{
    "abstract": "Worldwide, paracetamol poisoning is a common cause of acute liver failure and referral to transplant centers. Acetylcysteine has long been the mainstay of treatment, but recent literature suggests that a simplification of the \"three-bag\" method may decrease adverse effects. Our primary hypothesis is that a simplified dosing regimen (two-bag regimen) is non-inferior to the three-bag method in preventing liver injury. Our secondary hypothesis is that a simplified regimen will have lower rates of adverse effects.\nFollowing Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched Medline/PubMed, Google, Google Scholar, Cochrane Library, Embase and Toxnet on May 23, 2022. The Medical Subject Headings terms were NAC, acetaminophen toxicity, acetyl-cysteine, N-acetylcysteine, paracetamol, APAP, 2-bag, and 3-bag. The Embase terms were acetylcysteine, NAC, 2-bag, two bag, 3-bag, three bag, simplified dosing, acetaminophen, Tylenol\nOur search resulted in 657 total citations, which were reduced to unique citations. Of the 643 studies, 46 met the criteria for full text review, and eight met the study criteria. Of the eight studies investigating a simplified acetylcysteine regimen, four studies utilized some form of a modified two-bag infusion regimen, varying in duration or dosing of infusions, and four studies shared the same \"common\" two-bag treatment, a regimen that delivers acetylcysteine 200\u2009mg/kg over 4\u2009h, followed by 100\u2009mg/kg acetylcysteine over 16\u2009h. The six studies comparing a two-bag dosing regimen to the three-bag technique were utilized for our random effect model meta-analysis. We found no significant heterogeneity amongst the six studies for either hepatotoxicity (\nThe two-bag method is a safe and effective treatment for acute paracetamol poisoning. The two-bag regimen is correlated with a significant reduction in non-allergic anaphylactoid reactions, compared to the three-bag method, and is non-inferior with respect to hepatotoxicity. While we feel this information is practice changing for many, further research in the form of a randomized control trial would be beneficial to compare even more abbreviated methods such as a \"single bag method.\"\nTwo-bag acetylcysteine dosing regimens appear to be non-inferior to the three-bag method with respect to hepatotoxicity, and result in fewer anaphylactoid, cutaneous, and gastrointestinal reactions.",
    "authors": [
        {
            "affiliation": "Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA.",
            "firstname": "Larissa",
            "initials": "L",
            "lastname": "Nakatsu"
        },
        {
            "affiliation": "EMS Academy, University of New Mexico School of Medicine, Albuquerque, NM, USA.",
            "firstname": "Josh R",
            "initials": "JR",
            "lastname": "Lopez"
        },
        {
            "affiliation": "Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA.",
            "firstname": "Christian Mateo",
            "initials": "CM",
            "lastname": "Garcia"
        },
        {
            "affiliation": "Department of Emergency Medicine, Carle Foundation Hospital, Urbana, IL, USA.",
            "firstname": "Mathew",
            "initials": "M",
            "lastname": "Cherian"
        },
        {
            "affiliation": "Health Sciences Library and Informatics Center, University of New Mexico, Albuquerque, NM, USA.",
            "firstname": "Jacob",
            "initials": "J",
            "lastname": "Nash"
        },
        {
            "affiliation": "Department of Psychology, University of New Mexico, Albuquerque, NM, USA.",
            "firstname": "Davood",
            "initials": "D",
            "lastname": "Tofighi"
        },
        {
            "affiliation": "Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA.\nNew Mexico Poison and Drug Information Center, Albuquerque, NM, USA.",
            "firstname": "Steven A",
            "initials": "SA",
            "lastname": "Seifert"
        },
        {
            "affiliation": "New Mexico Poison and Drug Information Center, Albuquerque, NM, USA.",
            "firstname": "Susan",
            "initials": "S",
            "lastname": "Smolinske"
        },
        {
            "affiliation": "Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA.",
            "firstname": "Brandon J",
            "initials": "BJ",
            "lastname": "Warrick"
        }
    ],
    "conclusions": "Two-bag acetylcysteine dosing regimens appear to be non-inferior to the three-bag method with respect to hepatotoxicity, and result in fewer anaphylactoid, cutaneous, and gastrointestinal reactions.",
    "copyrights": null,
    "doi": "10.1080/15563650.2025.2456116",
    "journal": "Clinical toxicology (Philadelphia, Pa.)",
    "keywords": [
        "Acetaminophen",
        "acetylcysteine",
        "anaphylactoid",
        "hepatotoxicity",
        "meta-analysis",
        "overdose",
        "paracetamol systematic review",
        "three-bag method",
        "toxicity",
        "two-bag method"
    ],
    "methods": null,
    "publication_date": "2025-02-27",
    "pubmed_id": "40013897",
    "results": "Our search resulted in 657 total citations, which were reduced to unique citations. Of the 643 studies, 46 met the criteria for full text review, and eight met the study criteria. Of the eight studies investigating a simplified acetylcysteine regimen, four studies utilized some form of a modified two-bag infusion regimen, varying in duration or dosing of infusions, and four studies shared the same \"common\" two-bag treatment, a regimen that delivers acetylcysteine 200\u2009mg/kg over 4\u2009h, followed by 100\u2009mg/kg acetylcysteine over 16\u2009h. The six studies comparing a two-bag dosing regimen to the three-bag technique were utilized for our random effect model meta-analysis. We found no significant heterogeneity amongst the six studies for either hepatotoxicity (",
    "title": "Comparison of two-bag and three-bag acetylcysteine regimens in the treatment of paracetamol poisoning: a systematic review and meta-analysis.",
    "xml": "<Element 'PubmedArticle' at 0x7885055745e0>"
}