The potential for measurements of other markers to improve treatment selection is the subject of further research. This article discusses the issues that need to be elucidated to better target changes in acetylcysteine dose. The optimum management of these patients remains unclear, and one area of uncertainty is the dose and duration of acetylcysteine in various circumstances. While these have proved generally useful, patients still continue to develop hepatic damage after acetaminophen overdose, particularly if they present late after ingestion. Nomograms to predict possible hepatotoxicity based upon time of ingestion of acetaminophen were developed from a relatively arbitrary definition of toxicity as an aspartate aminotransferase/alanine aminotransferase (ALT/AST) greater than 1000 IU/L. This commentary addresses the reasons for this, and the background to choice of dose of acetylcysteine utilized in the oral and IV dosing regimens. Although prospective trials as to efficacy and safety of acetylcysteine were conducted, there were no randomized controlled trials. Acetylcysteine has been utilized successfully in the treatment of acetaminophen overdose since the 1970s.
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