Medication Summary

If ethylene glycol poisoning is suspected, begin antidotal therapy empirically while awaiting confirmation. Antidotes are fomepizole and ethanol. B-vitamin therapy may be used as an adjunct to antidotal therapy.

Fomepizole (Antizol)

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Antidote with better safety profile than ethanol. Easier to dose and administer. In contrast to ethanol, fomepizole levels do not need to be monitored during therapy. The biggest drawback is the cost of the antidote; however, compare the additional expenses of fomepizole with the high degree of required vigilance, need for intensive care unit monitoring, occasional treatment failure, and complications seen with ethanol.

Begin fomepizole treatment immediately upon suspicion of ethylene glycol ingestion based on patient history or anion gap metabolic acidosis, increased osmolar gap, oxalate crystals in urine, or documented serum methanol level.

Ethanol

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Goal is to maintain blood ethanol concentrations at 100-150 mg/dL. This completely saturates alcohol dehydrogenase (ADH). May be administered PO or IV, but IV is preferred if available. Measuring initial blood concentration is important; if >100 mg/dL, loading dose may be unnecessary and patient can be started on maintenance dose.

Frequent monitoring of blood ethanol concentrations is important, with adjustment of the infusion rate to maintain the serum concentration in the therapeutic range.

Class Summary

Pyridoxine enhances metabolism of glyoxylate to glycine. Thiamine catalyzes metabolism of glyoxylate from glycolic acid. Vitamin therapy is a safe and reasonable adjunct in patients with ethylene glycol poisoning. Regional poison centers may suggest the use of these therapies in certain cases.

Pyridoxine (Nestrex)

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Water-soluble vitamin B6, which is a cofactor in conversion of GA to nonoxalate compounds. Involved in synthesis of GABA within CNS.

Thiamine (Thiamilate)

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Vitamin B-1 is water-soluble and used in many cellular functions that involve energy formation and use. Promotes conversion of glyoxylate to a nontoxic metabolite, alpha-hydroxy-beta-ketoadipate.

Questions

[Guideline] Agency for Toxic Substances and Disease Registry. Medical Management Guidelines for Ethylene Glycol. ATSDR. Available at https://wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx?mmgid=82&toxid=21. October 21, 2014; Accessed: October 10, 2021.
Hodgman M, Marraffa JM, Wojcik S, Grant W. Serum Calcium Concentration in Ethylene Glycol Poisoning. J Med Toxicol. 2017 Jun. 13 (2):153-157. [QxMD MEDLINE Link].
Brent J, McMartin K, Phillips S, Burkhart KK, Donovan JW, Wells M, et al. Fomepizole for the treatment of ethylene glycol poisoning. Methylpyrazole for Toxic Alcohols Study Group. N Engl J Med. 1999 Mar 18. 340 (11):832-8. [QxMD MEDLINE Link].
Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Brooks DE, Dibert KW, et al. 2019 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 37th Annual Report. Clin Toxicol (Phila). 2020 Dec. 58 (12):1360-1541. [QxMD MEDLINE Link]. [Full Text].
Kraut JA, Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management. Clin J Am Soc Nephrol. 2008 Jan. 3 (1):208-25. [QxMD MEDLINE Link]. [Full Text].
Alkahtani S, Sammons H, Choonara I. Epidemics of acute renal failure in children (diethylene glycol toxicity). Arch Dis Child. 2010 Dec. 95 (12):1062-4. [QxMD MEDLINE Link].
Krasowski MD. Educational Case: Ethylene Glycol Poisoning. Acad Pathol. 2020 Jan-Dec. 7:2374289519900330. [QxMD MEDLINE Link]. [Full Text].
Soghoian S, Sinert R, Wiener SW, Hoffman RS. Ethylene glycol toxicity presenting with non-anion gap metabolic acidosis. Basic Clin Pharmacol Toxicol. 2009 Jan. 104 (1):22-6. [QxMD MEDLINE Link]. [Full Text].
LeBlanc C, Murphy N. Should I stay or should I go?: toxic alcohol case in the emergency department. Can Fam Physician. 2009 Jan. 55(1):46-9. [QxMD MEDLINE Link]. [Full Text].
Winter ML, Ellis MD, Snodgrass WR. Urine fluorescence using a Wood's lamp to detect the antifreeze additive sodium fluorescein: a qualitative adjunctive test in suspected ethylene glycol ingestions. Ann Emerg Med. 1990 Jun. 19(6):663-7. [QxMD MEDLINE Link].
Wallace KL, Suchard JR, Curry SC, Reagan C. Diagnostic use of physicians' detection of urine fluorescence in a simulated ingestion of sodium fluorescein-containing antifreeze. Ann Emerg Med. 2001 Jul. 38(1):49-54. [QxMD MEDLINE Link].
Ting SM, Ching I, Nair H, Langman G, Suresh V, Temple RM. Early and late presentations of ethylene glycol poisoning. Am J Kidney Dis. 2009 Jun. 53 (6):1091-7. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Barceloux DG, Krenzelok EP, Olson K, Watson W. American Academy of Clinical Toxicology Practice Guidelines on the Treatment of Ethylene Glycol Poisoning. Ad Hoc Committee. J Toxicol Clin Toxicol. 1999. 37(5):537-60. [QxMD MEDLINE Link].
Lung DD, Kearney TE, Brasiel JA, Olson KR. Predictors of Death and Prolonged Renal Insufficiency in Ethylene Glycol Poisoning. J Intensive Care Med. 2013 Dec 26. [QxMD MEDLINE Link].
Ghannoum M, Hoffman RS, Mowry JB, Lavergne V. Trends in toxic alcohol exposures in the United States from 2000 to 2013: a focus on the use of antidotes and extracorporeal treatments. Semin Dial. 2014 Jul. 27(4):395-401. [QxMD MEDLINE Link].
Corley RA, McMartin KE. Incorporation of therapeutic interventions in physiologically based pharmacokinetic modeling of human clinical case reports of accidental or intentional overdosing with ethylene glycol. Toxicol Sci. May 2005. 85(1):491-501. [QxMD MEDLINE Link]. [Full Text].
Jammalamadaka D, Raissi S. Ethylene glycol, methanol and isopropyl alcohol intoxication. Am J Med Sci. 2010 Mar. 339 (3):276-81. [QxMD MEDLINE Link].
Buchanan JA, Alhelail M, Cetaruk EW, Schaeffer TH, Palmer RB, Kulig K, et al. Massive ethylene glycol ingestion treated with fomepizole alone-a viable therapeutic option. J Med Toxicol. 2010 Jun. 6(2):131-4. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Oxalate crystals. Courtesy of John D Schaldenbrand, MD, Department of Pathology, St Joseph Mercy Health System, Ann Arbor, MI.
Ethylene glycol.

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Author

Daniel C Keyes, MD, MPH Associate Chair, Academic Affairs, Department of Emergency Medicine, St Joseph Mercy Hospital; Clinical Faculty, Emergency Medicine Residency, University of Michigan Medical School; Clinical Associate Professor, Department of Surgery, Division of Emergency Medicine and Toxicology, University of Texas Southwestern School of Medicine

Daniel C Keyes, MD, MPH is a member of the following medical societies: American Association of Poison Control Centers, American College of Emergency Physicians, American College of Medical Toxicology, American College of Physician Executives, American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

John T Hirsch, DO Resident Physician, Department of Emergency Medicine, St Mary Mercy Hospital

John T Hirsch, DO is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Ali Haidous Clinical Research Lead, Emergency Medicine Research Associate Program, St Mary Mercy Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT Associate Clinical Professor, Department of Surgery/Emergency Medicine and Toxicology, University of Texas School of Medicine at San Antonio; Medical and Managing Director, South Texas Poison Center

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, Texas Medical Association, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Abid A Kagalwalla, MD Resident Physician, Department of Emergency Medicine, St Joseph Mercy Hospital, University of Michigan Health System

Abid A Kagalwalla, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.