OUTPATIENT N-ACETYLCYSTEINE TREATMENT FOR ACETAMINOPHEN POISONING - AN ETHICAL DILEMMA OR A NEW FINANCIAL MANDATE

The mainstay of treatment for acetaminophen-induced hepatotoxicity, pr oduced by the accumulation of the toxic metabolite N-acetylbenzoquinon eimine, is an enteral 18-dose course of N-acetylcysteine (NAC). Howeve r, absence of characteristic symptomatology is a frequent reason for p remature cessation of NAC and early discharge of the toxic acetaminoph en poisoned patient. We report a series of confirmed acetaminophen poi sonings who were discharged early with NAC and instructions to self-ad minister. All cases of acute acetaminophen poisoning without concomita nt drugs, reported to a certified Regional Poison Information Center f or a 3-mo period of time, were reviewed. Inclusion criteria included p atients who were discharged with orders to complete the course of NAC outside of a hospital, despite toxic serum acetaminophen concentration s. Data parameters evaluated included age, amount taken, symptoms, lab oratory results, treatment, and medical outcome. 131 cases of confirme d toxic acetaminophen poisoning yielded 6 patients who received 4 to 6 doses of NAC during hospitalization, but were discharged to home with the remaining 11-13 doses. Patients' ages ranged from 16-28 y (mean 2 0.0 y). Serum acetaminophen concentrations measured at 4 h post-ingest ion ranged from 171-198 mcg/ml (mean 182 mcg/ml) Follow-up by the cert ified Regional poison Information Center at 1-3 w post-discharge deter mined dosing compliance to be 83%. All 6 patients remained asymptomati c with normal liver function testing. Since health care reform encoura ges practitioners to reconsider established approaches to the delivery of health care, perhaps home delivery of NAC would not only be clinic ally preferred to premature cessation of the antidote, but also offer cost savings. Self-administration of NAC in the home setting may be re presentative of a new era in America's health care delivery system.