What is the role of Mucomyst (Acetylcysteine) in preventing Contrast-Induced Acute Kidney Injury (AKI)?

From the Guidelines

N-acetylcysteine (Mucomyst) is not recommended for the prevention of Contrast-Induced Acute Kidney Injury (CI-AKI) due to lack of consistent benefit in high-quality studies. The most recent and highest quality evidence, including the Acetylcysteine for Contrast Nephropathy Trial (ACT) 1, has failed to demonstrate a significant reduction in the risk of CI-AKI with N-acetylcysteine. This trial, which randomly assigned 2,308 patients to receive N-acetylcysteine or placebo, found no difference in the incidence of CI-AKI between the two groups.

Key Findings

• The ACT trial found that the incidence of CI-AKI was 12.7% in both the N-acetylcysteine and control groups 1.
• A meta-analysis accompanying the ACT trial found that the benefits of N-acetylcysteine reported in prior studies were confined to trials with a high risk of bias, and that high-quality studies showed no effect of N-acetylcysteine on CI-AKI 1.
• The 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention also recommends against the use of N-acetylcysteine for the prevention of CI-AKI, citing a lack of benefit (Level of Evidence: A) 1.

Recommendations

• Adequate hydration with intravenous normal saline (1-1.5 mL/kg/hr for 6-12 hours before and after contrast) remains the cornerstone of CI-AKI prevention.
• Other effective preventive strategies include using the lowest possible dose of iso-osmolar or low-osmolar contrast media, avoiding nephrotoxic medications before procedures, and identifying high-risk patients (those with pre-existing kidney disease, diabetes, heart failure, or advanced age) who may benefit from additional preventive measures.
• The use of N-acetylcysteine is not supported by high-quality evidence and should not be recommended for routine use in the prevention of CI-AKI.

From the Research

Role of Mucomyst (Acetylcysteine) in Preventing Contrast-Induced Acute Kidney Injury (AKI)

• The role of Mucomyst (Acetylcysteine) in preventing Contrast-Induced Acute Kidney Injury (AKI) is controversial, with some studies suggesting moderate evidence in favor of its use 2, while others have found inconsistent results 3, 4.
• A study published in 2010 recommended the use of high-dose (1200-mg) N-acetylcysteine as a preventive measure for CI-AKI, in addition to hydration with normal saline or sodium bicarbonate 5.
• However, a randomized controlled trial published in 2014 found no evidence that intravenous isotonic saline and either NaHCO3 or else a high dose of NAC prevent CI-AKI in outpatients exposed to high osmolal iodinated contrast medium more than does saline alone 6.
• The current consensus is that hydration, particularly with isotonic saline or bicarbonate solution, remains the most reliable strategy for preventing CI-AKI, while the efficacy of other compounds, including N-acetylcysteine, is still uncertain 2, 3, 4.

Key Findings

• The incidence of CI-AKI can be reduced by implementing preventive measures, such as hydration and careful patient stratification before the administration of contrast media 2.
• The use of N-acetylcysteine, alone or in combination with other compounds, has been evaluated in several studies, but its effectiveness in preventing CI-AKI remains unclear 3, 4, 6.
• Further research is needed to determine the optimal strategies for preventing CI-AKI and to identify reliable markers of acute kidney injury 3, 4.