discovery of the mechanism of paracetamol hepatotoxicity, and the first effective treatment of overdosage with intravenous (IV) cysteamine. This had unpleasant side effects and administration was difficult. N-acetylcysteine soon became the treatment of choice for paracetamol overdose and given early it was very effective when administered either IV or orally. N-acetylcysteine could cause anaphylactoid reactions, particularly early during IV administration when the concentrations were highest. Simpler and shorter regimes with slower initial rates of infusion have now been introduced with a reduced incidence of these adverse effects. In addition, there has been a move to use larger doses of N-acetylcysteine given over longer periods for patients who are more severely poisoned and those with risk factors. There has been much interest recently in the search for novel biomarkers such as microRNAs, procalcitonin and cyclophilin that promise to have greater specificity and sensitivity than transaminases. Paracetamol-protein adducts predict hepatotoxicity and are specific biomarkers of toxic paracetamol metabolite exposure. Another approach would be measurement of the plasma levels of cysteine and inorganic sulfate. It is 50 years since the first effective treatment for paracetamol poisoning and, apart from liver transplantation, there is still no effective treatment for patients who present late.
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Affiliation(s)
- Laurie F Prescott
- Emeritus Professor of Clinical Pharmacology, University of Edinburgh, Edinburgh, UK
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2
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Pfaff A, Chernatynskaya A, Vineyard H, Ercal N. Thiol antioxidants protect human lens epithelial (HLE B-3) cells against tert-butyl hydroperoxide-induced oxidative damage and cytotoxicity. Biochem Biophys Rep 2022; 29:101213. [PMID: 35128081 PMCID: PMC8808075 DOI: 10.1016/j.bbrep.2022.101213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/06/2022] [Accepted: 01/18/2022] [Indexed: 12/20/2022] Open
Abstract
Oxidative damage to lens epithelial cells plays an important role in the development of age-related cataract, and the health of the lens has important implications for overall ocular health. As a result, there is a need for effective therapeutic agents that prevent oxidative damage to the lens. Thiol antioxidants such as tiopronin or N-(2-mercaptopropionyl)glycine (MPG), N-acetylcysteine amide (NACA), N-acetylcysteine (NAC), and exogenous glutathione (GSH) may be promising candidates for this purpose, but their ability to protect lens epithelial cells is not well understood. The effectiveness of these compounds was compared by exposing human lens epithelial cells (HLE B-3) to the chemical oxidant tert-butyl hydroperoxide (tBHP) and treating the cells with each of the antioxidant compounds. MTT cell viability, apoptosis, reactive oxygen species (ROS), and levels of intracellular GSH, the most important antioxidant in the lens, were measured after treatment. All four compounds provided some degree of protection against tBHP-induced oxidative stress and cytotoxicity. Cells treated with NACA exhibited the highest viability after exposure to tBHP, as well as decreased ROS and increased intracellular GSH. Exogenous GSH also preserved viability and increased intracellular GSH levels. MPG scavenged significant amounts of ROS, and NAC increased intracellular GSH levels. Our results suggest that both scavenging ROS and increasing GSH may be necessary for effective protection of lens epithelial cells. Further, the compounds tested may be useful for the development of therapeutic strategies that aim to prevent oxidative damage to the lens.
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Key Words
- 7-AAD, 7-aminoactinomycin D
- ATCC, American Type Culture Collection
- Antioxidant
- Carboxy-H2DCFDA, 6-carboxy-2′,7′-dichlorodihydrofluorescein diacetate
- Cataract
- EMEM, Eagle's minimum essential medium
- FBS, fetal bovine serum
- FDA, United States Food and Drug Administration
- GSH, glutathione
- GSSG, glutathione disulfide
- Glutathione
- H2O2, hydrogen peroxide
- HLE B-3, human (eye) lens epithelial cell line B-3
- Lens
- MPG, N-(2-mercaptopropionyl)glycine
- MTT, (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide)
- NAC, N-acetylcysteine
- NACA, N-acetylcysteine amide
- OH•, hydroxyl radical
- Oxidative stress
- PBS, phosphate-buffered saline
- ROS, reactive oxygen species
- Thiol
- tBHP, tert-butyl hydroperoxide
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Affiliation(s)
| | | | - Hannah Vineyard
- Department of Chemistry, Missouri University of Science & Technology, 104 Schrenk Hall, 400 W. 11th Street, Rolla, MO, 65409, USA
| | - Nuran Ercal
- Department of Chemistry, Missouri University of Science & Technology, 104 Schrenk Hall, 400 W. 11th Street, Rolla, MO, 65409, USA
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3
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Pedre B, Barayeu U, Ezeriņa D, Dick TP. The mechanism of action of N-acetylcysteine (NAC): The emerging role of H 2S and sulfane sulfur species. Pharmacol Ther 2021; 228:107916. [PMID: 34171332 DOI: 10.1016/j.pharmthera.2021.107916] [Citation(s) in RCA: 128] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 12/19/2022]
Abstract
Initially adopted as a mucolytic about 60 years ago, the cysteine prodrug N-acetylcysteine (NAC) is the standard of care to treat paracetamol intoxication, and is included on the World Health Organization's list of essential medicines. Additionally, NAC increasingly became the epitome of an "antioxidant". Arguably, it is the most widely used "antioxidant" in experimental cell and animal biology, as well as clinical studies. Most investigators use and test NAC with the idea that it prevents or attenuates oxidative stress. Conventionally, it is assumed that NAC acts as (i) a reductant of disulfide bonds, (ii) a scavenger of reactive oxygen species and/or (iii) a precursor for glutathione biosynthesis. While these mechanisms may apply under specific circumstances, they cannot be generalized to explain the effects of NAC in a majority of settings and situations. In most cases the mechanism of action has remained unclear and untested. In this review, we discuss the validity of conventional assumptions and the scope of a newly discovered mechanism of action, namely the conversion of NAC into hydrogen sulfide and sulfane sulfur species. The antioxidative and cytoprotective activities of per- and polysulfides may explain many of the effects that have previously been ascribed to NAC or NAC-derived glutathione.
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Affiliation(s)
- Brandán Pedre
- Division of Redox Regulation, DKFZ-ZMBH Alliance, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Uladzimir Barayeu
- Division of Redox Regulation, DKFZ-ZMBH Alliance, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; Faculty of Biosciences, Heidelberg University, 69120 Heidelberg, Germany
| | - Daria Ezeriņa
- Division of Redox Regulation, DKFZ-ZMBH Alliance, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; Faculty of Biosciences, Heidelberg University, 69120 Heidelberg, Germany
| | - Tobias P Dick
- Division of Redox Regulation, DKFZ-ZMBH Alliance, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; Faculty of Biosciences, Heidelberg University, 69120 Heidelberg, Germany.
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4
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Rind L, Ahmad M, Khan MI, Badruddeen, Akhtar J, Ahmad U, Yadav C, Owais M. An insight on safety, efficacy, and molecular docking study reports of N-acetylcysteine and its compound formulations. J Basic Clin Physiol Pharmacol 2021; 33:223-233. [PMID: 33638319 DOI: 10.1515/jbcpp-2020-0099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 09/12/2020] [Indexed: 01/07/2023]
Abstract
N-acetylcysteine (NAC) is considered as the body's major antioxidant molecules with diverse biological properties. In this review, the pharmacokinetics, safety and efficacy report on both the preclinical and clinical summary of NAC is discussed. Both in vitro and in vivo preclinical studies along with the clinical data have shown that NAC has enormous biological properties. NAC is used in the treatment of acetaminophen poisoning, diabetic nephropathy, Alzheimer's disease, schizophrenia, and ulcerative colitis, etc. Numerous analytical techniques, for instance, UPLC, LC-MS, HPLC, RP-IPC are primarily employed for the estimation of NAC in different single and fixed-dose combinations. The molecular docking studies on NAC demonstrate the binding within Sudlow's site-I hydrogen bonds and formation of NAC and BSA complexes. Various hydrophobic and hydrophilic amino acids generally exist in making contact with NAC as NAC-BSA complexes. Docking studies of NAC with the active site of the urease exposed an O-coordinated bond through nickel 3002 and a hydrogen bond through His-138. NAC and its analogs also made the allosteric pockets that helped to describe almost all favorable pose for the chaperone in a complex through the protein. Thus, we intended to highlight the several health benefits of this antioxidant compound and applications in pharmaceutical product development.
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Affiliation(s)
- Laiba Rind
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
| | - Mohammad Ahmad
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
| | | | - Badruddeen
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
| | - Juber Akhtar
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
| | - Usama Ahmad
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
| | - Chandan Yadav
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
| | - Mohammad Owais
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
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Mitra M, Bandyopadhyay A, Datta G, Nandi DK. Effective Dose of Herbal Gold Nanoparticles for Protection of Acetaminophen-Induced Hepatotoxicity in Male Albino Rats. BIONANOSCIENCE 2020. [DOI: 10.1007/s12668-020-00766-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nouiri E, Ben Ali R, Ghali R, Araoud M, Véronique El May M, Hedhili A. Protective and Curative Effects of Aqueous Extract of Terfezia Boudieri (Edible Desert Truffle Specie) against Paracetamol Acute Toxicity in the Rat. Nutr Cancer 2020; 73:113-123. [PMID: 32192374 DOI: 10.1080/01635581.2020.1742359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The current study was aimed to evaluate the protective and curative effect of aqueous extract of edible desert truffle specie (Terfezia boudieri) against rat's liver and kidney injuries induced by paracetamol (PCM). Terfezia boudieri was genetically identified by PCR and then sequencing (Genbank NCBI: LT718236.1). Terfezia boudieri aqueous extract (TBAE) was characterized by antioxidant capacity evaluated by 1,1-diphenyl-2-picryl-hydrazyl test (EC50 = 0.415 mg/ml). LC-MS analysis shows that TBAE contains several actives biomolecules such as B3 vitamin (2.73 ± 0.3 mg/100g dm), quinic acid (2 ± 0.22 mg/100g dm), chlorogenic acid (0.18 ± 0.02 mg/100g dm) and quercetin-3-o-rhamonoside (0.09 ± 0.01 mg/100g dm). Liver and kidney Biochemical parameters showed no significant variation in rat's plasma treated with PCM and/or TBAE. However, the histological studies showed that the liver injuries induced by PCM were characterized by hemorrhage and inflammation. The pretreatment by TBAE showed preservation of normal liver and kidney architecture, this finding suggests its protective effects on these two organs. The co-treatment by TBAE reduced the PCM hepatotoxicity proved by normal central vein and small vacuols. In addition, TBAE reduced kidney PCM toxicity proved by less area inflammation and normal glomerulus. Therefore, TBAE is promoting eventual protective and curative drug against acute toxicity.
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Affiliation(s)
- Ezzeddine Nouiri
- Mahmoud Yaacoub Center of Urgent Medical Assistance of Tunis, Laboratory of Toxicology and Environment (LR12SP07) - Montfleury, University of Carthage, Faculty of Sciences of Bizerte, Tunis, Tunisia
| | - Ridha Ben Ali
- Faculty of Medicine of Tunis15rue Jebbel Lakhdar, Unit of Experimental Medicine and Unit Research n°17/ES/13 Tunis El Manar University, Tunis, Tunisia
| | - Ridha Ghali
- Mahmoud Yaacoub Center of Urgent Medical Assistance of Tunis, Laboratory of Toxicology and Environment (LR12SP07) - Montfleury, Tunis, Tunisia
| | - Manel Araoud
- Mahmoud Yaacoub Center of Urgent Medical Assistance of Tunis, Laboratory of Toxicology and Environment (LR12SP07) - Montfleury, Tunis, Tunisia
| | - Michele Véronique El May
- Histology, Embryology and Cell Biology Laboratory, Unit research N°17ES13, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Abderrazek Hedhili
- Mahmoud Yaacoub Center of Urgent Medical Assistance of Tunis, Laboratory of Toxicology and Environment (LR12SP07) - Montfleury, Tunis, Tunisia
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7
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Arias JM, Cobos Picot RA, Tuttolomondo ME, Ben Altabef A, Díaz SB. Interaction of N-acetylcysteine with DPPC liposomes at different pH: a physicochemical study. NEW J CHEM 2020. [DOI: 10.1039/c9nj06167c] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The N-acetylcysteine (NAC) is a commonly used mucolytic and antioxidant agent.
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Affiliation(s)
- Juan Marcelo Arias
- INQUINOA-CONICET
- Cátedra de Fisicoquímica I
- Instituto de Química Física
- Facultad de Bioquímica
- Química y Farmacia
| | - Rafael A. Cobos Picot
- INQUINOA-CONICET
- Cátedra de Fisicoquímica I
- Instituto de Química Física
- Facultad de Bioquímica
- Química y Farmacia
| | - María Eugenia Tuttolomondo
- INQUINOA-CONICET
- Cátedra de Fisicoquímica I
- Instituto de Química Física
- Facultad de Bioquímica
- Química y Farmacia
| | - Aida Ben Altabef
- INQUINOA-CONICET
- Cátedra de Fisicoquímica I
- Instituto de Química Física
- Facultad de Bioquímica
- Química y Farmacia
| | - Sonia Beatriz Díaz
- INQUINOA-CONICET
- Cátedra de Fisicoquímica I
- Instituto de Química Física
- Facultad de Bioquímica
- Química y Farmacia
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8
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Heidari N, Sajedi F, Mohammadi Y, Mirjalili M, Mehrpooya M. Ameliorative Effects Of N-Acetylcysteine As Adjunct Therapy On Symptoms Of Painful Diabetic Neuropathy. J Pain Res 2019; 12:3147-3159. [PMID: 31819599 PMCID: PMC6875491 DOI: 10.2147/jpr.s228255] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/01/2019] [Indexed: 01/08/2023] Open
Abstract
Purpose Painful diabetic neuropathy (PDN) is a variant of diabetic peripheral neuropathy which is highly prevalent and distressing in diabetic patients. Despite its high burden, the optimal treatment of PDN has remained a clinical challenge. To explain the emergence and maintenance of PDN, increasing attention has been focused on dimensions of inflammation and oxidative toxic stress (OTS). Accordingly, the aim of this study was to investigate the effects of oral N-acetylcysteine (NAC), an agent with known anti-oxidant and anti-inflammatory effects, as an adjunct therapy in patients suffering from PDN. Patients and methods 113 eligible patients with type 2 diabetes suffering from PDN were randomly assigned to either the pregabalin + placebo or pregabalin + NAC group for 8 weeks (pregabalin at a dose of 150 mg per day, NAC and matched placebo at doses of 600 mg twice a day). Mean pain score was evaluated at baseline, week 1, 2, 4, 6, and 8 of the study based on the mean 24 hr average pain score, using an 11-point numeric rating scale (NRS). As secondary efficacy measures, mean sleep interference score (SIS) resulting from PDN, responder rates, Patient Global Impression of Change (PGIC), Clinical Global Impression of Change (CGIC), and safety were also assessed. Additionally, serum levels of total antioxidant capacity (TAC), total thiol groups (TTG), catalase activity (CAT), glutathione peroxidase (GPx), superoxide dismutase (SOD), nitric oxide (NO), and malondialdehyde (MDA) were assessed at baseline and at the end of the study. Results Ninety patients completed the eight-week course of the study. The decrease in mean pain scores and mean sleep interference score in pregabalin + NAC group was greater in comparison with pregabalin + placebo group (p value<0.001 in both conditions). Moreover, more responders (defined as ≥50% reduction in mean pain score from baseline to end-point) were observed in the pregabalin + NAC group, in comparison with pregabalin + placebo group (72.1% vs 46.8%). More improvement in PGIC and CGIC from baseline to the end of the study was reported in pregabalin + NAC group. Oral NAC had minimal adverse effects and was well tolerated in almost all patients. Furthermore, in respect to OTS biomarkers, adjuvant NAC significantly decreased serum level of MDA and significantly increased serum levels of SOD, GPx, TAC, and TTG. Conclusion The pattern of results suggests that compared to placebo and over a time period of 8 weeks, adjuvant NAC is more efficacious in improving neuropathic pain associated with diabetic neuropathy than placebo. Ameliorative effects of NAC on OTS biomarkers demonstrated that NAC may alleviate painful symptoms of diabetic neuropathy, at least in part by its antioxidant effects.
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Affiliation(s)
- Narges Heidari
- Department of Clinical Pharmacy, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Firozeh Sajedi
- Department of Internal Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Younes Mohammadi
- Modeling of Noncommunicable Diseases Research Center, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Mehrpooya
- Department of Clinical Pharmacy, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, Iran
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9
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Recombinant Human Superoxide Dismutase and N-Acetylcysteine Addition to Exogenous Surfactant in the Treatment of Meconium Aspiration Syndrome. Molecules 2019; 24:molecules24050905. [PMID: 30841517 PMCID: PMC6429363 DOI: 10.3390/molecules24050905] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 12/29/2022] Open
Abstract
This study aimed to evaluate the molecular background of N-acetylcysteine (NAC) and recombinant human superoxide dismutase (rhSOD) antioxidant action when combined with exogenous surfactant in the treatment of meconium aspiration syndrome (MAS), considering redox signalling a principal part of cell response to meconium. Young New Zealand rabbits were instilled with meconium suspension (Mec) and treated by surfactant alone (Surf) or surfactant in combination with i.v. NAC (Surf + NAC) or i.t. rhSOD (Surf + SOD), and oxygen-ventilated for 5 h. Dynamic lung-thorax compliance, mean airway pressure, PaO₂/FiO₂ and ventilation efficiency index were evaluated every hour; post mortem, inflammatory and oxidative markers (advanced oxidation protein products, total antioxidant capacity, hydroxynonenal (HNE), p38 mitogen activated protein kinase, caspase 3, thromboxane, endothelin-1 and secretory phospholipase A₂) were assessed in pulmonary tissue homogenates. rhSOD addition to surfactant improved significantly, but transiently, gas exchange and reduced levels of inflammatory and oxidative molecules with higher impact; Surf + NAC had stronger effect only on HNE formation, and duration of treatment efficacy in respiratory parameters. In both antioxidants, it seems that targeting reactive oxygen species may be strong supporting factor in surfactant treatment of MAS due to redox sensitivity of many intracellular pathways triggered by meconium.
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Verma AS, Mallick P, Dwivedi PD, Singh A. Exogenous supplementation of N-acetylcysteine Can Reduce Hepatotoxicity Induced by Ascites Fluid (Cell-Free) Adsorbed Over Protein-A-Containing Staphylococcus aureus Cowan-I Without Compromising Its Antitumor Effect. J Pharm Bioallied Sci 2019; 11:205-215. [PMID: 31555026 PMCID: PMC6662038 DOI: 10.4103/jpbs.jpbs_216_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Introduction: Hepatotoxicity along with enhanced mortality has remained a major concern during the development of antitumor therapy with the use of cell-free ascites fluid adsorbed (ad-AF) over Protein-A-containing Staphylococcus aureus Cowan I (SAC). Major issue with ad-AF inoculation is the significant depletion of hepatic glutathione (GSH). Exogenous supplementation of –SH contents to the host has offered an encouraging hope to explore the possibilities to use ad-AF as a therapeutic material due to its antitumor effects. GSH and l-cysteine have shown a promise with the recovery of –SH contents as well as the recovery of phase I and phase II biotransformation enzymes. Aforementioned observations prompted us to try other –SH donors. Materials and Methods: Therefore, in this study, N-acetylcysteine (NAC) was used as an exogenous source to provide –SH contents to reduce hepatotoxicity and mortality induced by ad-AF treatment. Results: Exogenous supplementation of NAC along with ad-AF treatment to ascites tumor bearers has shown a significant protection against hepatotoxicity and mortality caused by ad-AF. NAC substitution along with ad-AF has significantly enhanced the mean survival time (MST), without altering the antitumor effect of ad-AF as evident from tumor cell counts and viability. Discussion: NAC supplementation has been successful to recover hepatic –SH contents along with the significant recovery of phase I and phase II biotransformation enzymes. Marker enzymes for liver injury have also given clear-cut indications for the recovery of tumor bearers from hepatotoxicity induced by ad-AF. Conclusion: This study has shown that exogenous supplementation of NAC protects the host from the enhanced mortality and hepatotoxicity induced by ad-AF. These observations offer a hope to develop ad-AF as one of the probable treatment strategies for ascites tumors at least at experimental levels.
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Affiliation(s)
| | - Priyadarshini Mallick
- Department of Microbiology, Asutosh College, Bhowanipore, Kolkata, West Bengal, India
| | - Premendra D Dwivedi
- Food, Drug and Chemical Toxicology Group, Academy of Scientific and Innovative Research (AcSIR), Lucknow, Uttar Pradesh, India
| | - Anchal Singh
- Department of Biochemistry, Institute of Science, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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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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Cattermole GN. Should N-Acetylcysteine be Administered Orally or Intravenously for the Treatment of Paracetamol Overdose? HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790901600209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction Paracetamol is the most commonly used drug in deliberate poisoning. N-acetylcysteine is the standard antidote for significant acute paracetamol overdose, but the route of administration varies between countries. This review aimed to find and appraise those comparative studies which would help answer the following question: in patients who have taken an overdose of paracetamol requiring antidote, is there any difference between intravenous and oral N-acetylcysteine in mortality, hepatotoxicity, adverse drug reactions or cost? Methods A literature search was conducted using Medline and other databases. Relevant papers were identified and appraised. Results One animal study and seven comparative clinical studies were identified and appraised. The quality of the evidence was generally poor, and there was no clear difference in outcomes between the two routes of administration. Conclusions Without evidence of advantage for one route over the other, routine practice should not be changed. However, after 30 years experience, both routes appear to be effective and safe, and in countries where intravenous administration is the standard, it would be reasonable to consider the oral route as an alternative when intravenous access is problematic. There is a need for prospective, randomised trials to determine the relative effectiveness, safety and cost of intravenous and oral formulations of N-acetylcysteine.
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Mohammadi H, Jalilian J, Karimi MY, Shetab-Boushehri SV. In Vitro Cysteine Reactivates Organophosphate Insecticide Dichlorvos-Inhibited Human Cholinesterases. Sultan Qaboos Univ Med J 2017; 17:e293-e300. [PMID: 29062551 DOI: 10.18295/squmj.2017.17.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/01/2017] [Accepted: 06/18/2017] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Organophosphate (OP) pesticides inhibit both red blood cell (RBC) and plasma cholinesterases (ChEs). Oximes, especially pralidoxime (2-PAM), are widely used as antidotes to treat OP poisoning. In addition, N-acetylcysteine (NAC) is sometimes used as an adjuvant antidote. The current study aimed to assess the feasibility of using NAC as a single therapeutic agent for OP poisoning in comparison to in vitro 2-PAM. METHODS This study was carried out at the Razi Drug Research Center of Iran University of Medical Sciences, Tehran, Iran, between April and September 2014. A total of 22 healthy human subjects were recruited and 8 mL citrated blood samples were drawn from each subject. Dichlorvos-inhibited blood samples were separately exposed to low and high doses (final concentrations of 300 and 600 μmol.L-1, respectively) of 2-PAM, NAC and cysteine. Plasma and RBCs were then separated by centrifugation and their ChE activity was measured using spectrophotometry. RESULTS Although cysteine-and not NAC-increased the ChE activity of both plasma and RBCs over those of dichlorvos, it did not increase them over those of a high dose of 2-PAM. CONCLUSION These results suggest that the direct reactions of 2-PAM and cysteine with dichlorvos and the reactivation of phosphorylated ChEs occurr via an associative stepwise addition-elimination process. High therapeutic blood concentrations of cysteine are needed for the elevation of ChE activity in plasma and RBCs; however, both this agent and NAC may still be effective in the reactivation of plasma and RBC ChEs.
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Affiliation(s)
- Hamidreza Mohammadi
- Pharmaceutical Sciences Research Center, Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran.,Department of Toxicology & Pharmacology, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Jafar Jalilian
- Department of Toxicology & Pharmacology, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Y Karimi
- Razi Drug Research Center, School of Pharmacy, International Campus, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed V Shetab-Boushehri
- Razi Drug Research Center, School of Pharmacy, International Campus, Iran University of Medical Sciences, Tehran, Iran.,Department of Toxicology & Pharmacology, School of Pharmacy, International Campus, Iran University of Medical Sciences, Tehran, Iran
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Changizi V, Bahrami M, Esfahani M, Shetab-Boushehri SV. Prevention of γ-Radiation-Induced DNA Damage in Human Lymphocytes Using a Serine-Magnesium Sulfate Mixture. Sultan Qaboos Univ Med J 2017; 17:e162-e167. [PMID: 28690887 PMCID: PMC5488816 DOI: 10.18295/squmj.2016.17.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/26/2017] [Accepted: 03/23/2017] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Ionising radiation has deleterious effects on human cells. N-acetylcysteine (NAC) and cysteine, the active metabolite of NAC, are well-known radioprotective agents. Recently, a serine-magnesium sulfate combination was proposed as an antidote for organophosphate toxicity. This study aimed to investigate the use of a serine-magnesium sulfate mixture in the prevention of γ-radiation-induced DNA damage in human lymphocytes as compared to NAC and cysteine. METHODS This study was carried out at the Iran University of Medical Sciences, Tehran, Iran, between April and September 2016. Citrated blood samples of 7 mL each were taken from 22 healthy subjects. Each sample was divided into 1 mL aliquots, with the first aliquot acting as the control while the second was exposed to 2 Gy of γ-radiation at a dose rate of 102.7 cGy/minute. The remaining aliquots were separately incubated with 600 μM concentrations each of serine, magnesium sulfate, serine-magnesium sulfate, NAC and cysteine before being exposed to 2 Gy of γ-radiation. Lymphocytes were isolated using a separation medium and methyl-thiazole-tetrazolium and comet assays were used to evaluate cell viability and DNA damage, respectively. RESULTS The serine-magnesium sulfate mixture significantly increased lymphocyte viability and reduced DNA damage in comparison to serine, magnesium sulfate, NAC or cysteine alone (P <0.01 each). CONCLUSION The findings of the present study support the use of a serine-magnesium sulfate mixture as a new, non-toxic, potent and efficient radioprotective agent.
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Affiliation(s)
- Vahid Changizi
- Department of Technology of Radiology & Radiotherapy, Allied Medical Sciences School, Tehran, Iran
| | - Mona Bahrami
- Department of Technology of Radiology & Radiotherapy, Allied Medical Sciences School, Tehran, Iran
| | - Mahbod Esfahani
- Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed V. Shetab-Boushehri
- Department of Toxicology & Pharmacology, International Campus, Tehran, Iran
- Razi Drug Research Center, Iran University of Medical Sciences, Tehran, Iran
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Zyoud SH, Waring WS, Al-Jabi SW, Sweileh WM, Awang R. The 100 most influential publications in paracetamol poisoning treatment: a bibliometric analysis of human studies. SPRINGERPLUS 2016; 5:1534. [PMID: 27652107 PMCID: PMC5019997 DOI: 10.1186/s40064-016-3240-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Analysis of the most influential publications within paracetamol poisoning treatment can be helpful in recognizing main and novel treatment issues within the field of toxicology. The current study was performed to recognize and describe the most highly cited articles related to paracetamol poisoning treatment. METHODS The 100 most highly cited articles in paracetamol poisoning treatment were identified from the Scopus database in November 2015. All eligible articles were read for basic information, including total number of citations, average citations per year, authors' names, journal name, impact factors, document types and countries of authors of publications. RESULTS The median number of citations was 75 (interquartile range 56-137). These publications were published between 1974 and 2013. The average number of years since publication was 17.6 years, and 45 of the publications were from the 2000s. A significant, modest positive correlation was found between years since publication and the number of citations among the top 100 cited articles (r = 0.316; p = 0.001). A total of 55 journals published these 100 most cited articles. Nine documents were published in Clinical Toxicology, whereas eight documents were published in Annals of Emergency Medicine. Citations per year since publication for the top 100 most-cited articles ranged from 1.5 to 42.6 and had a mean of 8.5 citations per year and a median of 5.9 with an interquartile range of 3.75-10.35. In relation to the origin of the research publications, they were from 8 countries. The USA had the largest number of articles, 47, followed by the UK and Australia with 38 and nine articles respectively. CONCLUSIONS This study is the first bibliometric assessment of the top 100 cited articles in toxicology literature. Interest in paracetamol poisoning as a serious clinical problem continues to grow. Research published in high-impact journals and from high income countries is most likely to be cited in published paracetamol research.
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Affiliation(s)
- Sa’ed H. Zyoud
- Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), 11800 Pulau Pinang, Penang Malaysia
| | - W. Stephen Waring
- Acute Medical Unit, York Teaching Hospitals NHS Foundation Trust, Wigginton Road, York, YO31 8HE UK
| | - Samah W. Al-Jabi
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Waleed M. Sweileh
- Department of Pharmacology and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Rahmat Awang
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), 11800 Pulau Pinang, Penang Malaysia
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High oxygen modifies vasodilator effect of cysteine via enhanced oxidative stress and thromboxane production in the rat mesenteric artery. Pflugers Arch 2016; 468:1555-64. [PMID: 27389323 DOI: 10.1007/s00424-016-1857-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/28/2016] [Accepted: 06/30/2016] [Indexed: 01/09/2023]
Abstract
Whether high oxygen is harmful to the vascular function is unclear. The present study examined if high oxygen modifies vasodilator effect of cysteine via enhanced oxidative stress and thromboxane production. Rat mesenteric arteries with endothelium at 95 or 50 % oxygen were subjected to isometric force recordings, measurement of thromboxane B2 levels, determination of superoxide and peroxynitrite levels and evaluation of NADPH oxidase subunit protein expression, respectively. L-cysteine (0.01-3 mM) constricted or dilated arteries at 95 and 50 % oxygen, respectively. Thromboxane receptor antagonist SQ-29,548 (1 μM) abolished the constriction at 95 % oxygen. L-cysteine (3 mM) increased levels of thromboxane B2 in arteries upon 95 % oxygen application. L-cysteine relaxed arteries treated with superoxide inhibitor tiron (2 mM) or NADPH oxidase inhibitor gp91ds-tat (1 μM) irrespective of the oxygen concentration while ATP-sensitive K(+) channel inhibitor glibenclamide (1 μM) and cystathionine-γ-lyase (CSE) inhibitor DL-propargylglycine (10 mM) similarly abolished the relaxation. L-cysteine (3 mM) with 95 % oxygen augmented levels of superoxide as well as nitrotyrosine within the artery, concomitantly with enhanced membrane protein expression of NADPH oxidase subunit p47phox. The higher concentration of oxygen attenuates L-cysteine-induced vasodilation via superoxide production mediated by NADPH oxidase along with thromboxane A2 production, resulting in vasoconstriction. The increased levels of superoxide, as well as peroxynitrite, coexist with the impaired vasodilation related to ATP-sensitive K(+) channels and CSE. Higher oxygen with plasma cysteine may cause oxidative stress and vasoconstrictor prostanoid production in blood vessels.
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Wrotek S, Jędrzejewski T, Piotrowski J, Kozak W. N-Acetyl-l-cysteine exacerbates generation of IL-10 in cells stimulated with endotoxin in vitro and produces antipyresis via IL-10 dependent pathway in vivo. Immunol Lett 2016; 177:1-5. [PMID: 27363620 DOI: 10.1016/j.imlet.2016.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/20/2016] [Accepted: 06/26/2016] [Indexed: 01/08/2023]
Abstract
N-Acetyl-l-cysteine (NAC) is a well-known medication, primarily used as a mucolytic agent in pulmonary disease. Recently, we have found that NAC possesses antipyretic properties. The aim of the present study was to investigate the mechanism by which NAC attenuates fever. The concentration of interleukin (IL)-10 and prostaglandin (PG) E2 were measured using ELISA kit in the supernatants aspirated after stimulation of peripheral blood mononuclear cells (PBMCs) with lipopolysaccharide (LPS, 1μg/mL) and NAC (10mM). The body temperature of the Wistar rats was measured using biotelemetry system. To inhibit endotoxic fever, NAC (200mg/kg; i.p.) was injected into the rats one hour prior to the LPS administration (50μg/kg; i.p.). The pre-treatment of LPS-stimulated PBMCs with NAC resulted in a significant decrease in PGE2 concentration in comparison to the cells treated with LPS alone (PGE2 level was 386.1±61.9pg/mL vs. 2078.9±157.9pg/mL, respectively, p<0.001). Furthermore, in these cells we observed a significant increase in IL-10 level (142.1±2.62pg/mL in NAC+LPS stimulated cells vs. 54.4±0.6pg/mL in LPS stimulated cells, p<0.001). The injection of anti-IL-10 antibody into the rats abolished antipyretic properties of NAC. Body temperature in animals treated with anti-IL-10+NAC/LPS was 38.28±0.12°C vs. 37.73±0.06°C in IgG+NAC/LPS rats (p<0.001) and 38.31±0.20°C in NaCl/LPS-treated animals (n.s.). Based on these data, we conclude that NAC acts as an antipyretic via IL-10 stimulation. This finding provides a new insight into the immunopharmacology of NAC, and we believe that in a future it will contribute to the new and/or more accurate application of NAC in medicine.
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Affiliation(s)
- Sylwia Wrotek
- Department of Immunology, Nicolaus Copernicus University, Ul. Lwowska 1, 87-100, Torun, Poland.
| | - Tomasz Jędrzejewski
- Department of Immunology, Nicolaus Copernicus University, Ul. Lwowska 1, 87-100, Torun, Poland.
| | - Jakub Piotrowski
- Department of Immunology, Nicolaus Copernicus University, Ul. Lwowska 1, 87-100, Torun, Poland; Centre for Modern Interdisciplinary Technologies, Nicolaus Copernicus University, Wilenska 4, 87-100, Torun, Poland.
| | - Wiesław Kozak
- Department of Immunology, Nicolaus Copernicus University, Ul. Lwowska 1, 87-100, Torun, Poland.
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Önen Bayram FE, Sipahi H, Acar ET, Kahveci Ulugöl R, Buran K, Akgün H. The cysteine releasing pattern of some antioxidant thiazolidine-4-carboxylic acids. Eur J Med Chem 2016; 114:337-44. [PMID: 27017266 DOI: 10.1016/j.ejmech.2016.03.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/26/2016] [Accepted: 03/07/2016] [Indexed: 12/26/2022]
Abstract
Oxidative stress that corresponds to a significant increase in free radical concentration in cells can cause considerable damage to crucial biological macromolecules if not prevented by cellular defense mechanisms. The low-molecular-weight thiol glutathione (GSH) constitutes one of the main intracellular antioxidants. It is synthesized via cysteine, an amino acid found only in limited amounts in cells because of its neurotoxicity. Thus, to ensure an efficient GSH synthesis in case of an oxidative stress, cysteine should be provided extracellularly. Yet, given its nucleophilic properties and its rapid conversion into cystine, its corresponding disulfide, cysteine presents some toxicity and therefore is usually supplemented in a prodrug approach. Here, some thiazolidine-4-carboxylic acids were synthesized and evaluated for their antioxidant properties via the DDPH and CUPRAC assays. Then, the cysteine releasing capacity of the obtained compounds was investigated in aqueous and organic medium in order to correlate the relevant antioxidant properties of the molecules with their cysteine releasing pattern. As a result, the structures' antioxidative properties were not only attributed to cysteine release but also to the thiazolidine cycle itself.
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Affiliation(s)
- F Esra Önen Bayram
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Yeditepe University, Istanbul, Turkey.
| | - Hande Sipahi
- Department of Toxicology, Faculty of Pharmacy, Yeditepe University, Istanbul, Turkey
| | - Ebru Türköz Acar
- Department of Analytical Chemistry, Faculty of Pharmacy, Yeditepe University, Istanbul, Turkey
| | - Reyhan Kahveci Ulugöl
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Yeditepe University, Istanbul, Turkey
| | - Kerem Buran
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Yeditepe University, Istanbul, Turkey
| | - Hülya Akgün
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Yeditepe University, Istanbul, Turkey
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Lasram MM, Dhouib IB, Annabi A, El Fazaa S, Gharbi N. A review on the possible molecular mechanism of action of N-acetylcysteine against insulin resistance and type-2 diabetes development. Clin Biochem 2015; 48:1200-8. [DOI: 10.1016/j.clinbiochem.2015.04.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 04/18/2015] [Accepted: 04/21/2015] [Indexed: 01/01/2023]
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20
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Owumi SE, Andrus JP, Herzenberg LA, Herzenberg LA. Co-administration of N-Acetylcysteine and Acetaminophen Efficiently Blocks Acetaminophen Toxicity. Drug Dev Res 2015; 76:251-8. [DOI: 10.1002/ddr.21262] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 07/14/2015] [Indexed: 01/23/2023]
Affiliation(s)
- Solomon E Owumi
- Department of Genetics; Stanford University School of Medicine, B007 Beckman Center; 279 Campus Drive Stanford CA USA
| | - James P Andrus
- Department of Pediatric Critical Care; Pediatrix Medical Group of Nevada; 3186 Maryland Pkwy Las Vegas NV USA
| | - Leonard A Herzenberg
- Department of Genetics; Stanford University School of Medicine, B007 Beckman Center; 279 Campus Drive Stanford CA USA
| | - Leonore A Herzenberg
- Department of Genetics; Stanford University School of Medicine, B007 Beckman Center; 279 Campus Drive Stanford CA USA
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Li M, Gao W, Ma J, Zhu Y, Li X. Early-stage lupus nephritis treated with N-acetylcysteine: A report of two cases. Exp Ther Med 2015; 10:689-692. [PMID: 26622376 DOI: 10.3892/etm.2015.2510] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 04/21/2015] [Indexed: 12/24/2022] Open
Abstract
The oxidative-antioxidative status is closely associated with the progression of systemic lupus erythematosus (SLE), and oxidative stress is customarily found in patients with SLE. N-acetylcysteine (NAC), a typical antioxidant, is reliable and often applied for clinical treatment. Lupus nephritis (LN) is a kidney disorder associated with SLE, but the treatment of LN with antioxidants is rarely documented. The present report describes two cases of early-stage LN that were orally treated with 1,200 mg NAC in addition to the standard therapy with hydroxychloroquine and calcitriol. Following the NAC administration, the glutathione level largely increased while the level of the lipid peroxidation biomarker 8-iso-prostaglandin F2α declined in both cases. In addition, the routine blood counts, 24-h urine protein, erythrocyte sedimentation rate and the SLE disease activity index were markedly improved. In conclusion, the present report of two cases has shown that NAC, as an antioxidant, may exert a beneficial effect to modulate the oxidative status in LN; however, the underlying mechanisms require further investigation.
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Affiliation(s)
- Ming Li
- Department of Rheumatism and Immunity, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China ; Department of Rheumatism and Immunity, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Wenjuan Gao
- Department of Ultrasound, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Jingjing Ma
- Department of Rheumatism and Immunity, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Yun Zhu
- Department of Rheumatism and Immunity, Weifang People's Hospital, Weifang, Shandong 261041, P.R. China
| | - Xingfu Li
- Department of Rheumatism and Immunity, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
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Mast C, Lyan B, Joly C, Centeno D, Giacomoni F, Martin JF, Mosoni L, Dardevet D, Pujos-Guillot E, Papet I. Assessment of protein modifications in liver of rats under chronic treatment with paracetamol (acetaminophen) using two complementary mass spectrometry-based metabolomic approaches. J Proteomics 2015; 120:194-203. [DOI: 10.1016/j.jprot.2015.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 02/27/2015] [Accepted: 03/15/2015] [Indexed: 01/22/2023]
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Mahmoudi GA, Astaraki P, Mohtashami AZ, Ahadi M. N-acetylcysteine overdose after acetaminophen poisoning. Int Med Case Rep J 2015; 8:65-9. [PMID: 25767408 PMCID: PMC4354467 DOI: 10.2147/imcrj.s74563] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
N-acetylcysteine (NAC) is used widely and effectively in oral and intravenous forms as a specific antidote for acetaminophen poisoning. Here we report a rare case of iatrogenic NAC overdose following an error in preparation of the solution, and describe its clinical symptoms. Laboratory results and are presented and examined. A 23-year-old alert female patient weighing 65 kg presented to the emergency ward with weakness, lethargy, extreme fatigue, nausea, and dizziness. She had normal arterial blood gas and vital signs. An excessive dosage of NAC over a short period of time can lead to hemolysis, thrombocytopenia, and acute renal failure in patients with normal glucose-6-phosphate dehydrogenase, and finally to death. Considering the similarity between some of the clinical symptoms of acetaminophen overdose and NAC overdose, it is vitally important for the administration phases and checking of the patient’s symptoms to be carried out attentively and cautiously.
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Affiliation(s)
- Ghafar Ali Mahmoudi
- Faculty of Medicine, Department of Internal Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Peyman Astaraki
- Faculty of Medicine, Department of Internal Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Azita Zafar Mohtashami
- Faculty of Medicine, Department of Internal Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Maryam Ahadi
- Legal Medicine Research Center of Lorestan, Khorramabad, Iran
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El-Sayed ESM, Mansour AM, Nady ME. Protective Effects of Pterostilbene against Acetaminophen-Induced Hepatotoxicity in Rats. J Biochem Mol Toxicol 2014; 29:35-42. [DOI: 10.1002/jbt.21604] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 08/01/2014] [Indexed: 12/22/2022]
Affiliation(s)
- El-Sayed M. El-Sayed
- Pharmacology and Toxicology Department, Faculty of Pharmacy; Al-Azhar University; Nasr-City Cairo Egypt
| | - Ahmed M. Mansour
- Pharmacology and Toxicology Department, Faculty of Pharmacy; Al-Azhar University; Nasr-City Cairo Egypt
| | - Mohamed E. Nady
- Pharmacology and Toxicology Department, Faculty of Pharmacy; Al-Azhar University; Nasr-City Cairo Egypt
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25
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Comparsi B, Meinerz DF, Dalla Corte CL, Prestes AS, Stefanello ST, Santos DB, Souza DD, Farina M, Dafre AL, Posser T, Franco JL, Rocha JBT. N-acetylcysteine does not protect behavioral and biochemical toxicological effect after acute exposure of diphenyl ditelluride. Toxicol Mech Methods 2014; 24:529-35. [DOI: 10.3109/15376516.2014.920449] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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26
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Shohrati M, Karimzadeh I, Saburi A, Khalili H, Ghanei M. The role ofN-acetylcysteine in the management of acute and chronic pulmonary complications of sulfur mustard: a literature review. Inhal Toxicol 2014; 26:507-23. [DOI: 10.3109/08958378.2014.920439] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Efficacy of N-acetylcysteine on neuroclinical, biochemical, and histopathological parameters in experimental spinal cord trauma: comparison with methylprednisolone. Eur J Trauma Emerg Surg 2014; 40:363-71. [PMID: 26816073 DOI: 10.1007/s00068-013-0349-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 11/04/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND N-acetylcysteine (NAC) is an antioxidant agent that has been shown to have beneficial effects when treating various diseases. The aim of this study was to investigate the effects of NAC on spinal cord injury in an experimental rat model. METHODS A total of 48 adult male wistar albino rats were divided into six groups. Group C included the control rats, group L included the rats that underwent laminectomy, and group T included the rats in which spinal cord trauma was induced by the weight-drop method after laminectomy. Groups M (the methylprednisolone group), N (the NAC group), and MN (the methylprednisolone + NAC group) were the treatment groups. In the fourth group (group M), 30 mg/kg methylprednisolone (MP) was administered as a bolus intraperitoneally (IP), and a standard MP treatmentat a dose of 5.4 mg/kg was applied for 24 h. In the fifth group (group N), only 300 mg/kg NAC was administered as a bolus IP. In the sixth group (group MN), the standard MP treatment and a single 300 mg/kg dose of NAC were administered as a bolus IP. The motor functions of the rats were evaluated on the 1st, 7th, and 14th days using the inclined plane test defined by Rivlin and Tator and the motor scale defined by Gale et al. Spinal cord samples were obtained on the 14th day. The samples were evaluated using pathological and biochemical analysis. RESULTS In the neuroclinical assessment, no differences were observed between groups T and M in terms of motor improvement. However, statistically significant differences were observed between group T and groups N and MN (p < 0.001, p = 0.01, respectively). Statistically significant differences were also seen between group M and groups N and MN on the 1st and 7th days (p < 0.017, p < 0.01, respectively). Additionally, when groups N and MN were compared with groups T and M,the pathological and biochemical analyses were found to be statistically different (p < 0.05, p < 0.001, respectively). CONCLUSION It was concluded that NAC treatment and the combined NAC + MP treatment may be more useful for healing in rats with experimental spinal cord injury in terms of neuroclinical, pathological, and biochemical results than MP-only therapy.
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Sikorska M, Lanthier P, Miller H, Beyers M, Sodja C, Zurakowski B, Gangaraju S, Pandey S, Sandhu JK. Nanomicellar formulation of coenzyme Q10 (Ubisol-Q10) effectively blocks ongoing neurodegeneration in the mouse 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine model: potential use as an adjuvant treatment in Parkinson's disease. Neurobiol Aging 2014; 35:2329-46. [PMID: 24775711 DOI: 10.1016/j.neurobiolaging.2014.03.032] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 03/25/2014] [Accepted: 03/28/2014] [Indexed: 12/13/2022]
Abstract
Although the support for the use of antioxidants, such as coenzyme Q(10) (CoQ(10)), to treat Parkinson's disease (PD) comes from the extensive scientific evidence, the results of conducted thus far clinical trials are inconclusive. It is assumed that the efficacy of CoQ(10) is hindered by insolubility, poor bioavailability, and lack of brain penetration. We have developed a nanomicellar formulation of CoQ(10) (Ubisol-Q(10)) with improved properties, including the brain penetration, and tested its effectiveness in mouse MPTP (1-methyl-4-phenyl-1, 2, 3, 6-tetrahydropyridine) model with the objectives to assess its potential use as an adjuvant therapy for PD. We used a subchronic MPTP model (5-daily MPTP injections), characterized by 50% loss of dopamine neurons over a period of 28 days. Ubisol-Q(10) was delivered in drinking water. Prophylactic application of Ubisol-Q(10), started 2 weeks before the MPTP exposure, significantly offset the neurotoxicity (approximately 50% neurons died in MPTP group vs. 17% in MPTP+ Ubisol-Q(10) group by day 28). Therapeutic application of Ubisol-Q(10), given after the last MPTP injection, was equally effective. At the time of intervention on day 5 nearly 25% of dopamine neurons were already lost, but the treatment saved the remaining 25% of cells, which otherwise would have died by day 28. This was confirmed by cell counts, analyses of striatal dopamine levels, and improved animals' motor skill on a beam walk test. Similar levels of neuroprotection were obtained with 3 different Ubisol-Q(10) concentrations tested, that is, 30 mg, 6 mg, or 3 mg CoQ(10)/kg body weight/day, showing clearly that high doses of CoQ(10) were not required to deliver these effects. Furthermore, the Ubisol-Q(10) treatments brought about a robust astrocytic activation in the brain parenchyma, indicating that astroglia played an active role in this neuroprotection. Thus, we have shown for the first time that Ubisol-Q(10) was capable of halting the neurodegeneration already in progress; however, to maintain it a continuous supplementation of Ubisol-Q(10) was required. The pathologic processes initiated by MPTP resumed if supplementation was withdrawn. We suggest that in addition to brain delivery of powerful antioxidants, Ubisol-Q(10) might have also supported subcellular oxidoreductase systems allowing them to maintain a favorable cellular redox status, especially in astroglia, facilitating their role in neuroprotection. Based on this data further clinical testing of this formulation in PD patients might be justifiable.
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Affiliation(s)
- Marianna Sikorska
- Department of Translational Bioscience, Human Health Therapeutics Portfolio, National Research Council Canada, Ottawa, Ontario, Canada
| | - Patricia Lanthier
- Department of Translational Bioscience, Human Health Therapeutics Portfolio, National Research Council Canada, Ottawa, Ontario, Canada
| | - Harvey Miller
- Department of Translational Bioscience, Human Health Therapeutics Portfolio, National Research Council Canada, Ottawa, Ontario, Canada
| | - Melissa Beyers
- Department of Translational Bioscience, Human Health Therapeutics Portfolio, National Research Council Canada, Ottawa, Ontario, Canada
| | - Caroline Sodja
- Department of Translational Bioscience, Human Health Therapeutics Portfolio, National Research Council Canada, Ottawa, Ontario, Canada
| | - Bogdan Zurakowski
- Department of Translational Bioscience, Human Health Therapeutics Portfolio, National Research Council Canada, Ottawa, Ontario, Canada
| | - Sandhya Gangaraju
- Department of Translational Bioscience, Human Health Therapeutics Portfolio, National Research Council Canada, Ottawa, Ontario, Canada
| | - Siyaram Pandey
- Department of Chemistry and Biochemistry, University of Windsor Essex Hall, Windsor, Ontario, Canada
| | - Jagdeep K Sandhu
- Department of Translational Bioscience, Human Health Therapeutics Portfolio, National Research Council Canada, Ottawa, Ontario, Canada.
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Li IC, Chiu CY, Wu CL, Chi JY, Jian SR, Wang SW, Chang CL. A dual-fluorescent reporter facilitates identification of thiol compounds that suppress microsatellite instability induced by oxidative stress. Free Radic Biol Med 2014; 69:86-95. [PMID: 24412704 DOI: 10.1016/j.freeradbiomed.2013.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/13/2013] [Accepted: 12/19/2013] [Indexed: 01/22/2023]
Abstract
The DNA mismatch-repair (MMR) system corrects replicative errors and minimizes mutations that occur at a high rate in microsatellites. Patients with chronic inflammation or inflammation-associated cancer display microsatellite instability (MSI), indicating a possible MMR inactivation. In fact, H2O2-generated oxidative stress inactivates the MMR function and increases mutation accumulation in a reporter microsatellite. However, it remains unclear whether MSI induced by oxidative stress is preventable because of the lack of a sufficiently sensitive detection assay. Here, we developed and characterized a dual-fluorescent system, utilizing DsRed harboring the (CA)13 microsatellite as a reporter and GFP for normalization, in near-isogenic human colorectal cancer cell lines. Via flow cytometry, this reporter sensitively detected H2O2-generated oxidative microsatellite mutations in a dose-dependent manner. The reporter further revealed that glutathione or N-acetylcysteine was better than aspirin and ascorbic acid for suppressing oxidative microsatellite mutations. These two thiol compounds also partially suppressed oxidative frameshift mutations in the coding microsatellites of the hMSH6 and CHK1 genes based on a fluoresceinated PCR-based assay. MSI suppression by N-acetylcysteine appears to be mediated through reduction of oxidative frameshift mutations in the coding microsatellite of hMSH6 and protection of hMSH6 and other MMR protein levels from being decreased by H2O2. Our findings suggest a linkage between oxidative damage, MMR deficiency, and MSI. The two thiol compounds are potentially valuable for preventing inflammation-associated MSI. The dual-fluorescent reporter with improved features will facilitate identification of additional compounds that modulate MSI, which is relevant to cancer initiation and progression.
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Affiliation(s)
- I-Chen Li
- Institute of Molecular Medicine, National Cheng Kung University, Tainan 70101, Taiwan
| | - Chien-Yuan Chiu
- Institute of Oral Medicine, and National Cheng Kung University, Tainan 70101, Taiwan
| | - Chang-Lin Wu
- Institute of Basic Medical Sciences, National Cheng Kung University, Tainan 70101, Taiwan
| | - Jhih-Ying Chi
- Institute of Molecular Medicine, National Cheng Kung University, Tainan 70101, Taiwan
| | - Siao-Ru Jian
- Institute of Oral Medicine, and National Cheng Kung University, Tainan 70101, Taiwan
| | - Shainn-Wei Wang
- Institute of Molecular Medicine, National Cheng Kung University, Tainan 70101, Taiwan; Institute of Basic Medical Sciences, National Cheng Kung University, Tainan 70101, Taiwan
| | - Christina L Chang
- Institute of Molecular Medicine, National Cheng Kung University, Tainan 70101, Taiwan; Institute of Oral Medicine, and National Cheng Kung University, Tainan 70101, Taiwan; Institute of Basic Medical Sciences, National Cheng Kung University, Tainan 70101, Taiwan.
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Curative Effects of Thiacremonone against Acetaminophen-Induced Acute Hepatic Failure via Inhibition of Proinflammatory Cytokines Production and Infiltration of Cytotoxic Immune Cells and Kupffer Cells. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:974794. [PMID: 23935693 PMCID: PMC3725907 DOI: 10.1155/2013/974794] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 04/22/2013] [Indexed: 01/13/2023]
Abstract
High doses of acetaminophen (APAP; N-acetyl-p-aminophenol) cause severe hepatotoxicity after metabolic activation by cytochrome P450 2E1. This study was undertaken to examine the preventive effects of thiacremonone, a compound extracted from garlic, on APAP-induced acute hepatic failure in male C57BL/6J. Mice received with 500 mg/kg APAP after a 7-day pretreatment with thiacremonone (10–50 mg/kg). Thiacremonone inhibited the APAP-induced serum ALT and AST levels in a dose-dependent manner, and markedly reduced the restricted area of necrosis and inflammation by administration of APAP. Thiacremonone also inhibited the APAP-induced depletion of intracellular GSH, induction of nitric oxide, and lipid peroxidation as well as expression of P450 2E1. After APAP injection, the numbers of Kupffer cells, natural killer cells, and cytotoxic T cells were elevated, but the elevated cell numbers in the liver were reduced in thiacremonone pretreated mice. The expression levels of I-309, M-CSF, MIG, MIP-1α, MIP-1β, IL-7, and IL-17 were increased by APAP treatment, which were inhibited in thiacremonone pretreated mice. These data indicate that thiacremonone could be a useful agent for the treatment of drug-induced hepatic failure and that the reduction of cytotoxic immune cells as well as proinflammatory cytokine production may be critical for the prevention of APAP-induced acute liver toxicity.
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Abstract
Acetaminophen poisoning remains one of the more common drugs taken in overdose with potentially fatal consequences. Early recognition and prompt treatment with N-acetylcysteine can prevent hepatic injury. With acute overdose, the Rumack-Matthew nomogram is a useful tool to assess risk and guide management. Equally common to acute overdose is the repeated use of excessive amounts of acetaminophen. Simultaneous ingestion of several different acetaminophen-containing products may result in excessive dosage. These patients also benefit from N-acetylcysteine. Standard courses of N-acetylcysteine may need to be extended in patients with persistently elevated plasma concentrations of acetaminophen or with signs of hepatic injury.
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Affiliation(s)
- Michael J Hodgman
- Department of Emergency Medicine, Upstate New York Poison Center, SUNY Upstate Medical University, Suite 202, 250 Harrison Street, Syracuse, NY 13202, USA.
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Fakurazi S, Sharifudin SA, Arulselvan P. Moringa oleifera hydroethanolic extracts effectively alleviate acetaminophen-induced hepatotoxicity in experimental rats through their antioxidant nature. Molecules 2012; 17:8334-50. [PMID: 22781444 PMCID: PMC6268890 DOI: 10.3390/molecules17078334] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 06/25/2012] [Accepted: 06/26/2012] [Indexed: 01/18/2023] Open
Abstract
The aim of the study was to investigate the in vitro antioxidant properties Moringa oleifera Lam. (MO) extracts and its curative role in acetaminophen (APAP)- induced toxic liver injury in rats caused by oxidative damage. The total phenolic content and antioxidant properties of hydroethanolic extracts of different MO edible parts were investigated by employing an established in vitro biological assay. In the antihepatotoxic study, either flowers or leaves extract (200 mg/kg or 400 mg/kg, i.p) were administered an hour after APAP administration, respectively. N-Acetylcysteine was used as the positive control against APAP-induced hepatotoxicity. The levels of liver markers such as alanine aminotransferase (ALT) and the levels of oxidative damage markers including malondialdehyde (MDA), 4-hydroxynonenal (4-HNE) protein adduct, reduced glutathione (GSH), superoxide dismutase (SOD) and catalase (CAT) were analysed and compared between experimental groups. Among MO edible parts the flower extracts contain the highest total phenolic content and antioxidant capacity, followed by leaves extract. The oxidative marker MDA, as well as 4-HNE protein adduct levels were elevated and GSH, SOD and CAT were significantly decreased in groups treated with hepatotoxin. The biochemical liver tissue oxidative markers measured in the rats treated with MO flowers and leaves hydroethanolic extracts showed a significant (p < 0.05) reduction in the severity of the liver damage. The results of this study strongly indicate the therapeutic properties of MO hydroethanolic extracts against acute liver injury and thereby scientifically support its traditional use.
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Affiliation(s)
- Sharida Fakurazi
- Faculty of Medicine and Health Sciences, Department of Human Anatomy, Universiti Putra Malaysia, UPM Serdang 43400, Selangor, Malaysia;
- Laboratory of Vaccines and Immunotherapeutics, Institute of Bioscience, Universiti Putra Malaysia, UPM Serdang 43400, Selangor, Malaysia;
- Author to whom correspondence should be addressed; ; Tel.: +603-8947-2331; Fax: +603-8942-2341
| | - Syazana Akmal Sharifudin
- Faculty of Medicine and Health Sciences, Department of Human Anatomy, Universiti Putra Malaysia, UPM Serdang 43400, Selangor, Malaysia;
| | - Palanisamy Arulselvan
- Laboratory of Vaccines and Immunotherapeutics, Institute of Bioscience, Universiti Putra Malaysia, UPM Serdang 43400, Selangor, Malaysia;
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Affiliation(s)
- Jacqueline D Ogilvie
- Department of Pediatrics, Department of Medicine, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
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Pujos-Guillot E, Pickering G, Lyan B, Ducheix G, Brandolini-Bunlon M, Glomot F, Dardevet D, Dubray C, Papet I. Therapeutic paracetamol treatment in older persons induces dietary and metabolic modifications related to sulfur amino acids. AGE (DORDRECHT, NETHERLANDS) 2012; 34:181-193. [PMID: 21340541 PMCID: PMC3260351 DOI: 10.1007/s11357-011-9218-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 01/30/2011] [Indexed: 05/30/2023]
Abstract
Sulfur amino acids are determinant for the detoxification of paracetamol (N-acetyl-p-aminophenol) through sulfate and glutathione conjugations. Long-term paracetamol treatment is common in the elderly, despite a potential cysteine/glutathione deficiency. Detoxification could occur at the expense of anti-oxidative defenses and whole body protein stores in elderly. We tested how older persons satisfy the extra demand in sulfur amino acids induced by long-term paracetamol treatment, focusing on metabolic and nutritional aspects. Effects of 3 g/day paracetamol for 14 days on fasting blood glutathione, plasma amino acids and sulfate, urinary paracetamol metabolites, and urinary metabolomic were studied in independently living older persons (five women, five men, mean (±SEM) age 74 ± 1 years). Dietary intakes were recorded before and at the end of the treatment and ingested sulfur amino acids were evaluated. Fasting blood glutathione, plasma amino acids, and sulfate were unchanged. Urinary nitrogen excretion supported a preservation of whole body proteins, but large-scale urinary metabolomic analysis revealed an oxidation of some sulfur-containing compounds. Dietary protein intake was 13% higher at the end than before paracetamol treatment. Final sulfur amino acid intake reached 37 mg/kg/day. The increase in sulfur amino acid intake corresponded to half of the sulfur excreted in urinary paracetamol conjugates. In conclusion, older persons accommodated to long-term paracetamol treatment by increasing dietary protein intake without any mobilization of body proteins, but with decreased anti-oxidative defenses. The extra demand in sulfur amino acids led to a consumption far above the corresponding population-safe recommendation.
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Affiliation(s)
- Estelle Pujos-Guillot
- Plateforme d’Exploration du Métabolisme, INRA, Centre Clermont-Ferrand—Theix, UMR 1019 Nutrition Humaine, Saint-Genès-Champanelle, 63122 France
| | - Gisèle Pickering
- Centre de Pharmacologie Clinique, Inserm CIC 501, INSERM U766, Faculté de Médecine, Clermont-Ferrand, 63003 France
| | - Bernard Lyan
- Plateforme d’Exploration du Métabolisme, INRA, Centre Clermont-Ferrand—Theix, UMR 1019 Nutrition Humaine, Saint-Genès-Champanelle, 63122 France
| | - Gilles Ducheix
- Centre de Pharmacologie Clinique, Inserm CIC 501, INSERM U766, Faculté de Médecine, Clermont-Ferrand, 63003 France
| | | | - Françoise Glomot
- INRA, Centre Clermont-Ferrand—Theix, UMR 1019 Unité de Nutrition Humaine, 63122 Saint-Genès-Champanelle, France
- Univ Clermont 1, UFR Médecine, UMR 1019, Unité Nutrition Humaine, 63001 Clermont-Ferrand, France
| | - Dominique Dardevet
- INRA, Centre Clermont-Ferrand—Theix, UMR 1019 Unité de Nutrition Humaine, 63122 Saint-Genès-Champanelle, France
- Univ Clermont 1, UFR Médecine, UMR 1019, Unité Nutrition Humaine, 63001 Clermont-Ferrand, France
| | - Claude Dubray
- Centre de Pharmacologie Clinique, Inserm CIC 501, INSERM U766, Faculté de Médecine, Clermont-Ferrand, 63003 France
| | - Isabelle Papet
- INRA, Centre Clermont-Ferrand—Theix, UMR 1019 Unité de Nutrition Humaine, 63122 Saint-Genès-Champanelle, France
- Univ Clermont 1, UFR Médecine, UMR 1019, Unité Nutrition Humaine, 63001 Clermont-Ferrand, France
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Assessment of the Clinical Use of Intravenous and Oral N-Acetylcysteine in the Treatment of Acute Acetaminophen Poisoning in Children: A Retrospective Review. Clin Ther 2011; 33:1322-30. [DOI: 10.1016/j.clinthera.2011.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2011] [Indexed: 01/09/2023]
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The clinical management of acetaminophen poisoning in a community hospital system: factors associated with hospital length of stay. J Med Toxicol 2011; 7:4-11. [PMID: 20857257 DOI: 10.1007/s13181-010-0115-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Acetaminophen (APAP) overdose is the most common pharmaceutical poisoning. The objective of this study was to examine the management of patients admitted for treatment of APAP overdose. Factors impacting hospital length of stay (LOS) were of particular interest. This was a retrospective cohort study of patients admitted to Kaiser Permanente Northern California hospitals for APAP overdose from July 2003 through December 2007. Medical records were abstracted for patient demographic data, key factors of overdose, California Poison Control System (CPCS) contact, data regarding hospital course, transfer for liver transplantation, and death. Four hundred thirty-five patients were included. The mean hospital LOS was 66.5 h (95% CI 62.1, 71.0). Four patients (0.9%) died. Eight patients (1.8%) were transferred for liver transplantation, but all of these patients later recovered without transplant. Of 289 cases eligible for placement on the Rumack-Matthew nomogram (acute ingestion with known time of ingestion <24 h and normal liver enzymes), 161 (55.7%) had APAP levels above the "200" line and 77 (26.6%) fell below the "150" line. CPCS was contacted in 295 cases (67.8%). Mean LOS in cases with CPCS consultation was 61.9 h (95% CI 57.2, 66.5 h) versus 76.3 h (95% CI 66.6, 86.0 h) in those without. LOS in cases treated with IV NAC was 67.1 h (95% CI 57.7, 76.5 h) versus 66.4 h (95% CI 61.2, 71.5 h) in cases treated with oral NAC. Many patients admitted for APAP overdose had serum APAP levels below the minimum toxicity level. Use of IV NAC did not impact hospital LOS. CPCS consultation appeared to decrease mean hospital LOS.
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van Hoving D, Veale D, Müller G. WITHDRAWN: Emergency management of acute poisoning. Afr J Emerg Med 2011. [DOI: 10.1016/j.afjem.2011.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Oakley E, Robinson J, Deasy C. Using 0.45% saline solution and a modified dosing regimen for infusing N-acetylcysteine in children with paracetamol poisoning. Emerg Med Australas 2011; 23:63-7. [PMID: 21284815 DOI: 10.1111/j.1742-6723.2010.01376.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION N-acetylcysteine (NAC) administration is recommended to all patients judged to be at risk of developing hepatotoxicity following paracetamol overdose. However, it has been shown that standard i.v. dosing can cause symptomatic hyponatraemia in children. We describe a case series using 0.45% NaCl plus 5% dextrose for infusing i.v. NAC in children with paracetamol poisoning. CASE SERIES A retrospective review of medical records of patients treated with NAC using 0.45% saline plus 5% dextrose, and a novel two-stage dosing regimen between January 2003 and July 2006 were undertaken. RESULTS A total of 40 patients (20 male and 20 female) who received NAC in 0.45% sodium chloride (NaCl) with 5% dextrose were identified. Mean age was 9 years 6 months (95% CI 4 years 4 months to 15 years 1 month) and the range 3 months to 17 years. All patients had NAC infused in a two-stage infusion regimen (150 mg/kg bolus over 1 h followed by a continuous infusion of 10 mg/kg/h for 20 h). The serum sodium was measured in all 40 patients with a mean of 140 (range of 133 to 152 mmol/L). Repeat sodium was measured in 35 cases, with a mean of 140 mmol/L (range from 134 to 149 mmol/L). CONCLUSION These findings support the use of saline-containing solutions to administer NAC as an alternative to 5% dextrose, and suggest that a two-stage infusion regimen should be further investigated with prospective studies.
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Affiliation(s)
- Ed Oakley
- Department of Emergency Medicine, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168, Australia.
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Chandrasekaran VRM, Chien SP, Hsu DZ, Liu MY. Anti-hepatotoxic effects of 3,4-methylenedioxyphenol and N-acetylcysteine in acutely acetaminophen-overdosed mice. Hum Exp Toxicol 2011; 30:1609-15. [DOI: 10.1177/0960327110394226] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
3,4-Methylenedioxyphenol (sesamol) is effective against acetaminophen-induced liver injury in rats. Whether sesamol’s anti-hepatotoxic effect is comparable to that of N-acetylcysteine has never been studied. We investigated the anti-hepatotoxic effects of sesamol and N-acetylcysteine on acetaminophen-induced hepatotoxicity in mice. Equimolar doses (1 mmol/kg) of sesamol and N-acetylcysteine significantly inhibited acetaminophen (300 mg/kg)-increased serum aspartate transaminase and alanine transaminase levels 6 h post-administration. Sesamol and N-acetylcysteine maintained hepatic glutathione levels and inhibited lipid peroxidation. Moreover, the combination of sesamol and N-acetylcysteine antagonistically inhibited sesamol’s protection against acetaminophen-induced liver injury. We conclude that the protective effect of sesamol against acetaminophen-induced liver damage is comparable to that of N-acetylcysteine by maintaining glutathione levels and inhibiting lipid peroxidation in mice.
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Affiliation(s)
| | - Se-Ping Chien
- Institute of Living Science, Tainan University of Technology, Tainan, Taiwan
| | - Dur-Zong Hsu
- Department of Environmental and Occupational Health, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Ming-Yie Liu
- Department of Environmental and Occupational Health, National Cheng Kung University Medical College, Tainan, Taiwan
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Chandrasekaran VRM, Periasamy S, Liu LL, Liu MY. 17β-Estradiol protects against acetaminophen-overdose-induced acute oxidative hepatic damage and increases the survival rate in mice. Steroids 2011; 76:118-24. [PMID: 20933533 DOI: 10.1016/j.steroids.2010.09.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 09/24/2010] [Accepted: 09/28/2010] [Indexed: 11/17/2022]
Abstract
Acetaminophen overdose causes acute liver injury or even death in both humans and experimental animals. We investigated the effect of 17β-estradiol against acetaminophen-induced acute liver injury and mortality in mice. Male mice were given acetaminophen (p-acetamidophenol; 300 mg/kg; orally) to induce acute liver injury. Acetaminophen significantly increased the levels of aspartate transaminase, alanine transaminase, myeloperoxidase, lipid peroxidation, and glutathione reductase, but it decreased superoxide dismutase, catalase, and glutathione. In addition, acetaminophen-induced mortality began 4h post-treatment, and all mice died within 9h. 17β-Estradiol (200 μg/kg; i.p.) protected against acetaminophen-induced oxidative hepatic damage by inhibiting neutrophil infiltration and stimulating the antioxidant defense system. However, 17β-estradiol did not affect acetaminophen-induced glutathione depletion or increased glutathione reductase activity. We conclude that 17β-estradiol specifically attenuates acute hepatic damage and decreases mortality in acetaminophen-overdosed male mice.
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Zheng J, Lou JR, Zhang XX, Benbrook DM, Hanigan MH, Lind SE, Ding WQ. N-Acetylcysteine interacts with copper to generate hydrogen peroxide and selectively induce cancer cell death. Cancer Lett 2010; 298:186-94. [PMID: 20667650 DOI: 10.1016/j.canlet.2010.07.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 06/03/2010] [Accepted: 07/01/2010] [Indexed: 11/26/2022]
Abstract
A variety of metal-binding compounds have been found to exert anti-cancer activity. We postulated that N-acetylcysteine (NAC), which is a membrane-permeable metal-binding compound, might have anti-cancer activity in the presence of metals. We found that NAC/Cu(II) significantly alters growth and induces apoptosis in human cancer lines, yet NAC/Zn(II) and NAC/Fe(III) do not. We further confirmed that this cytotoxicity of NAC/Cu(II) is attributed to reactive oxygen species (ROS). These findings indicate that the combination of Cu(II) and thiols generates cytotoxic ROS that induce apoptosis in cancer cells. They also indicate a fourth class of anti-neoplastic metal-binding compounds, the "ROS generators".
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Affiliation(s)
- Jie Zheng
- Department of Pathology, University of Oklahoma Health Sciences Center, USA
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Lee R, Britz-McKibbin P. Differential rates of glutathione oxidation for assessment of cellular redox status and antioxidant capacity by capillary electrophoresis-mass spectrometry: an elusive biomarker of oxidative stress. Anal Chem 2010; 81:7047-56. [PMID: 19610656 DOI: 10.1021/ac901174g] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Glutathione metabolism plays a fundamental role in maintaining homeostasis and regulating the redox environment of a cell. Despite the widespread interest in quantifying glutathione metabolites in oxidative stress research, conventional techniques are hampered by complicated sample handling procedures to prevent significant oxidation artifacts generated during sample collection, sample pretreatment, and/or chemical analysis. In this report, a simple and validated method for glutathione analysis from filtered red blood cell (RBC) lysates was developed using capillary electrophoresis-electrospray ionization-mass spectrometry (CE-ESI-MS) in conjunction with fingerprick microsampling and ultrafiltration. About a 3-fold improvement in precision with nanomolar detection limits was achieved when using online sample preconcentration with CE-ESI-MS via a modified injection sequence, which permitted accurate determination of the intracellular reduced/oxidized glutathione ratio (GSH/GSSG), as well as other glutathione species, including protein-bound glutathione mixed disulfide (PSSG), free glutathione mixed disulfides (GSSR) and glutathione thioether conjugates (GSX). In this work, the redox status of filtered hemolysates was determined by the equilibrium half-cell reduction potential for glutathione (E(GSSG/2GSH)), whereas its intrinsic antioxidant capacity was assessed by the apparent rate of metal-catalyzed oxidation of glutathione. In-vitro incubation studies of intact RBCs with 1-chloro-2,4-dinitrobenzene (CDNB) and N-acetyl-L-cysteine (NAC) were found to significantly alter E(GSSG/2GSH) and/or glutathione oxidation kinetics (e.g., k(GSSG)) relative to normal controls based on their function as a toxic electrophilic compound and a competitive free radical scavenging/reducing agent, respectively. Differential rates of glutathione oxidation (DIRGO) using CE-ESI-MS offers a novel strategy for global assessment of the impact of intrinsic metabolite constituents (i.e., metabolome) and/or extrinsic perturbants on cellular redox status that is relevant to improved understanding of aging and the pathogenesis of acute or chronic disease states.
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Affiliation(s)
- Richard Lee
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, Ontario L8S 4M1, Canada
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Life-threatening hyponatremia due to intravenous n-acetylcysteine treatment in an infant: a case report. CASES JOURNAL 2009; 2:8347. [PMID: 19918421 PMCID: PMC2769431 DOI: 10.4076/1757-1626-2-8347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 08/17/2009] [Indexed: 11/30/2022]
Abstract
Introduction N-acetylcysteine has proven to be effective in paracetamol intoxications, but there is no consensus regarding its way of administration. Here, we report a case to highlight the importance of careful management of intravenous n-acetylcysteine. Case presentation A two-month old infant was seen in our paediatric emergency department due to paracetamol poisoning after repeated supratherapeutic doses. She was treated with intravenous n-acetylcysteine diluted with dextrose 5%, according to the 20-hour standard protocol. Eight hours later she developed two tonic-clonic seizures and was subsequently intubated. By that time, she had received almost 1 liter of 5% dextrose, and serum sodium was 114 mg/dL. A rapid correction was done with hypertonic saline and the child experienced a good outcome, without any sequelae. Conclusion Intravenous n-acetylcysteine administration must be done carefully. Amount of liquid administrated and sodium monitoring should be kept in mind, with special care in small children.
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Cantrell L, Shah N, Anderson PO, Birnbaum K, Kearney TE. Assessing the Influence of Acetadote on Use of Intravenous N-acetylcysteine for Acetaminophen Poisonings. Hosp Pharm 2009. [DOI: 10.1310/hpj4406-491] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Until recently in the United States, the intravenous (IV) administration of N-acetylcysteine (NAC) in acetaminophen (APAP) poisonings was reserved for patients unable to take or tolerate oral NAC. Aside from these situations, oral administration of NAC was preferred. In February 2004 an IV formulation of NAC, Acetadote, was approved by the US Food and Drug Administration. This study was designed to examine the influence of Acetadote availability on the use of IV NAC in the treatment of APAP poisonings. Methods A retrospective review of poison center records was performed for cases reported to a poison control system 6 months before (PRE) and 6 months after (POST) the release of Acetadote. Extracted variables included patient age and sex, reason for exposure, type of APAP product involved, exposure duration, rationale for use of IV NAC, reported adverse reactions, medical outcomes, and source of IV. Also, the average wholesale price for Acetadote, Mucomyst, and generic NAC were obtained. Results IV NAC was administered to 50 (2.9%) patients in the PRE group and to 183 (9.6%) patients in the POST group. Demographic data were similar for both groups. Adverse reactions to IV NAC included 2 allergic-type reactions and 1 complaint of chest tightness in the POST group and 1 allergic-type reaction in the PRE group. Discussion The release of Acetadote was associated with a 266% (2.9% to 9.6%) increase in IV NAC use. This change occurred despite a higher risk of serious adverse events with the IV route, an increase in cost when using Acetadote with equivalent treatment durations, and a lack of convincing data demonstrating that the IV route is superior in efficacy to the oral route. Conclusion The change in IV NAC usage without published rationale may be the result of effective promotional campaigns by the manufacturer of Acetadote or the assumption that newly approved products are superior to existing products.
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Affiliation(s)
- Lee Cantrell
- California Poison Control System–San Diego Division; University of California, San Francisco, School of Pharmacy
| | - Nilofar Shah
- California Poison Control System–San Diego Division
| | - Philip O. Anderson
- University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences
| | | | - Thomas E. Kearney
- California Poison Control System–San Francisco Division; University of California, San Francisco, School of Pharmacy
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Abstract
INTRODUCTION Paracetamol (acetaminophen) is one of the most common agents deliberately ingested in self-poisoning episodes and a leading cause of acute liver failure in the western world. Acetylcysteine is widely acknowledged as the antidote of choice for paracetamol poisoning, but its use is not without risk. Adverse reactions, often leading to treatment delay, are frequently associated with both intravenous and oral acetylcysteine and are a common source of concern among treating physicians. METHODS A systematic literature review investigating the incidence, clinical features, and mechanisms of adverse effects associated with acetylcysteine. RESULTS A variety of adverse reactions to acetylcysteine have been described ranging from nausea to death, most of the latter due to incorrect dosing. The pattern of reactions differs with oral and intravenous dosing, but reported frequency is at least as high with oral as intravenous. The reactions to the intravenous preparation result in similar clinical features to true anaphylaxis, including rash, pruritus, angioedema, bronchospasm, and rarely hypotension, but are caused by nonimmunological mechanisms. The precise nature of this reaction remains unclear. Histamine now seems to be an important mediator of the response, and there is evidence of variability in patient susceptibility, with females, and those with a history of asthma or atopy are particularly susceptible. Quantity of paracetamol ingestion, measured through serum paracetamol concentration, is also important as higher paracetamol concentrations protect patients against anaphylactoid effects. Most anaphylactoid reactions occur at the start of acetylcysteine treatment when concentrations are highest. Acetylcysteine also affects clotting factor activity, and this affects the interpretation of minor disturbances in the International Normalized Ratio in the context of paracetamol overdose. CONCLUSION This review discusses the incidence, clinical features, underlying pathophysiological mechanisms, and treatment of adverse reactions to acetylcysteine and identifies particular "at-risk" patient groups. Given the commonality of adverse reactions associated with acetylcysteine, it is important to ensure that any adverse event does not preclude patients from receiving maximal hepatic protection, particularly in the context of significant paracetamol ingestion. Further work on mechanisms should allow specific therapies to be developed.
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Affiliation(s)
- E A Sandilands
- NPIS Edinburgh - SPIB, Royal Infirmary of Edinburgh, UK.
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Doyon S, Klein-Schwartz W. Hepatotoxicity despite early administration of intravenous N-acetylcysteine for acute acetaminophen overdose. Acad Emerg Med 2009; 16:34-9. [PMID: 19007345 DOI: 10.1111/j.1553-2712.2008.00296.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective was to evaluate the effectiveness of intravenous N-acetylcysteine (IV NAC; 300 mg/kg over 21 hours) in early acute acetaminophen (APAP) overdose patients. METHODS This observational case series included patients hospitalized between 2004 and 2007 for acute APAP overdoses and who were reported to a regional poison center. Inclusion criteria were plasma APAP concentrations on or above the treatment line on the Rumack-Matthew nomogram, administration of IV NAC within 8 hours of ingestion, and follow-up to known outcome. The hospital chart of each patient who received IV NAC for longer than the standard 21 hours was reviewed. Hepatotoxicity was defined as hepatic aminotransferase levels greater than 1,000 IU/L. RESULTS Seventy-seven patients met inclusion criteria and received at least 21 hours of IV NAC for an acute APAP overdose. Seven patients received antidotal therapy for greater than 21 hours. These patients tended to have ingested combination preparations, have very high initial plasma APAP concentrations, and had persistently elevated plasma concentrations during their hospital stay. Hepatotoxicity occurred in 4 patients (5.2%, 95% confidence interval [CI] = 0.2% to 10.1%), including 1 death and 1 liver transplantation. CONCLUSIONS Hepatotoxicity developed in 5.2% of cases, suggesting that the 21-hour IV NAC regimen is suboptimal in some patients. In addition to high initial plasma APAP concentrations, APAP product formulation and persistently elevated plasma APAP concentrations were identified as factors possibly associated with developing hepatotoxicity. The authors propose a tailored approach to the discontinuation of IV NAC and point out the need for reevaluation of optimal doses and duration of therapy.
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Affiliation(s)
- Suzanne Doyon
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA.
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Dodd S, Dean O, Copolov DL, Malhi GS, Berk M. N-acetylcysteine for antioxidant therapy: pharmacology and clinical utility. Expert Opin Biol Ther 2008; 8:1955-62. [DOI: 10.1517/14728220802517901] [Citation(s) in RCA: 268] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Zimmerman JL, Rudis M. Poisonings. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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