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Fomepizole Treats Ethylene Glycol Poisoning

Ethylene glycol poisoning can result in metabolic acidosis, renal failure, hypocalcemia, and oxaluria, as well as neurologic and cardiovascular toxicity. Traditional treatment is with ethanol, which preferentially occupies alcohol dehydrogenase, the enzyme that breaks down ethylene glycol into toxic metabolites. Fomepizole (4-methylpyrazole) also inhibits alcohol dehydrogenase but does not appear to have the side effects or unpredictability of ethanol.

In this industry-supported study, 19 patients with plasma ethylene glycol levels at or above 20 mg/dl were treated with IV fomepizole. The drug was given in a loading dose of 15 mg/kg, then at 10 mg/kg every 12 hours for 48 hours, followed by 15 mg/kg every 12 hours until plasma ethylene glycol levels dropped below 20 mg/dl. Seventeen patients with plasma ethylene glycol levels above 50 mg/dl also underwent hemodialysis. None of the 18 survivors had neurologic injury. The one fatality was a patient with concomitant MI and cardiogenic shock. In the 15 patients who initially had acidosis, acid-base normalization began within hours after fomepizole treatment. All nine patients with initially high serum creatinine levels had worsening of their renal function, but the 10 patients with initially normal levels never developed renal dysfunction.

Comment: Fomepizole appears to be safe and effective for ethylene glycol poisoning, but a prospective, randomized trial is needed. Ethical considerations may make such a trial difficult to conduct, but this report is not sufficient to make fomepizole the standard of care.

— JG Adams

Published in Journal Watch Emergency Medicine April 1, 1999

Citation(s):

Brent J et al. Fomepizole for the treatment of ethylene glycol poisoning. N Engl J Med 1999 Mar 18 340 832-838.

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