The role of NAD(P)H:quinone reductase (QR; EC 1.6.99.2) in the alcohol-derived protective effect against hepatotoxicity caused by acetaminophen (APAP) was studied. In mice pretreated with dicoumarol (30 mg/kg), an inhibitor of QR, hepatic necrosis caused by APAP (400 mg/kg) was potentiated. Hepatocellular injuries induced by APAP, as assessed by liver histology, serum aminotransferase activities, hepatic glutathione (reduced and oxidized) contents, and liver microsomal aminopyrine N-demethylase activities, all were potentiated by pretreatment of mice with dicoumarol. Even in mice given APAP and ethanol (4 g/kg), in which APAP-inducible hepatic necrosis was abolished, the dicoumarol pretreatment again produced moderate hepatotoxicity and reversed the protective effect of ethanol. In mice pretreated with dicoumarol and ethanol, levels of APAP in blood and bile fluid between 90 and 240 min were higher than those in mice given ethanol. However, the biliary contents of sulfate and glucuronide conjugates of APAP were much lower than those in the ethanol group, particularly at early time points. In contrast, the biliary level of APAP-cysteine conjugate, which in the ethanol group was at its basal level, was increased maximally in the dicoumarol-pretreated mice. In the mice given dicoumarol and ethanol, the biliary APAP-cysteine conjugate level was increased moderately. These results suggest that ethanol inhibited not only the microsomal (CYP2E1 mediated) formation of a toxic quinone metabolite from APAP, but also accelerated the conversion of the toxic quinone metabolite produced back to APAP by stimulating cytoplasmic QR activity. In the presence of dicoumarol, however, QR activity was inhibited, and conversion of the toxic quinone metabolite back to APAP became inhibited and diminished the alcohol-dependent protective effect against APAP-induced hepatic injury.