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Acetaminophen-related ALF was the most common etiology Return to top The physiology of acetaminophen overdose 2 Acetaminophen Metabolism Acetaminophen is metabolized through 3 different pathways: 42% to 67% undergoes glucuronidation and is excreted in urine 26% to 36% undergoes sulfation and is excreted in urine 5% to 8% passes through the cytochrome P-450 pathway producing a potentially hepatotoxic metabolite, N-acetyl-p-benzoquinone imine (NAPQI) In normal dosing, NAPQI is conjugated with the antioxidant, glutathione, and excreted in urine Return to top Mechanism of Action Overdose depletes the available glutathione and unbound NAPQI destroys liver cells