Main pathways of<unk>  metabolism (click to enlarge). The pathway leading to NAPQI is shown in red. When taken in normal therapeutic doses,<unk>  has been shown to be safe. Following a therapeutic dose, it is mostly converted to nontoxic metabolites via Phase II metabolism by conjugation with sulfate and glucuronide, with a small portion being oxidized via the cytochrome P450 enzyme system. Cytochromes and 3A4 convert approximately 5% of<unk>  to a highly reactive intermediary metabolite, N-acetyl-p-benzoquinone imine (NAPQI). Under normal conditions, NAPQI is detoxified by conjugation with glutathione to form cysteine and mercapturic acid conjugates. In cases of<unk>  overdose, the sulfate and glucuronide pathways become saturated, and more<unk>  is shunted to the cytochrome P450 system to produce NAPQI. As a result, hepatocellular supplies of glutathione become depleted, as the demand for glutathione is higher than its regeneration. NAPQI therefore remains in its toxic form in the liver and reacts with cellular membrane molecules, resulting in widespread hepatocyte damage and death, leading to acute liver necrosis. In animal studies, the liver's stores of glutathione must be depleted to less than 70% of normal levels before liver toxicity occurs.
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