In acute OD acidosis and elevated INR can precede transaminitis
At very high levels acts as mitochondrial poison and inhibits oxidative phosphorylation -> acidosis – this problem not solved by NAC
Workup
Might need 10 hr level for extended release formulations
Treatment
Activated charcoal
No benefit of NAC prior to 4 hrs, probably doesn’t even matter as long as it’s on within 8 hrs of ingestion
Start NAC for:
any level over R-M nomogram
Unknown TOI w/ any detectable APAP or elevated transaminitis
Ingestion of >10g or 200 mg/kg
Can be dialyzed in the case of massive overdose causing mitochondrial poisoning and that is at high risk for death despite NAC
e.g. any level >600-900 and evidence of mitochondrial dysfunction (e.g. elevated lactate and acidosis) or sustained high level and worsening despite NAC