N‐acetylcysteine for non‐paracetamol drug‐induced liver injury: a systematic review

Aims N‐acetylcysteine (NAC) may be useful in the management of non‐paracetamol drug‐induced liver injury (DILI). Our objective was to review systematically evidence for the use of NAC as a therapeutic option for non‐paracetamol DILI. Methods We searched for randomized controlled trials (RCTs) and prospective cohort studies. We searched several bibliographic databases, grey literature sources, conference proceedings and ongoing trials. Our pre‐specified primary outcomes were all cause and DILI related mortality, time to normalization of liver biochemistry and adverse events. Secondary outcomes were proportion receiving liver transplant, time to transplantation, transplant‐free survival and hospitalization duration. Results We identified one RCT of NAC vs. placebo in patients with non‐paracetamol acute liver failure. There was no difference in the primary outcomes of overall survival at 3 weeks between NAC [70%, 95% confidence interval (CI) = 60%, 81%, n = 81] and placebo (66%, 95% CI = 56%, 77%, n = 92). NAC significantly improved the secondary outcomes of transplant‐free survival compared with placebo: 40% NAC (95% CI = 28%, 51%) vs. 27% placebo (95% CI = 18%, 37%). A subgroup analysis according to aetiology found improved transplant‐free survival in patients with non‐paracetamol DILI, NAC (58%, n = 19) vs. placebo (27%, n = 26), odds ratio (OR) 0.27 (95% CI = 0.076, 0.942). Overall survival was similar, NAC (79%) vs. placebo (65%);, OR 0.50 (95% CI = 0.13, 1.98). Conclusion Current available evidence is limited and does not allow for any firm conclusions to be made regarding the role of NAC in non‐paracetamol DILI. We therefore highlight the need for further research in this area.