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Anaphylactoid Reactions to Intravenous N-Acetylcysteine during Treatment for Acetaminophen Poisoning

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A Correction to this article was published on 12 March 2018

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Abstract

Background

Anaphylactoid reactions to intravenous (IV) N-acetylcysteine (NAC) are well-recognized adverse events during treatment for acetaminophen (APAP) poisoning. Uncertainty exists regarding their incidence, severity, risk factors, and management. We sought to determine the incidence, risk factors, and treatment of anaphylactoid reactions to IV NAC in a large, national cohort of patients admitted to hospital for acetaminophen overdose.

Methods

This retrospective medical record review included all patients initiated on the 21-h IV NAC protocol for acetaminophen poisoning in 34 Canadian hospitals between February 1980 and November 2005. The primary outcome was any anaphylactoid reaction, defined as cutaneous (urticaria, pruritus, angioedema) or systemic (hypotension, respiratory symptoms). We examined the incidence, severity and timing of these reactions, and their association with patient and overdose characteristics using multivariable analysis.

Results

An anaphylactoid reaction was documented in 528 (8.2%) of 6455 treatment courses, of which 398 (75.4%) were cutaneous. Five hundred four (95.4%) reactions occurred during the first 5 h. Of 403 patients administered any medication for these reactions, 371 (92%) received an antihistamine. Being female (adjusted OR 1.24 [95%CI 1.08, 1.42]) and having taken a single, acute overdose (1.24 [95%CI 1.10, 1.39]) were each associated with more severe reactions, whereas higher serum APAP concentrations were associated with fewer reactions (0.79 [95%CI 0.68, 0.92]).

Conclusion

Anaphylactoid reactions to the 21-h IV NAC protocol were uncommon and involved primarily cutaneous symptoms. While the protective effects of higher APAP concentrations are of interest in understanding the pathophysiology, none of the associations identified are strong enough to substantially alter the threshold for NAC initiation.

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Change history

  • 12 March 2018

    The original article has been corrected. Table 4 in PDF version of this article has been corrected since the original publication of the article because the first column of numbers (under the heading “Female”) in the original PDF version was typeset poorly.

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Author information

Authors and Affiliations

  1. Poison and Drug Information Service, Foothills Medical Centre, 1403-29th St NW, Calgary, Alberta, T2N 2T9, Canada

    Mark Yarema & David Johnson

  2. Section of Clinical Pharmacology and Toxicology, Alberta Health Services, Calgary, AB, Canada

    Mark Yarema

  3. Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada

    Mark Yarema & Puja Chopra

  4. Departments of Emergency Medicine, and of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada

    Marco L. A. Sivilotti

  5. Ontario Poison Centre, Toronto, ON, Canada

    Marco L. A. Sivilotti & Margaret Thompson

  6. Department of Pediatrics, University of Calgary, Calgary, AB, Canada

    David Johnson & Alberto Nettel-Aguirre

  7. Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada

    Alberto Nettel-Aguirre

  8. Alberta Children’s Hospital Research Institute for Child and Maternal Health, Calgary, AB, Canada

    Alberto Nettel-Aguirre

  9. Division of Emergency Medicine, Department of Pediatrics, CHU Sainte Justine, Montréal, Quebec, Canada

    Benoit Bailey

  10. Prairie Regional Research Data Centre, Statistics Canada, Calgary, AB, Canada

    Charlemaigne Victorino

  11. Centre Antipoison du Québec, Québec City, Québec, Canada

    Sophie Gosselin

  12. Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada

    Roy Purssell

  13. Department of Emergency Medicine, Oregon Health Sciences University, Portland, OR, USA

    Daniel Spyker

  14. Department of Pediatrics, University of Colorado School of Medicine, Denver, CO, USA

    Barry Rumack

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  1. Mark Yarema
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  3. Marco L. A. Sivilotti
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  6. Benoit Bailey
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  8. Sophie Gosselin
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Correspondence to Mark Yarema.

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The authors declare that they have no conflicts of interest.

Additional information

The original version of this article was revised: Table 4 in PDF version of this article has been corrected since the original publication of the article because the first column of numbers (under the heading “Female”) in the original PDF version was typeset poorly so that the numbers could not be correctly interpreted.

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Yarema, M., Chopra, P., Sivilotti, M.L.A. et al. Anaphylactoid Reactions to Intravenous N-Acetylcysteine during Treatment for Acetaminophen Poisoning. J. Med. Toxicol. 14, 120–127 (2018). https://doi.org/10.1007/s13181-018-0653-9

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  • DOI: https://doi.org/10.1007/s13181-018-0653-9

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