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If the dose exceeds the recommended daily dose (4 g per day for healthy adults), there is a high possibility for AILI ( 2.2.1 Acetaminophen metabolism When APAP is administered at the therapeutic dose, approximately 85%–90% of APAP is metabolized by phase II conjugating enzymes and excreted in the urine (Yan et al., 2018), of which about 50% is converted to APAP-GLU by UDP-glucuronosyltransferase (UGT) and around 30% is converted to APAP-SUL by sulfotransferase (SULT) (Slitt et al., 2003)
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Also, potential contamination, spoilage, or microbial activity during the fermentation can alter the metabolite profile
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