Quantitative Analysis of Small Molecular Weight Thiols and Disulfides in Blood from a Sickle Cell Disease Patient Infused with N-Acetyl-L-Cysteine

N-acetyl-L-cysteine (NAC) is an FDA approved drug used to treat acetaminophen overdose or as a mucolytic agent in respiratory disorders. The commonly accepted mechanism of action is that NAC undergoes deacetylation to cysteine, which is then used to synthesize glutathione (GSH), a major intracellular antioxidant. Like other thiol-containing compounds, NAC can also act as a reducing agent to break protein disulfide bonds or as a scavenger of reactive oxygen species. Due to its antioxidant properties, NAC has been proposed as a potential treatment for many diseases associated with oxidative stress, including sickle cell disease (SCD), neurological disorders, infectious diseases, and cancers. Though NAC has been widely studied, a full understanding of the mechanism by which NAC is effective in vivo has been limited by challenges in accurately quantifying NAC and its metabolites.

As part of a clinical trial of NAC therapy in SCD, we have developed a liquid chromatography-mass spectrometry (LC-MS) based assay to quantify small molecule free thiols and disulfides using isotopically labeled internal standards. We applied this method to quantify small molecular thiols and disulfides in whole blood, red blood cells, and plasma from a SCD patient before (pre) and at 1, 8, 24 and 72 hr time points of intravenous administration of NAC at a dose of 300 mg/kg (a bolus infusion of 150 mg/kg for 1 hour followed by 150 mg/kg given over the next 7 hr). The cysteine concentration in whole blood increased to 286 μM at 1 hr from 97 μM at baseline, indicating that NAC is indeed rapidly metabolized (deacetylated) to cysteine. Interestingly, although cysteine concentration in RBCs increased over 4 fold at 1 hr and remained high compared to baseline, the highest concentration of total GSH in blood was observed at 24 hr (743 μM compared to 494 μM at baseline). Intracellular availability of cysteine is known as a rate-limiting step for GSH synthesis, and the delayed accumulation of GSH may suggest that NAC is involved in the extracellular deficit of reducing equivalents before it serves as a substrate in GSH synthesis.

To explore this possibility, we quantitated NAC and its oxidation products, homo- and mixed disulfides. We found that total NAC concentration reached 1.58 mM in whole blood at 1 hr, but 44% of NAC was oxidized to N-acetyl-cystine (NAC-ss) or formed mixed disulfides with GSH (GS-ss-NAC) and Cys (Cys-ss-NAC), whereas the NAC used for infusion contained less than 0.5% in the oxidized form (NAC-ss). Concurrent with the formation of NAC disulfides, the levels of oxidized GSH (GSSG, GS-ss-Cys) and cysteine (cystine) were significantly decreased. These observations suggest that NAC administration of SCD not only increases GSH levels by raising the cysteine concentration, but also directly functions as an antioxidant to reduce oxidative stress. SCD patients are known to have low levels of GSH and frequently experience oxidative stress. NAC treatment is likely to address both issues. We plan to analyze the effects of NAC on blood small molecule thiol concentrations in several more SCD patients.