Ethanol metabolism in heavy drinkers after massive and moderate alcohol intake

The Self-Rated Effects of Alcohol Are Related to Presystemic Metabolism of Alcohol

AIMS

A high number of alcohol units required to feel a subjective effect of alcohol predicts future alcohol use disorders (AUDs). The subjective response to alcohol can be measured using the validated retrospective self-rated effects of alcohol (SRE) questionnaire. Few studies have investigated the specific relationship between SRE and blood alcohol concentration (BAC) in an experimental setting.

METHODS

Twenty healthy young adult male volunteers who had experience with binge drinking, but did not have AUD, filled out the SRE-questionnaire and were served with a fixed amount of alcohol per body weight. BACs were measured throughout a 12-hour period, reaching a maximum BAC of ~0.13%. Median split of SRE-scores was utilized to compare BACs among participants with relatively high effects (low SRE) and relatively low effects (high SRE) of alcohol.

RESULTS

Participants reporting a relatively low SRE-score had a statistically significant higher measured BAC at all time points until alcohol was eliminated. This was especially pronounced during the first 2 hours after alcohol (P = 0.015) without a significant difference in the alcohol elimination rate being detected.

CONCLUSION

The study indicates that a self-ated SRE-score is related to BACs after the ingestion of a standardized amount of alcohol per body weight. Reporting a higher number of alcohol units before feeling an effect was related to a lower BAC. As the differences in BAC between relatively high and low self-rated effects appeared rapidly after intake, this could be interpreted as an effect of presystemic metabolism of alcohol.

The Feasibility, Tolerability, and Safety of Administering a Very High Alcohol Dose to Drinkers with Alcohol Use Disorder

INTRODUCTION

There remains a paucity of research quantifying alcohol's effects in drinkers with alcohol use disorder (AUD), particularly responses to very high alcohol doses (≥0.8 g/kg). As drinkers with AUD frequently engage in very heavy drinking (8 to 10 drinks/occasion), doses of ≤0.8 g/kg may lack ecological validity. The present study examined the feasibility, tolerability, and safety of administering a very high alcohol dose (1.2 g/kg) to non-treatment-seeking AUD participants.

METHODS

Sixty-one young adult AUD drinkers enrolled in the Chicago Social Drinking Project and completed 3 laboratory sessions at which they consumed a beverage with 1.2, 0.8, and 0.0 g/kg alcohol. Physiological responses (vital signs, nausea and vomiting, breath alcohol concentrations [BrAC]) were monitored throughout the sessions. After each session, participants completed a next-day survey of substance use, engagement in risky behaviors, and related consequences.

RESULTS

Overall, the sample demonstrated good compliance with study procedures; 93% of participants adhered to presession alcohol abstinence requirements (indicated by BrAC < 0.003 g/dl), with no participants exhibiting serious alcohol withdrawal symptoms at arrival to study visits. The 1.2 g/kg alcohol dose achieved an expected mean peak BrAC of 0.13 g/dl at 60 minutes after drinking, which was well tolerated; the majority of the sample did not experience nausea (70%) or vomiting (93%), and dose effects on vital signs were not clinically significant. Finally, we demonstrated that the 1.2 g/kg alcohol dose is safe and not associated with postsession consequences, including reduced sleep time, atypical substance use, accidents or injuries, and severe hangovers.

CONCLUSION

Results support the feasibility, tolerability, and safety of administering a very high alcohol dose to young adult drinkers with AUD within the context of a well-validated laboratory alcohol challenge paradigm. Utilizing an alcohol dose more consistent with naturalistic drinking patterns may foster greater ecological validity of laboratory paradigms for persons with moderate to severe AUD.

The Association between Ethanol Elimination Rate and Hangover Severity

Assessments in blood and saliva suggests that the amount of ethanol present in the first hours after alcohol consumption and into the following morning is associated with hangover severity. The current analysis determines how ethanol elimination rate is related to hangover severity reported throughout the day. n = 8 subjects participated in two studies. The first was a naturalistic study comprising an evening of alcohol consumption. Hangover severity was assessed hourly from 10 a.m. to 4 p.m., using a 1-item hangover severity scale ranging from 0 (absent) to 10 (extreme). The second study comprised a highly controlled alcohol challenge to reach a breath alcohol concentration (BrAC) of 0.05%. Breathalyzer tests were conducted every 5 min until BrAC reached zero. The ethanol elimination rate, expressed in BrAC%/hour, was computed by dividing the peak BrAC (%) by the time to BrAC of zero (h). At 11:00, 13:00, and 14:00, there were significant negative partial correlations, controlling for estimated BrAC, between ethanol elimination rate and hangover severity. The findings suggest that drinkers with a faster ethanol elimination rate experience less severe hangovers. The observations should be confirmed in a larger sample of subjects who participate in a single study that assesses both hangover severity and ethanol elimination rate.

Ethanol elimination kinetics following massive ingestion in an ethanol naive child

OBJECTIVE

At low-to-moderate concentrations, ethanol elimination follows zero-order kinetics. It is unknown whether renal, pulmonary or other first-order processes become significant in patients with very high serum ethanol concentrations. Additionally, it is unclear whether ethanol naive subjects induce their metabolism during acute intoxication. We present the toxicokinetic analysis in a child with a massive ingestion of ethanol.

CASE REPORT

A 15-year-old girl without significant medical history presented to the Emergency Department after drinking 24 ounces of tequila. She was found unresponsive at home with a Glasgow Coma Score of 3. Her presenting vitals were as follows: 118/69 mmHg blood pressure; pulse rate was 88 beats per minute; respiratory rate of 20 breaths per minute; pulse-oximetry is 96% on room air. Other than obtundation, her physical examination was normal. She was intubated for airway protection and admitted to the ICU. Her initial serum ethanol concentration was 543 mg/dL. A repeat level 3 h later was 722 mg/dL. Post-absorptive ethanol concentrations decreased from 693 mg/dL to 291 mg/dL over the following 15.5 h. The patient had spontaneous eye opening 24 h after presentation. Her projected serum ethanol concentration at that time was 215 mg/dL. She was extubated 2 h later and had an uneventful recovery.

RESULTS

The elimination of ethanol in the post-absorptive phase remained zero-order at a rate of 26.3 mg/dL/h (5.7 mmol/L/h) with a Pearson's correlation coefficient (R (2)) of 0.9968 (p < 0.01). There was no evidence of acute induction in metabolism although pharmacodynamic tolerance likely occurred.

CONCLUSION

Even at very high ethanol concentrations in ethanol naive subjects, elimination of ethanol follows a zero-order toxicokinetic model.

Population pharmacokinetics and pharmacogenetics of alcohol in Chinese and Indians in Singapore

WHAT IS KNOWN AND OBJECTIVE

  Interindividual variability in alcohol pharmacokinetics is influenced by a number of factors, including polymorphisms in genes mediating alcohol pharmacology, ethnicity, sex and body size. Several studies have evaluated the population pharmacokinetics of alcohol from breath alcohol measures. None of these studies, however, have evaluated ethnicity and alcohol-metabolizing enzyme genotypes as covariates in their population pharmacokinetic modelling. We aimed to develop a population pharmacokinetic model using clinical and genetic factors and to identify covariates that influenced interindividual variability in alcohol clearance and volume of distribution.

METHODS

  Hundred and eighty healthy subjects (90 Chinese and 90 Indians; 45 males and 45 females from each ethnic group) ingested a vodka-orange juice mixture to simulate social drinking. Subjects were genotyped for the ADH1B (Arg48His), ALDH2 (Glu504Lys) and CYP2E1 (c.-1293G>C and c.-1053C>T) polymorphisms. A base pharmacokinetic model was developed using the nonmem software (NONMEM Project Group, University of California, San Francisco, San Francisco, CA, USA) to determine the alcohol clearance and volume of distribution. The model was extended to include covariates that influenced the between-subject variability.

RESULTS AND DISCUSSION

  Body weight and sex significantly influenced absorption rate and volume of distribution of alcohol. Body weight and ADH1B Arg48His polymorphism significantly influenced alcohol clearance. The Michaelis-Menten elimination rate (Vmax ) was decreased by 10% in homozygous ADH1B*1/*1 subjects. Ethnicity was not determined to be a significant covariate in the final population pharmacokinetic model.

WHAT IS NEW AND CONCLUSION

  Gender and body weight were covariates that contributed most to explaining the observed interindividual alcohol pharmacokinetic variability. Of the four SNPs examined in this study, only ADH1B Arg48His polymorphism had a significant, though modest, effect on the pharmacokinetics of alcohol.

Hepatic ethanol elimination kinetics in patients with cirrhosis

OBJECTIVE

To address the question of whether increased ethanol elimination in alcoholics can be ascribed to increased metabolism via alcohol dehydrogenase (ADH; K(m) around 0.2 mM) or the microsomal ethanol-oxidizing system (MEOS; K(m) 10 mM) by kinetic analysis of hepatic ethanol elimination in recently drinking patients with alcoholic cirrhosis and healthy subjects. A further objective was to investigate whether systemic clearance of ethanol at low arterial ethanol concentrations can be used as a measure of hepatic blood flow.

MATERIAL AND METHODS

Six patients with alcoholic cirrhosis were enrolled after 2 days of abstinence, along with 6 healthy subjects. Ethanol was administered as 6 successive infusions in increasing doses. Arterial and hepatic venous blood concentrations of ethanol were measured; hepatic blood flow was measured simultaneously. Kinetic parameters were calculated according to the sinusoidal perfusion model of enzymatic elimination by the intact liver.

RESULTS

Mean hepatic K(m) for ethanol was 0.16 mM (range 0.09-0.36) in healthy subjects and 0.36 mM (range 0.16-0.69) in patients with cirrhosis (p>0.3), both compatible with the K(m) for ADH. The two groups of subjects had similar V(max) values (p>0.3). Extrahepatic elimination of ethanol accounted for more than 50% of total elimination in both groups, which precludes the use of systemic clearance as a measure of hepatic blood flow.

CONCLUSIONS

The results support the hypothesis that ADH remains the main pathway for hepatic elimination of ethanol in recently drinking patients with alcoholic cirrhosis. We interpret this as evidence against a significant contribution of MEOS in vivo.

Interference of ethanol and methylmercury in the developing central nervous system

Studies involving alcohol and its interactions with other neurotoxicants represent the focus of several works of research due to the fact that the use of alcohol can sometimes leads to serious health problems. Fetal exposure to alcohol and mercury has a high incidence in some regions of Brazil, where there are pregnant women who are alcoholics and live in mining areas. This work was conducted to examine the effects of combined exposure to ethanol (EtOH) and methylmercury (MeHg) in rats during the development of the central nervous system (CNS). Experimental behavioral animal models/tests were used in order to examine locomotion, anxiety, depression and memory. Pregnant rats received tap water or EtOH 22.5% w/v (6.5 g/kg per day), by gavage) during pregnancy and breast-feeding. On the 15th day of pregnancy, some groups received 8 mg/kg of MeHg (by gavage). The groups were as follows: control, EtOH, MeHg and EtOH+MeHg. The experimental results showed that the EtOH, MeHg and EtOH+MeHg groups reduced the percentage of frequency and time spent in the open arms entries of the elevated plus-maze (EPM) test, when compared to the control group. This result suggests an anxiogenic behavioral response. The MeHg group increased locomotor activity in the arena and the immobility time in the forced swimming test, suggestive of depression-like behavior. The EtOH+MeHg group showed greater reductions in the percentages of frequency and time spent in the open arms entries in the EPM test, suggesting a sedative-behavior since the frequency of enclosed arm entries was affected. In the inhibitory avoidance task, the EtOH+MeHg group reduced the latency of the step-down response onto the grid floor, suggesting a cognitive and behavior dysfunctions. Taken together, the results suggest that EtOH and/or MeHg intoxication during the developing CNS may be a risk for deficits related to locomotor impairment, anxiety, depression and neurocognitive functions. There is a possibility that EtOH may prevent some of the MeHg responses, but the precise mechanism of action involved in this process needs to be considered for future research.

Ultra-rapid rate of ethanol elimination from blood in drunken drivers with extremely high blood-alcohol concentrations

The rate of alcohol elimination from blood was determined in drunken drivers by taking two blood samples about 1 h apart. These cases were selected because the individuals concerned had reached an extremely high blood-alcohol concentration (BAC) when they were apprehended. This suggests a period of continuous heavy drinking leading to the development of metabolic tolerance. Use of double blood samples to calculate the elimination rate of alcohol from blood is valid provided that drunken drivers are in the post-absorptive phase of the BAC curve, the time between sampling is not too short, and that zero-order elimination kinetics operates. Evidence in support of this came from other drunken drivers in which three consecutive blood samples were obtained at hourly intervals. The mean BAC (N = 21) was 4.05 g/l (range, 2.71-5.18 g/l), and the average rate of alcohol elimination from blood was 0.33 g l(-1) h(-1) with a range of 0.20-0.62 g l(-1) h(-1). The possibility of ultra-rapid rates of ethanol elimination from blood in drunken drivers having extremely high BAC deserves to be considered in forensic casework, e.g., when retrograde extrapolations and other blood-alcohol calculations are made. The mechanism accounting for more rapid metabolism is probably related to induction of the microsomal enzyme (CYP2E1) pathway for ethanol oxidation, as one consequence of continuous heavy drinking. However, the dose of alcohol and the duration of drinking necessary to boost the activity of CYP2E1 enzymes in humans have not been established.

Development of hypoxemia in alcoholic liver disease

The aim of this study was to investigate the arterial hypoxemia in Japanese patients with alcoholic liver disease (ALD) with regard to alcohol consumption and/or disease severity. Hypoxemia was observed in 78% patients with ALD and in all 46 patients with alcoholic liver cirrhosis (ALC) and 33 (56%) of 59 patients with noncirrhotic alcoholic liver disease (NCALD) (P < 0.0001). The partial pressure of oxygen (PaO2) was 71.1 +/- 5.2 mm Hg in ALC and 78.7 +/- 6.3 mm Hg in NCALD (P < 0.0001). The oxygen consumption in ALD was significantly higher than that in control subjects (P < 0.0001), and a high oxygen consumption was seen in 88% of the patients with ALD, in all 46 ALC patients, and in 46 (78%) of 59 NCALD patients (P < 0.01). Following abstinence from alcohol, the PaO2 and oxygen consumption significantly recovered after day 2 (P < 0.0001), whereas the prothrombin index did not change in either NCALD or ALC patients. Multivariate analysis showed that alcohol consumption and oxygen consumption were significant independent predictors of PaO2. In conclusion, the present findings suggest that increased oxygen consumption due to alcohol ingestion is principally responsible for the hypoxemia in ALD patients.

Role of variability in explaining ethanol pharmacokinetics: research and forensic applications

Variability in the rate and extent of absorption, distribution and elimination of ethanol has important ramifications in clinical and legal medicine. The speed of absorption of ethanol from the gut depends on time of day, drinking pattern, dosage form, concentration of ethanol in the beverage, and particularly the fed or fasting state of the individual. During the absorption phase, a concentration gradient exists between the stomach, portal vein and the peripheral venous circulation. First-pass metabolism and bioavailability are difficult to assess because of dose-, time- and flow-dependent kinetics. Ethanol is transported by the bloodstream to all parts of the body. The rate of equilibration is governed by the ratio of blood flow to tissue mass. Arterial and venous concentrations differ as a function of time after drinking. Ethanol has low solubility in lipids and does not bind to plasma proteins, so volume of distribution is closely related to the amount of water in the body, contributing to sex- and age-related differences in disposition. The bulk of ethanol ingested (95-98%) is metabolised and the remainder is excreted in breath, urine and sweat. The rate-limiting step in oxidation is conversion of ethanol into acetaldehyde by cytosolic alcohol dehydrogenase (ADH), which has a low Michaelis-Menten constant (Km) of 0.05-0.1 g/L. Moreover, this enzyme displays polymorphism, which accounts for racial and ethnic variations in pharmacokinetics. When a moderate dose is ingested, zero-order elimination operates for a large part of the blood-concentration time course, since ADH quickly becomes saturated. Another ethanol-metabolising enzyme, cytochrome P450 2E1, has a higher Km (0.5-0.8 g/L) and is also inducible, so that the clearance of ethanol is increased in heavy drinkers. Study design influences variability in blood ethanol pharmacokinetics. Oral or intravenous administration, or fed or fasted state, might require different pharmacokinetic models. Recent work supports the need for multicompartment models to describe the disposition of ethanol instead of the traditional one-compartment model with zero-order elimination. Moreover, appropriate statistical analysis is needed to isolate between- and within-subject components of variation. Samples at low blood ethanol concentrations improve the estimation of parameters and reduce variability. Variability in ethanol pharmacokinetics stems from a combination of both genetic and environmental factors, and also from the nonlinear nature of ethanol disposition, experimental design, subject selection strategy and dose dependency. More work is needed to document variability in ethanol pharmacokinetics in real-world situations.

Acute exposure to the nutritional toxin alcohol reduces brain protein synthesis in vivo

Few studies have measured brain protein synthesis in vivo using reliable methods that consider the precursor pool, and there is a paucity of data on the regional sensitivity of this organ to nutritional or toxic substances. We hypothesized that different areas of the brain will exhibit variations in protein synthesis rates, which might also be expected to show different sensitivities to the nutritional toxin, ethanol. To test this, we dosed male Wistar rats with ethanol (75 mmol/kg body weight) and measured rates of protein synthesis (ie, the fractional rate of protein synthesis, defined as the percentage of the protein pool renewed each day; k(s), %/d) in different brain regions 2.5 hours later with the flooding dose method using L-[4-(3)H] phenylalanine. In the event that some regions were refractory to the deleterious effects of ethanol, we also predosed rats with cyanamide, an aldehyde dehydrogenase inhibitor (ie, cyanamide + ethanol), to increase endogenous acetaldehyde, a potent neurotoxic agent. The results indicated the mean fractional rates of protein synthesis in the cortex was 21.1%/d, which was significantly lower than either brain stem (30.2%/d, P <.025), cerebellum (30.1%/d, P <.01), or midbrain (29.8%, P <.025). Ethanol significantly decreased protein synthesis in the cortex (21%, P < 0.01), cerebellum (19%, P <.025), brain stem (44%, P <.025), but not in the midbrain (not significant [NS]). However, significant reductions in protein synthesis in the midbrain occurred in cyanamide + ethanol-dosed rats (60%, P <.0001). Cyanamide + ethanol treatment also reduced k(s) in the brain stem (66%, P <.001), cortex (59%, P <.001), and cerebellum (55%, P <.001). In conclusion, the applicability of the flooding dose technique to measure protein synthesis in the brain in vivo is demonstrated by its ability to measure regional difference. Impaired protein synthesis rates may contribute to or reflect the pathogenesis of alcohol-induced brain damage.

Relationship between Genetic Polymorphisms of Alcohol-metabolizing Enzymes and Changes in Risk Factors for Coronary Heart Disease Associated with Alcohol Consumption

Background: There are large individual variations in the responses of risk factors for coronary heart disease to alcohol consumption. To clarify the factors responsible for these individual variations, we studied the relationship between blood pressure, serum lipids, and uric acid and the genetic polymorphisms of alcohol dehydrogenase (ADH) 2 and aldehyde dehydrogenase (ALDH) 2 in alcohol drinkers.

Methods: We examined 133 male workers who drank &gt;300 g of alcohol per week. Information regarding lifestyle habits was obtained by questionnaire. The ADH2 genotype was determined by PCR and subsequent digestion with MaeIII. The ALDH2 genotype was determined based on amplified product length polymorphisms.

Results: When the workers were divided into three groups: the ADH21/21, ADH21/22, and ADH22/22 groups, the mean triglycerides and γ-glutamyl transpeptidase concentrations were significantly higher in the ADH22/22 group than in the ADH21/21 group. In addition, multiple logistic regression analysis showed that the frequencies of individuals whose systolic blood pressure, triglycerides, and uric acid values were in the highest one third were significantly higher in the ADH22/22 group than in the ADH21/21 group. In contrast, no difference was observed between the ALDH21/21 and (ALDH21/22 + ALDH22/22) groups with regard to the mean value of any variable and to the frequency of individuals with any variable value in the highest one third.

Conclusion: Individuals with the ADH21/21 genotype might suffer fewer negative effects of drinking.

Cardioprotective effect of propranolol from alcohol-induced heart muscle damage as assessed by plasma cardiac troponin-t

BACKGROUND

Heavy alcohol consumption from either long-term misuse or binge drinking is associated with poor cardiac contractility, mitochondrial dysfunction, and ventricular arrhythmias. The aim of this study was to measure circulating cardiac troponin-T as a marker for myocardial damage following acute and chronic alcohol administration.

METHODS

In acute studies, male Wistar rats were treated with alcohol (75 mmol/kg body weight, intraperitoneal) and plasma was collected 2.5 hr after alcohol administration for analysis of rat cardiac troponin-T. In addition, rats were pretreated with cyanamide (an inhibitor of acetaldehyde dehydrogenase), various beta-blockers, xanthine oxidase inhibitors, or lisinopril before acute alcohol dosing. In chronic studies, rats were fed alcohol (as 35% of total dietary calories) for 6 weeks.

RESULTS

The results of the time course study showed that acute alcohol administration significantly raised plasma cardiac troponin-T levels after 2.5 hr and 6 hr, but not after 24 hr. The effects of alcohol on cardiac troponin-T were potentiated with cyanamide pretreatment. Acute ethanol, alone or with cyanamide pretreatment, decreased systolic blood pressure and increased heart rates. Beta-blocker pretreatment with propranolol reduced the alcohol-induced increase in plasma troponin-T, whereas lisinopril potentiated this effect. The beta-blockers, atenolol and metoprolol, and the xanthine oxidase inhibitors, allopurinol and oxypurinol, were unable to reduce elevated troponin-T. However, pretreatment with the beta-blocker timolol moderated the acute alcohol-induced increase in troponin-T. In the chronic alcohol rat model, no differences were observed between alcohol and control pair-fed rats, suggesting the inducement of tolerance.

CONCLUSIONS

In conditions of acute exposure, ethanol-induced lesions are characterized by raised plasma cardiac troponin-T possibly due to beta1 and/or beta2 adrenergic activation.

Ethanol metabolism in patients with liver cirrhosis

Aspects of human metabolism of ethanol are reviewed with the main focus on the rate of ethanol clearance from blood in patients suffering from liver cirrhosis. Studies in humans and experimental animals do not support the notion of a slower rate of ethanol metabolism in patients with liver cirrhosis compared with those with normal liver function. The rate of ethanol disappearance from blood in healthy non-alcoholic subjects falls within the range 9-20 mg/dL/h and there is no compelling evidence to suggest that this should be much different in cirrhotic patients.

Molecular biological aspects of alcohol-induced liver disease

Molecular biological investigations have become a predominant methodology applied to the study of alcohol-induced liver disease. The enzymatic pathways responsible for ethanol metabolism, and their genetic as well as environmental control, have become the focus of detailed investigation. More recently, the significance of cytokines in the pathogenesis of alcohol-induced liver disease has also become a major area of speculation. This review focuses on the advances made in studies of two important enzymes responsible for alcohol metabolism, alcohol dehydrogenase and aldehyde dehydrogenase, as well as the investigation of the proinflammatory and profibrogenic cytokines involved in the process of hepatic fibrogenesis. The quality and quantity of new discoveries made in the field of alcohol-induced liver disease is impressive, especially when one realizes that molecular biological approaches have been employed in this area for only 15 years. However, in most cases the studies have been predominantly descriptive, with little direct relevance to the therapeutics of alcoholism and alcohol-induced organ injury. Because the groundwork has been laid, one hopes that the next 15 years will rectify this failure.

Alcohol consumption and alcohol pharmacokinetics: interactions within the normal population

We have analyzed the interrelationships between habitual alcohol consumption, peak blood alcohol concentration after a standard dose, and rate of alcohol metabolism in a group of 199 male and 213 female twins. Both peak concentration and rate of metabolism are strongly associated with alcohol consumption levels, even in the range of 0-10 g of alcohol/day. The peak concentration and rate of metabolism were strongly correlated in both men and women; this is not due to their common dependence on alcohol intake nor to experimental error. These results show that the threshold for effects of habitual consumption on alcohol pharmacokinetics is much lower than previously suspected, and that there are factors that reduce preabsorptive or first-pass metabolism but increase postabsorptive metabolism.

The NMDA receptor antagonist dizocilpine differentially affects environment-dependent and environment-independent ethanol tolerance

Antagonists of the N-methyl-D-aspartate subtype of glutamate receptor have been reported to block the development of tolerance to various effects of ethanol and opiates, using paradigms in which tolerance is believed to be governed by learning. There is considerable evidence to implicate the N-methyl-D-aspartate receptor in learning processes, and therefore the ability of the antagonists to block tolerance has been attributed to their effects on learning. To evaluate this hypothesis, we compared, in C57BL/6 mice, the effect of the uncompetitive N-methyl-D-aspartate receptor antagonist, dizocilpine, on environment-dependent (associative) tolerance to ethanol, which is governed by learning, and on environment-independent (nonassociative) ethanol tolerance, in which learning plays a minimal role. Environment-dependent tolerance was induced by repeated ethanol injections, and dizocilpine blocked the development of this type of tolerance to the hypothermic and incoordinating effects of ethanol. In contrast, when environment-independent ethanol tolerance was induced by feeding the mice an ethanol-containing liquid diet, dizocilpine treatment had no effect on the development of tolerance to the hypothermic, incoordinating or hypnotic effects of ethanol. The results support the hypothesis that the effect of N-methyl-D-aspartate receptor antagonists on ethanol tolerance reflects the more general role of this receptor in processes involving learning and memory.

Rate of clearance of ethanol from the blood of intoxicated patients in the emergency department

One hundred and three patients presenting to the Mt. Sinai Medical Center emergency department (ED), who appeared on clinical grounds to be acutely intoxicated, were studied to determine the rate of clearance of ethanol from blood. The mean presenting serum ethanol level was 299 mg/dL. The rate of clearance was found to be 20.43 mg/dL/h with a standard deviation of 6.86 mg/dL/h. No correlation was found between rate of ethanol clearance and serum levels of amylase, alkaline phosphatase, glutamate-oxaloacetate or glutamate-pyruvate transaminase, lactic dehydrogenase, or total bilirubin. Similarly, no correlation was found between rate of clearance and race, sex, age, or time of day. We conclude that although the average patient presenting to the emergency department will clear ethanol at about 20 mg/dL/h, a standard deviation of 6 mg/dL/h means that only 83% of these patients will have clearance rates between 8 and 32 mg/dL/h, and that if accurate estimates are necessary, serial determinations of two or more levels are needed.

A new approach to the determination of ethanol elimination rate in vivo: an extension of Widmark's equation

In order to provide more experimental data about a single ethanol elimination sequence, tracer amounts of 14C-labelled ethanol were given intravenously in fed and fasted rats into a preexisting pool of unlabelled ethanol. The profiles of the elimination curves of 14C-labelled ethanol were distinctly different from those of unlabelled ethanol. This necessitated the elaboration of a mathematical model based on a two-compartment system, which by using the early distribution phase of the 14C-labelled ethanol and the linear part of the elimination curve of unlabelled ethanol enables the determination of the time-rate constants for distribution of ethanol, K12 and K21 and ethanol elimination rate Q. It is shown that the ratio K21'/(K21' + K12') is "r", the distribution volume of ethanol in the sense of Widmark, K12' is K12 divided with Va (initial distribution space of ethanol) and K21' is K21 divided with Vb (the peripheral compartment). The mean value +/- S.E.M. is 0.57 +/- 0.05 for fed rats and 0.49 +/- 0.03 for fasted. The slope of the time-concentration curve of ethanol, Widmark's beta, is shown to be K12'/(K12' x K21') x Q where Q is ethanol elimination rate. The mean elimination rate is 0.303 +/- 0.036 mmol x l-1 x min-1 in fed rats and 0.219 +/- 0.015 mmol x l-1 x min.-1 in fasted (P less than 0.05). It is concluded that we are now able to extend Widmark's equation by an independent determination of the distribution factor "r".

Disappearance rate of alcohol from the blood of drunk drivers calculated from two consecutive samples; what do the results really mean?

Based on a large material (N = 2354) of double blood specimens from drunk drivers apprehended in The Netherlands, we selected 1314 cases for further evaluation. The difference BAC2-BAC1 was used as index of alcohol elimination rate from the blood. The results ranged from below 0.10 to 0.64 mg/ml/h, with a mean of 0.22 mg/ml/h. At least about 2% of drivers were still absorbing alcohol as indicated by a rising BAC. Some likely mechanisms are discussed that might account for the wide range of alcohol elimination rates observed.

Comparative study on ethanol elimination and blood acetaldehyde between alcoholics and control subjects

Factors influencing ethanol elimination rate and blood acetaldehyde concentration with regard to age, blood ethanol concentration, and degrees of alcoholic liver disorder were studied in alcoholic patients vis-à-vis healthy subjects. Ninety-four male alcoholic patients were divided into five groups according to age and into three groups according to blood ethanol concentration which ranged between 4.21 and 0.29 mg/ml. It was noted that as age increased, blood ethanol concentration decreased. Groups A, B, and C consisted of subjects whose ethanol levels were more than 2.5, between 1.0 and 2.5, and less than 1.0 mg/ml, respectively. Average values of ethanol elimination rate in Groups A, B, and C were 0.26, 0.23, and 0.18 mg/ml/hr, respectively. The rate increased as blood ethanol concentration elevated. The rate in Group B was significantly higher than that in the healthy control subjects who had blood ethanol levels between 1.0 and 2.5 mg/ml. The rate of ethanol elimination was independent of liver disorder judged by liver function test values. Blood acetaldehyde concentrations in the patients were less than 1.48 micrograms/ml, with an average value of 0.58 microgram/ml, and were significantly correlated with blood ethanol levels in both alcoholics and healthy subjects.

Ethanol elimination-rates determined by breath analysis as a marker of recent excessive ethanol consumption

The rate of ethanol elimination was studied in two groups of men by means of an Alcotest 7010 breath analyser. The experimental group consisted of 15 skid-row alcoholics undergoing detoxification. Their median daily ethanol consumption was 211 (range 26-476) g pure ethanol during the last year. The control group was made up of 12 age-matched healthy social drinkers consuming 9 (range 4-23) g day-1 pure ethanol during the last year. The median ethanol elimination-rate in the elimination phase was 0.25 (range 0.13-0.31) g 1-1 h-1 during the detoxification period in the experimental group. This value was approximately 70% higher than in the control group (0.14(0.12-0.17) g 1-1 h-1). Some correlation was found between reported ethanol intake, and the calculated ethanol elimination-rate, as well as gamma glutamyl transferase (GGT), alanine amino transferase (ALAT), aspartate amino transferase (ASAT), glutamate dehydrogenase (GLDH), mean corpuscular volume (MCV) and HDL-cholesterol. Of these measures, ethanol elimination-rate showed highest sensitivity and efficiency for detection of ethanol consumption above the limit of 50 g per day.

Severe alcohol intoxication: a study of 204 consecutive patients

We report a five month retrospective analysis of 204 consecutive patients seen in an adult medical emergency department with blood alcohol concentrations (BAC) in excess of 400 mg/dl. The average BAC was 467 mg/dl with a range of 400-719 mg/dl. In 153 patients (75%) the BAC was 400-500 mg/dl, in 47 patients (23%) the BAC was 500-600 mg/dl and in 4 patients (2%) the BAC was greater than 600 mg/dl. Eighty-eight percent of the patients were oriented to person, place, and time upon questioning, 12% were disoriented or unresponsive to noxious stimuli. None of the four patients whose BAC was greater than 600 mg/dl were initially alert and oriented and only eight of the unresponsive patients had a BAC below 500 mg/dl (p less than .001). Sixteen patients (8%) were admitted. Three of the admissions were for continued unresponsiveness presumed due to ethanol, the other thirteen were for coexistent medical conditions. There were no significant associations between BAC and vital sign abnormalities.

Mechanism and regulation of ethanol elimination in humans: intermolecular hydrogen transfer and oxidoreduction in vivo

Ethanol metabolism was studied in four healthy volunteers by intravenous infusion of a mixture of [1,1-2H2]ethanol (1.0 mmol/kg) and [2,2,2-2H3]ethanol (1.0 mmol/kg) followed by blood sampling at 10-min intervals. The concentrations of ethanols labeled with 1, 2, 3, and 4 deuterium atoms were determined by gas chromatography/mass spectrometry of the 3,5-dinitrobenzoates. During the first 30 min mono- and tetradeuteriated molecules appeared rapidly, which indicates that a fraction of the ethanol was formed from acetaldehyde by exchange. This fraction was calculated to be 38-58% and the hydrogen incorporated during the reduction was mainly (63-82%) derived from C-1 of ethanol, indicating slow exchange of enzyme-bound NADH. After 30 min the elimination followed first-order kinetics with t1/2 of 18-31 min and with a small primary isotope effect (1.05-1.11). This indicates almost complete removal of ethanol from blood passing through the liver when the concentration is low (below 1 mM). The results indicate that as long as hepatic blood flow is not limiting, the rate of alcohol dehydrogenase-catalyzed elimination of a small dose of ethanol in vivo is limited by the dissociation of NADH from the enzyme and by the rates of oxidation of acetaldehyde and reoxidation of NADH.

Factors affecting the drinking driver

Although the relationship between alcohol and traffic safety has been the subject of numerous studies, much remains unknown about the mechanisms by which alcohol contributes to traffic accidents. A number of other factors, which are reviewed in this paper, also can contribute to car accidents. They may also interact with alcohol, perhaps in a complex manner. Therefore, multiple factors rather than one single factor may contribute to automobile accidents for those who drink and drive.

Ethanol metabolism

Alcohol is metabolized by two pathways in humans: the ADH pathway which accounts for the bulk of the metabolism, and the MEOS pathway which contributes to the increased rate of ethanol elimination at high blood alcohol levels. The increased rate of elimination which results from chronic alcohol consumption is due to an increase in MEOS activity. The activities of these pathways are influenced by environmental factors such as smoking, diet, and endocrine factors. In addition, individuals inherit different types of ADH isoenzymes which have different kinetic properties. Individuals with different phenotypic variants, e.g. the beta 1 vs beta 2 isoenzymes, appear to have different rates of ethanol elimination. The cloning of the ADH genes and the availability of molecular hybridization methods now make it possible to genotype individuals and to correlate the genotype with both alcohol elimination rates and with the risk of developing medical complications of alcoholism or even of developing alcoholism itself.

Lack of first-pass metabolism of ethanol at blood concentrations in the social drinking range

Previously published data are displayed in a new manner and show that there is complete systemic availability of oral doses of 23-47 g of ethanol (0.35-0.75 g/kg or 30-60 ml of 95% ethanol) in man when administered in the fasting state relative to an intravenous infusion of the same doses administered over a 2-hr period. A previous report by other authors that oral ethanol (0.15 g/kg) in man had a mean systemic availability of only 29% is explained by the fact that the subjects were fed one hour prior to administration of the alcohol and that the intravenous dose was infused over only a 20 minute period.

Genetic polymorphism of human liver alcohol and aldehyde dehydrogenases, and their relationship to alcohol metabolism and alcoholism

It is now widely accepted that the various pharmacologic and addictive consequences of alcohol consumption are related to the tissue concentration of ethanol or its metabolic products. The oxidative metabolism of ethanol in liver is principally catalyzed by alcohol dehydrogenase and aldehyde dehydrogenase. Both of these enzymes exist in multiple molecular forms, and genetic models have been proposed to account for the multiplicity of isoenzymes. Alcohol dehydrogenase subunits are encoded at five different gene loci, and genetic polymorphism occurs at two alcohol dehydrogenase loci. Variant isoenzymes produced at the two polymorphic alcohol dehydrogenase loci account for the differences in enzyme electrophoretic patterns observed among individuals. Some of these variant isoenzymes exhibit widely different kinetic properties, and this may account for the 2- to 3-fold variation in alcohol elimination rate among individuals. Since the protein sequence of several of the alcohol dehydrogenase subunits has been determined and several of the alcohol dehydrogenase genes has been cloned, some of the structural changes which give rise to differences in catalytic and electrophoretic properties are now known. Genetic polymorphism also occurs at the aldehyde dehydrogenase gene locus which encodes the mitochondrial low Km for acetaldehyde aldehyde dehydrogenase isoenzyme. The variant isoenzyme exhibits little or no catalytic activity. Individuals with this "null" variant have higher than normal blood acetaldehyde levels and exhibit an alcohol-flush reaction which appears to be a deterrent to heavy drinking and alcoholism.(ABSTRACT TRUNCATED AT 250 WORDS)

Interindividual variations in the disposition and metabolism of ethanol in healthy men

Forty-eight healthy men each drank a dose of ethanol, 0.68 g/kg of body weight, as neat whisky at about 09.00, after fasting overnight. The drink was finished within 20 min and the concentrations of ethanol in samples of capillary blood were determined at 30-60 min intervals for 7 hr. Rectilinear regression lines were fitted to the elimination phase of blood concentration time profiles and blood-ethanol parameters were calculated as described by Widmark. In 23, 14, 8 and 3 subjects the peak blood ethanol concentrations were reached at 30, 60, 90 and 120 min timed from starting to drink. The highest concentration of ethanol in blood was 0.92 +/- 0.022 mg/ml (mean +/- SE) and the coefficient of variation (CV) was 16.8%. The blood concentration of ethanol extrapolated to zero-time was 0.98 +/- 0.009 mg/ml (CV = 6.5%) and the apparent volume of distribution (Vd) was 0.695 +/- 0.0064 L/kg (CV = 6.4%). The rate of ethanol elimination from blood was 0.126 +/- 0.0018 mg/ml/hr (CV = 9.9%) and the body clearance was 87.5 +/- 1.1 mg/kg/hr (CV = 8.7%). The apparent volume of distribution of ethanol was inversely related to the subject's body weight (r = -0.59 +/- 0.118, p less than 0.001). The elimination rate from blood was lower in those subjects with larger distribution volume; the parameters were negatively correlated (r = -0.52 +/- 0.126, p less than 0.001). The results show that blood-ethanol parameters calculated according to Widmark's method have low intersubject variability when the dose of ethanol administered and the condition of the test subjects are carefully controlled.(ABSTRACT TRUNCATED AT 250 WORDS)