An assessment of the variation in the concentration of acetylcysteine in infusions for the treatment of paracetamol overdose

N-Acetylcysteine Interference with a Glucose Dehydrogenase Linked Glucose Meter

BACKGROUND

Our objective was to determine the effect of therapeutic concentrations of N-acetylcysteine, following intravenous infusion, on the measurement of blood glucose using a Roche Diagnostics glucose dehydrogenase-linked glucose meter compared to hospital laboratory methods.

METHODS

N-acetylcysteine was added to aliquots of blood, with glucose promptly measured by the glucose meter, blood gas analyzer (glucose oxidase comparative method) and following centrifugation, plasma glucose measured with a hexokinase spectrophotometric comparative method. Glucose results were evaluated with linear regression and Bland Altman plots.

RESULTS

In the presence of NAC, at concentrations greater than 5 mg/dL (0.31 mmol/L), positively biased glucose meter results were compared to the clinical laboratory results. Multivariate linear regression revealed that NAC-mediated meter results are influenced by NAC and glucose concentrations.

CONCLUSIONS

The addition of therapeutic concentrations of NAC to blood produces statistically significant positive biases when measured with the glucose dehydrogenase linked glucose meter device.

Protective effect of γ-glutamylcysteine against UVB radiation in NIH-3T3 cells

BACKGROUND

Ultraviolet (UV) radiation-induced oxidative stress is the main cause of photodamage to the skin. Glutathione (GSH) serves important physiological functions, including scavenging oxygen-free radicals and maintaining intracellular redox balance. γ-glutamylcysteine (γ-GC), as an immediate precursor of GSH and harboring antioxidant and anti-inflammatory properties, represents an unexplored option for skin photodamage treatment.

PURPOSE

The purpose of this study was to investigate whether γ-GC can reduce UVB-induced NIH-3T3 cell damage.

METHODS

The experimental groups were as follows: control, UVB radiation, UVB radiation after pretreatment with γ-GC. Cell counting kit-8 (CCK-8) assays were used to measure cell proliferation, flow cytometry, and immunoblotting to detect the apoptosis rate and apoptosis-associated proteins. The levels of Reactive Oxygen Species (ROS), Superoxide Dismutase (SOD), and GSH/GSSG (oxidized GSH) were measured to assess oxidative stress. Immunoblotting and immunofluorescence were used to detect DNA damage. The members of the MAPK signaling pathways were detected by immunoblotting.

RESULTS

UVB irradiation significantly reduced cell viability and destroyed the oxidative defense system. Pretreatment with γ-GC reduced UVB-induced cytotoxicity, restored the oxidation defense system, and inhibited activation of the MAPK pathway. It also reduced the apoptosis rate, downregulated the levels of cleaved caspase 3 and cleaved PARP. Furthermore, pretreatment with γ-GC reduced the accumulation of γH2AX after UVB radiation exposure, indicating that γ-GC could protect cells from DNA damage.

CONCLUSION

γ-GC protected NIH-3T3 from damage caused by UVB irradiation. The photoprotective effect of γ-GC is mediated via strengthening the endogenous antioxidant defense system, which prevents DNA damage and inhibits the activation of the MAPK pathway.

An evaluation of the role of mixing techniques in the observed variation in acetylcysteine infusion concentrations

Intravenous acetylcysteine is commonly prescribed as a course of three infusions for the management of paracetamol poisoning. Previous studies have demonstrated large variation in administered doses of intravenous acetylcysteine, which has been attributed to numerous factors, including inadequate mixing of infusion bags. The aim of this study was to determine whether the amount of mixing of infusion bags contributes significantly to this variation. Using acetylcysteine doses for a 60-69 kg patient, we added the appropriate volume of acetylcysteine to 5% glucose and subsequently inverted the infusion bags 0-5 times to mix the solutions. Infusion bags were then run through using an infusion pump and acetylcysteine concentrations measured at the beginning and end of the infusions. We found no significant difference between the beginning and end concentrations of acetylcysteine regardless of whether bags were mixed or not; infusion 1 (150 mg kg^-1 ) showed beginning and end concentrations of 44.61 and 42.48 mg ml^-1 respectively after 0 mixes, whilst beginning and end concentrations were 44.45 and 44.58 mg ml^-1 respectively after five mixes. The same trend was observed for infusions 2 and 3. This confirmed that mixing does not play a substantial role in variation of drug concentrations; these are likely to be caused by an accumulation of small errors in infusion preparation.

γ-glutamylcysteine exhibits anti-inflammatory effects by increasing cellular glutathione level

Sepsis is a life-threatening organ dysfunction caused by dysregulated host response to infection and characterized by redox imbalance and severe oxidative stress. Glutathione (GSH) serves several vital functions, including scavenging free radicals and maintaining intracellular redox balance. Extracellular GSH is unable to be taken into the majority of human cells, and the GSH prodrug N-acetyl-l-cysteine (NAC) does not exhibit promising clinical effects. γ-glutamylcysteine (γ-GC), an intermediate dipeptide of the GSH-synthesis pathway and harboring anti-inflammatory properties, represents a relatively unexplored option for sepsis treatment. The anti-inflammatory efficiency of γ-GC and the associated molecular mechanism need to be explored. In vivo investigation showed that γ-GC reduced sepsis lethality and attenuated systemic inflammatory responses in mice, as well as inhibited lipopolysaccharide (LPS)-stimulated production of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), high-mobility group box 1 (HMGB1), and nitric oxide (NO) and the expression of inducible NO synthase and cyclooxygenase 2 in RAW264.7 cells. Moreover, both in vivo and in vitro experiments demonstrated that γ-GC exhibited better therapeutic effects against inflammation compared with N-acetyl-L-cysteine (NAC) and GSH. Mechanistically, γ-GC suppressed LPS-induced reactive oxygen species accumulation and GSH depletion. Inflammatory stimuli, such as LPS treatment, upregulated the expression of glutathione synthetase via activating nuclear factor-erythroid 2-related factor (Nrf2) and nuclear factor kappa B (NF-κB) pathways, thereby promoting synthesis of GSH from γ-GC. These findings suggested that γ-GC might represent a potential therapeutic agent for sepsis treatment.

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γ-GC reduces sepsis lethality and attenuates inflammatory responses in BALB/c mice.

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γ-GC suppresses LPS-induced inflammation, ROS accumulation, and GSH depletion.

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Nrf2 and NF-κB pathways are essential for upregulating GSS level to promote GSH synthesis from γ-GC.

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γ-GC is more effective in attenuation inflammation than NAC and GSH.

N-acetylcysteine for major mental disorders: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis of randomized controlled trials (RCTs) examined the efficacy and safety of adjunctive N-acetylcysteine (NAC), an antioxidant drug, in treating major depressive disorder (MDD), bipolar disorder, and schizophrenia.

METHODS

The PubMed, Cochrane Library, PsycINFO, CNKI, CBM, and WanFang databases were independently searched and screened by two researchers. Standardized mean differences (SMDs), risk ratios, and their 95% confidence intervals (CIs) were computed.

RESULTS

Six RCTs (n = 701) of NAC for schizophrenia (three RCTs, n = 307), bipolar disorder (two RCTs, n = 125), and MDD (one RCT, n = 269) were identified and analyzed as separate groups. Adjunctive NAC significantly improved total psychopathology (SMD = -0.74, 95% CI: -1.43, -0.06; I² = 84%, P = 0.03) in schizophrenia, but it had no significant effect on depressive and manic symptoms as assessed by the Young Mania Rating Scale in bipolar disorder and only a small effect on major depressive symptoms. Adverse drug reactions to NAC and discontinuation rates between the NAC and control groups were similar across the three disorders.

CONCLUSIONS

Adjunctive NAC appears to be a safe treatment that has efficacy for schizophrenia, but not for bipolar disorder or MDD. Further higher quality RCTs are warranted to determine the role of adjunctive NAC in the treatment of major psychiatric disorders.

An assessment of the variation in the concentration of acetylcysteine in infusions for the treatment of paracetamol overdose

BACKGROUND

Intravenous acetylcysteine is the treatment of choice for paracetamol poisoning. A previous UK study in 2001 found that 39% of measured acetylcysteine infusion concentrations differed by >20% from anticipated concentrations. In 2012, the UK Commission on Human Medicines made recommendations for the management of paracetamol overdose, including provision of weight-based acetylcysteine dosing tables. The aim of this study was to assess variation in acetylcysteine concentrations in administered infusions following the introduction of this guidance.

METHODS

A 6-month single-centre prospective study was undertaken at a UK teaching hospital. After preparation, 5-ml samples were taken from the first, second and third/any subsequent acetylcysteine infusions. Acetylcysteine was measured in diluted (1:50) samples by high-performance liquid chromatography. Comparisons between measured and expected concentrations based on prescribed weight-based dose and volume were made for each infusion.

RESULTS

Ninety samples were collected. There was a variation of ≤10% in measured compared to expected concentration for 45 (50%) infusions, of 10-20% for 27 (30%) infusions, 20.1-50% for 14 (16%) infusions and >50% for four (4%) infusions. There was a median (interquartile range) variation in measured compared to expected concentration of -3.6 mg ml^-1 (-6.7 to -2.3) for the first infusion, +0.2 mg ml^-1 (-0.9 to +0.4) for the second infusion and -0.3 mg ml^-1 (-0.6 to +0.2) for third and fourth infusions.

CONCLUSION

There has been a moderate improvement in the variation in acetylcysteine dose administered by infusion. Further work is required to understand the continuing variation and consideration should be given to simplification of acetylcysteine regimes to decrease the risk of administration errors.