Metabolomic Evaluation of N-Acetyl-p-Benzoquinone Imine Protein Adduct Formation with Therapeutic Acetaminophen Administration: Sex-based Physiologic Differences

J Med Toxicol. 2022 Oct;18(4):297-310. doi: 10.1007/s13181-022-00903-5. Epub 2022 Jun 24.


Background: Acetaminophen (APAP)-associated transaminase elevation, induced by N-acetyl-p-benzoquinone imine (NAPQI) protein adduction, remains an area of research interest. Distinct from known genetic, physiologic, and dosage associations dictating severity of hepatic injury, no known factors predict an absence of protein adduct formation at therapeutic APAP dosing.

Hypothesis: Sex-based physiology is predictive of APAP-induced protein adduct formation and differential metabolite expression at therapeutic doses.

Methods: This retrospective study interrogated serum samples collected for a prior study investigating fluctuations of alanine aminotransferase (ALT) over time with 4G daily APAP dosing for ≥ 16 days in subjects from Denver, Colorado. Subjects were grouped by adduct formation (n = 184) vs no adducts (n = 20). Samples were run on ultra-high-performance liquid chromatography mass spectrometry from study days 0, 7, 16, and 31. Significant metabolite expressions were identified using t-tests with false discovery rate correction (FDR), partial least squares discriminant, and ANOVA simultaneous comparison analyses. Demographic and clinical data were explored using t-tests with FDR (age, weight, BMI, ALT) and Chi-square (sex, ethnicity, race) analyses.

Results: In pre-treatment samples, relative quantitation caprylic acid was expressed ninefold higher and 6-carboxyhexanoate was expressed threefold lower in subjects who did not develop adducts. Lactate had greater expression in the no adducts group (p = 0.001). Using absolute quantitation, glutathione was expressed 2.6-fold greater among no adduct subjects. Odds of males developing NAPQI protein adducts at therapeutic APAP dosing were 5.91 times lower than females (95% CI = 2.3-14.9; p = 0.0001).

Conclusion: Multiple metabolites were differentially expressed based on adduct group and sex. Metabolites were identified unique to adduct development independent of sex. At therapeutic APAP dosing, males were less likely to develop APAP protein adducts. Further research into lipid biosynthesis and metabolism may provide further insight into physiology associated with adduct production.

Keywords: Acetaminophen; Adducts; Hepatotoxicity; Metabolomics; Therapeutic; Tylenol.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Acetaminophen* / administration & dosage
  • Acetaminophen* / pharmacology
  • Adult
  • Alanine Transaminase* / metabolism
  • Analgesics, Non-Narcotic* / administration & dosage
  • Analgesics, Non-Narcotic* / pharmacology
  • Benzoquinones* / metabolism
  • Female
  • Glutathione / metabolism
  • Humans
  • Imines* / metabolism
  • Lactates / metabolism
  • Lipids / biosynthesis
  • Male
  • Metabolome*
  • Retrospective Studies
  • Sex Factors


  • Analgesics, Non-Narcotic
  • Benzoquinones
  • Imines
  • Lactates
  • Lipids
  • Acetaminophen
  • quinone
  • Alanine Transaminase
  • N-acetyl-4-benzoquinoneimine
  • Glutathione