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McMartin K, Jacobsen D, Hovda KE. Antidotes for poisoning by alcohols that form toxic metabolites. Br J Clin Pharmacol 2024. [PMID: 39234820 DOI: 10.1111/bcp.16232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 08/08/2024] [Accepted: 08/13/2024] [Indexed: 09/06/2024] Open
Abstract
The alcohols methanol, ethylene glycol and diethylene glycol share many characteristics. The most important is that the compounds themselves are relatively nontoxic but are metabolized, initially by alcohol dehydrogenase, to various toxic intermediates. These compounds are readily available worldwide in commercial products as well as in homemade alcoholic beverages, both of which lead to most of the poisonings, from either unintentional or intentional ingestion. Although relatively infrequent, toxic alcohol poisonings do unfortunately occur in outbreaks and can result in severe morbidity and mortality. These poisonings have traditionally been treated with ethanol since it competes for the active site of alcohol dehydrogenase and decreases the formation of toxic metabolites. Although ethanol can be an effective antidote, there are substantial practical problems with its use. Therefore fomepizole, a potent competitive inhibitor of alcohol dehydrogenase, was developed for a hopefully better treatment for metabolically toxic alcohol poisonings. Fomepizole has few side effects and is easy to use in practice and it may obviate the need for haemodialysis in some, but not all, patients. Hence, fomepizole has largely replaced ethanol as the toxic alcohol antidote in many countries. Nevertheless, ethanol remains an important alternative because access to fomepizole can be limited, the cost may appear excessive or the physician may prefer ethanol due to experience.
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Affiliation(s)
- Kenneth McMartin
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana, USA
| | - Dag Jacobsen
- Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The National Poison Information Centre, National Institute of Health, Oslo, Norway
| | - Knut Erik Hovda
- Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The National Poison Information Centre, National Institute of Health, Oslo, Norway
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2
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AlSamh DA, Kramer AH. Neurologic Complications in Critically Ill Patients with Toxic Alcohol Poisoning: A Multicenter Population-Based Cohort Study. Neurocrit Care 2024; 40:734-742. [PMID: 37697128 DOI: 10.1007/s12028-023-01821-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/24/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Toxic alcohol poisoning is regularly encountered in emergency departments and intensive care units (ICUs). Most patients present with an altered level of consciousness, but the subsequent course and spectrum of neurologic complications and outcomes is highly variable. METHODS We performed a population-based, multicenter retrospective cohort study of critically ill patients with toxic alcohol poisoning admitted to ICUs in Alberta, Canada, between 2007 and 2019 to describe neurologic sequelae, including seizures, coma, neuroimaging abnormalities, persistent cognitive or visual impairment, and mortality. Multivariate analysis was performed to identify predictors of poor outcome. RESULTS We identified 104 patients, including 55 (53%) with methanol ingestion, 36 (35%) with ethylene glycol ingestion, and 13 (13%) with isopropanol ingestion. In patients who underwent neuroimaging, abnormalities were detected in 9 of 24 (38%) with methanol toxicity, 5 of 20 (25%) with ethylene glycol toxicity, and 0 of 10 with isopropanol toxicity (p = 0.07). Basal ganglia were commonly involved with both methanol and ethylene glycol poisoning, but prominent subcortical involvement and restricted diffusion were observed only with methanol poisoning. The composite of death, persistent cognitive impairment, or visual loss occurred in 13 (24%) patients with methanol poisoning, compared with one (3%) with ethylene glycol poisoning and none with isopropanol poisoning (p = 0.006). Among patients with methanol toxicity, greater elevation of the anion gap and lower Glasgow Coma Scale score were independent predictors of poor outcome. No patient with an anion gap ≥ 28 at presentation had a favorable recovery. Progression to death by neurologic criteria occurred in 3 of 55 (5%) patients with methanol poisoning and in none with other toxic alcohols. CONCLUSIONS Methanol overdose is the most common form of toxic alcohol poisoning to result in ICU admission. Poor neurologic outcomes may occur especially with methanol poisoning, with more than one in five patients dying or having persistent cognitive or visual impairment. A wide anion gap independently predicts poor outcome, emphasizing the importance of expeditious recognition and treatment.
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Affiliation(s)
- Danah Abo AlSamh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Andreas H Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, McCaig Tower, Foothills Medical Center, University of Calgary, 3134 Hospital Drive NW Calgary, Calgary, AB, T2N 2T9, Canada.
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Ezhilarasu P, Srinivasan R. Beyond the Usual Suspects: Ethylene Glycol Poisoning Complicated by Rare Neurological Sequelae. Cureus 2024; 16:e57868. [PMID: 38725760 PMCID: PMC11081402 DOI: 10.7759/cureus.57868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
Ethylene glycol poisoning is a known clinical entity with established diagnostic and management protocols. However, instances presenting with rare neurological complications pose diagnostic challenges and necessitate prompt recognition and intervention. This report details the case of ethylene glycol poisoning in a 38-year-old male patient who initially presented with a history of brake oil consumption at his residence, followed by a delayed presentation with vomiting, abdominal pain, and reduced urine output, and subsequently developed unusual neurological sequelae, including unsteadiness, hearing difficulties, and an inability to close his eyes. Diagnostic assessment revealed cerebellar ataxia with bilateral sensory-neural hearing loss and facial nerve palsy. The patient was subsequently managed primarily for ethylene glycol poisoning, with conservative management for the neurological sequelae, and improved with no residual deficits. This case underscores the importance of promptly managing ethylene poisoning to prevent complications and sequelae as well as reduce morbidity for patients.
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Affiliation(s)
- Preetham Ezhilarasu
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Ragunanthanan Srinivasan
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
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Hidayati EL, Fahlevi R, Puspitasari HA, Tartila, Puspaningtyas NW, Primacakti F, Saraswati M, Miranda ME, Prawira Y, Prayitno A, Pardede SO, Putri ND. Emerging progressive atypical acute kidney injury in young children linked to ethylene glycol and diethylene glycol intoxication. Pediatr Nephrol 2024; 39:897-904. [PMID: 37755463 DOI: 10.1007/s00467-023-06157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/31/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND There had been a sudden surge of unusually severe and rapidly progressing acute kidney injury (AKI) incidence in Indonesia since August 2022 which did not correspond to the rise of COVID-19 incidence. We suspected this was related to ethylene glycol (EG) and diethylene glycol (DEG) intoxication. This study is aimed at describing the clinical and laboratory characteristics of AKI related to D(EG) intoxication in order to spread awareness of the possibility of intoxication in cases of rapidly progressing AKI with unknown etiology. METHODS We conducted a cross-sectional study by collecting secondary data from the pediatric AKI registry at a national referral hospital in Jakarta, Indonesia. Data on children admitted from January to November 2022 with diagnosis of stage 3 AKI based on KDIGO criteria were included. Data regarding demographics, symptoms prior to anuria, laboratory results, infection panel including COVID-19 status, treatment administered, and mortality were analyzed. RESULTS Sixteen patients tested positive for EG and DEG, all with history of consuming syrup-based medications. High anion gap metabolic acidosis was observed in majority of patients with mean pH 7.33 ± 0.07 and mean anion gap 15.6 ± 7.8 mEq/L. No patient had high osmolal gap (mean osmolal gap 3.46 ± 4.68). One deceased patient, who had kidney biopsy performed, showed severe damage and calcium oxalate crystals in the kidney tissue. Mortality was recorded in six patients (37.5%). CONCLUSION Careful history taking of patient's clinical course, including consumption of syrup-based medications and laboratory findings, might aid clinicians to establish a working diagnosis of D(EG) intoxication without needing to wait for blood toxicology test. Early diagnosis and therapy are crucial to prevent substantial mortality.
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Affiliation(s)
- Eka Laksmi Hidayati
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
| | - Reza Fahlevi
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Henny Adriani Puspitasari
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Tartila
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Niken Wahyu Puspaningtyas
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Fitri Primacakti
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Meilania Saraswati
- Department of Pathological Anatomy, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Monik Ediana Miranda
- Department of Pathological Anatomy, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Yogi Prawira
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Ari Prayitno
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Sudung Oloan Pardede
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Nina Dwi Putri
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Leonard JB, Minhaj FS, Erickson K, King J. Fomepizole use reported to United States Poison Centers from 2010 to 2021. Clin Toxicol (Phila) 2024; 62:120-125. [PMID: 38465690 DOI: 10.1080/15563650.2024.2319863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/09/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The diagnosis of toxic alcohol poisoning is often based on clinical presentation and nonspecific surrogate laboratory studies due to limited testing availability. Fomepizole is the recommended antidote and often administered empirically. The objective of this study is to identify substances that mimic toxic alcohols and compare key clinical factors between toxic alcohol and non-toxic alcohol exposures when fomepizole was administered. METHODS This study was a retrospective evaluation using the National Poison Data System from January 1, 2010 through December 31, 2021. Exposures were included if fomepizole was administered. Toxic alcohol exposures had ethylene glycol or methanol as a coded substance. For exposures not coded as a toxic alcohol, the first substance was described. Paracetamol (acetaminophen) exposures from 2020 and 2021 were excluded. RESULTS Fomepizole was reportedly used 25,110 times over 12 years. Use increased from 1,955 in 2010 to 2,710 in 2021. Most administrations were for reported toxic alcohol poisoning (60 percent) but use in reported non-toxic alcohol poisoning was greater starting in 2020. Toxic alcohol exposures were older (43.3 versus 39.8 years; P < 0.001) and more likely male (65.7 percent versus 58.2 percent). Level of care was mostly a critical care unit (67.7 percent), which was less common in toxic alcohol (63.3 percent) than non-toxic alcohol exposures (74.2 percent). The most common non-toxic alcohol substances were ethanol (24.9 percent) or an unknown drug (17.5 percent). Acidosis, increased creatinine concentration, anion gap, and osmolal gap, and kidney failure were coded in a lower proportion of toxic alcohol exposures than non-toxic alcohol exposures (P < 0.001). DISCUSSION The inability to provide rapid clinical confirmation of toxic alcohol poisoning results in the empiric administration of fomepizole to many patients who will ultimately have other diagnoses. Although fomepizole is relative well tolerated we estimated that this practice costs between $1.5 to $2.5 million. The major limitations of this work include the biases associated with retrospective record review, and the inability to confirm the exposures which may have resulted in allocation error. CONCLUSION Most fomepizole use was for a presumed toxic alcohol. This recently shifted to greater use in likely non-toxic alcohol poisoning. Key difference between the groups suggest fomepizole administration was likely due to the difficulty in diagnosis of toxic alcohol poisoning along with the efficacy and safety of fomepizole. Increased toxic alcohol laboratory testing availability could improve timely diagnosis, reserving fomepizole use for toxic alcohol poisoning.
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Affiliation(s)
- James B Leonard
- Maryland Poison Center, Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | - Kennedy Erickson
- Washington State University College of Pharmacy and Pharmaceutical Sciences, Spokane, WA, USA
| | - Joshua King
- Maryland Poison Center, Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
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Khator R, Monga V. Recent advances in the synthesis and medicinal perspective of pyrazole-based α-amylase inhibitors as antidiabetic agents. Future Med Chem 2024. [PMID: 38230638 DOI: 10.4155/fmc-2023-0285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
Diabetes is a serious health threat across the globe, claiming millions of lives worldwide. Among the various strategies employed, inhibition of α-amylase is a therapeutic protocol for the management of Type 2 diabetes mellitus. α-Amylase is a crucial enzyme involved in the breakdown of dietary starch into simpler units. However, the clinically used α-amylase inhibitors have various drawbacks. Therefore, design and development of novel α-amylase inhibitors have gained significant attention. The pyrazole motif has been identified as a versatile scaffold in medicinal chemistry, and recent studies have led to the identification of various pyrazole-based α-amylase inhibitors. This review compiles therapeutic implications of pyrazole-appended α-amylase inhibitors; their synthesis, biological activities, structure-activity relationships and molecular docking studies are discussed.
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Affiliation(s)
- Rakesh Khator
- Drug Design & Molecular Synthesis Laboratory, Department of Pharmaceutical Sciences & Natural Products, Central University of Punjab, VPO-Ghudda, 151401, Bathinda, Punjab, India
| | - Vikramdeep Monga
- Drug Design & Molecular Synthesis Laboratory, Department of Pharmaceutical Sciences & Natural Products, Central University of Punjab, VPO-Ghudda, 151401, Bathinda, Punjab, India
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Bai J, Xie Y, Li M, Huang X, Guo Y, Sun J, Tang Y, Liu X, Wei C, Li J, Yang Y. Ultrasound-assisted extraction of emodin from Rheum officinale Baill and its antibacterial mechanism against Streptococcus suis based on CcpA. ULTRASONICS SONOCHEMISTRY 2024; 102:106733. [PMID: 38150957 PMCID: PMC10765492 DOI: 10.1016/j.ultsonch.2023.106733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 12/29/2023]
Abstract
Emodin was extracted from Rheum officinale Baill by ultrasound-assisted extraction (UAE), and ethanol was chosen as the suitable solvent through SEM and molecular dynamic simulation. Under the optimum conditions (power 541 W, time 23 min, liquid to material ratio 13:1 mL/g, ethanol concentration 83 %) predicted by RSM, the yield of emodin was 2.18 ± 0.11 mg/g. Moreover, ultrasound power and time displayed the significant effects on the extraction process. Extracting dynamics analysis indicated that the extraction process of emodin by UAE conformed to Fick's second diffusion law. The results of antibacterial experiments suggested that emodin can damage cell membrane and inhibit the expression of cps2A, sao, mrp, epf, neu and the hemolytic activity of S. suis. Biolayer interferometry and FT-IR multi-peak fitting assays demonstrated that emodin induced a secondary conformational shift in CcpA. Molecular docking and molecular dynamics confirmed that emodin bound to CcpA through hydrogen bonding (ALA248, GLU249, GLY129 and ASN196) and π-π T-shaped interaction (TYR225 and TYR130), and the mutation of amino acid residues affected the affinity of CcpA to emodin. Therefore, emodin inhibited the sugar utilization of S. suis through binding to CcpA, and CcpA may be a potential target to inhibit the growth of S. suis.
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Affiliation(s)
- Jingwen Bai
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China
| | - Yu Xie
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China
| | - Miao Li
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China
| | - Xianjun Huang
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China
| | - Yujia Guo
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China
| | - Jingwen Sun
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China
| | - Yang Tang
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China
| | - Xuantong Liu
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China
| | - Chi Wei
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China
| | - Jianqiang Li
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China
| | - Yu Yang
- College of Art and Science, Northeast Agricultural University, Harbin 150030, People's Republic of China.
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8
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Sadeghi M, Fakhar M, Hoseininejad SM, Zakariaei Z, Sadeghi A. The clinico-epidemiological, diagnostic and therapeutic aspects of methanol poisoning: A five-year retrospective study, northern Iran. Drug Alcohol Depend 2023; 253:111024. [PMID: 38006673 DOI: 10.1016/j.drugalcdep.2023.111024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 10/23/2023] [Accepted: 11/03/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION Methanol poisoning (MP) is a serious health issue that has become more prevalent in recent years and has resulted in numerous deaths. Early detection and timely treatment are critical for preventing fatalities and reducing the incidence of neurological complications. PATIENTS AND METHODS This study was designed as a retrospective investigation with the purpose of analyzing the clinico-epidemiological, diagnostic, and therapeutic aspects of patients who were admitted to two training hospitals in northern Iran due to MP. The selection of samples for this study was based on a pre-defined checklist. Following the completion of the treatment period in the hospital, the patients were categorized into three groups based on their clinical outcome. All relevant variables for each group were recorded and reported separately, using the SciPy library in the Python programming language. RESULTS The majority of the patients (88.12%) were male (P=0.012), the average age was 41.46, and mostly (82.18%) lived in urban regions (P=0.025). The primary clinical complaint reported was visual disorders, accounting for 75.25% of the cases, followed by nervous, gastrointestinal, respiratory, and chest pain accordingly. The average hospitalization length for the patients was 5.065 days. Out of the 101 patients, 65 (64.36%) were discharged without any complications, 17 (16.83%) were discharged with complications, and unfortunately, 19 (18.81%) were died. CONCLUSION A decreased level of consciousness and severe metabolic acidosis are commonly associated with unfavorable outcomes in MP. The use of systemic corticosteroids as a treatment method has a significant association with reducing mortality rates.
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Affiliation(s)
- Mahdieh Sadeghi
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahdi Fakhar
- Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Zakaria Zakariaei
- Toxicology and Forensic Medicine Division, Mazandaran Registry Center for Opioids Poisoning, Antimicrobial Resistance Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Alireza Sadeghi
- Intelligent Mobile Robot Lab (IMRL), Department of Mechatronics Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
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Etemadi Y, Akakpo JY, Ramachandran A, Jaeschke H. Nrf2 as a therapeutic target in acetaminophen hepatotoxicity: A case study with sulforaphane. J Biochem Mol Toxicol 2023; 37:e23505. [PMID: 37598316 PMCID: PMC10842847 DOI: 10.1002/jbt.23505] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
Acetaminophen (APAP) overdose can cause severe liver injury and acute liver failure. The only clinically approved antidote, N-acetylcysteine (NAC), is highly effective but has a narrow therapeutic window. In the last 2 decades, activation of the transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2), which regulates acute phase proteins and antioxidant defense genes, has emerged as a putative new therapeutic target against APAP hepatotoxicity. However, virtually all studies that propose Nrf2 activation as mechanism of protection used prolonged pretreatment, which is not a clinically feasible approach to treat a drug overdose. Therefore, the objective of this study was to assess if therapeutic activation of Nrf2 is a viable approach to treat liver injury after APAP overdose. We used the water-soluble Nrf2 activator sulforaphane (SFN; 5 mg/kg) in a murine model of APAP hepatotoxicity (300 mg/kg). Our results indicate that short-term treatment (≤3 h) with SFN alone did not activate Nrf2 or its target genes. However, posttreatment with SFN after APAP partially protected at 6 h likely due to more rapid activation of the Nrf2-target gene heme oxygenase-1. A direct comparison of SFN with NAC given at 1 h after APAP showed a superior protection with NAC, which was maintained at 24 h unlike with SFN. Thus, Nrf2 activators have inherent problems like the need to create a cellular stress to activate Nrf2 and delayed adaptive responses which may hamper sustained protection against APAP hepatotoxicity. Thus, compared to the more direct acting antidote NAC, Nrf2 activators are less suitable for this indication.
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Affiliation(s)
- Yasaman Etemadi
- Department of Pharmacology, Toxicology, and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jephte Y Akakpo
- Department of Pharmacology, Toxicology, and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Anup Ramachandran
- Department of Pharmacology, Toxicology, and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Hartmut Jaeschke
- Department of Pharmacology, Toxicology, and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
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10
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Sanghavi SF, Swenson ER. Arterial Blood Gases and Acid-Base Regulation. Semin Respir Crit Care Med 2023; 44:612-626. [PMID: 37369215 DOI: 10.1055/s-0043-1770341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Disorders of acid-base status are common in the critically ill and prompt recognition is central to clinical decision making. The bicarbonate/carbon dioxide buffer system plays a pivotal role in maintaining acid-base homeostasis, and measurements of pH, PCO2, and HCO3 - are routinely used in the estimation of metabolic and respiratory disturbance severity. Hypoventilation and hyperventilation cause primary respiratory acidosis and primary respiratory alkalosis, respectively. Metabolic acidosis and metabolic alkalosis have numerous origins, that include alterations in acid or base intake, body fluid losses, abnormalities of intermediary metabolism, and renal, hepatic, and gastrointestinal dysfunction. The concept of the anion gap is used to categorize metabolic acidoses, and urine chloride excretion helps define metabolic alkaloses. Both the lungs and kidneys employ compensatory mechanisms to minimize changes in pH caused by various physiologic and disease disturbances. Treatment of acid-base disorders should focus primarily on correcting the underlying cause and the hemodynamic and electrolyte derangements that ensue. Specific therapies under certain conditions include renal replacement therapy, mechanical ventilation, respiratory stimulants or depressants, and inhibition of specific enzymes in intermediary metabolism disorders.
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Affiliation(s)
- Sarah F Sanghavi
- Division of Nephrology, Department of Medicine, University of Washington, Puget Sound Veterans Affairs Healthcare System, Seattle, Washington
| | - Erik R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Puget Sound Veterans Affairs Healthcare System, Seattle, Washington
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11
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Pepin L, Matsler N, Fontes A, Heard K, Flaherty BF, Monte AA. Fomepizole Therapy for Acetaminophen-Induced Liver Failure in an Infant. Pediatrics 2023; 152:e2022061033. [PMID: 37681263 DOI: 10.1542/peds.2022-061033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 09/09/2023] Open
Abstract
Acetaminophen overdose is common in the pediatric population. N-acetylcysteine (NAC) is effective at preventing liver injury in most patients when started shortly after the overdose. Delays to therapy increase risk of hepatotoxicity and liver failure that may necessitate organ transplant. Animal studies have demonstrated fomepizole may provide added benefit in acetaminophen overdose because of its ability to block the metabolic pathway that produces the toxic acetaminophen metabolite and downstream inhibition of oxidative stress pathways that lead to cell death. Several adult case reports describe use of fomepizole in patients at higher risk for poor outcomes despite NAC. We describe a case of a 7-month-old female who presented in acute liver failure with persistently elevated acetaminophen concentration secondary to repeated supratherapeutic doses of acetaminophen to manage fever. Fomepizole and NAC antidotes were used in the management of the patient. She fully recovered despite demonstrating multiple markers of poor outcome on initial presentation. Although randomized trials are lacking, this case suggests that fomepizole may safely provide additional benefit in pediatric patients at risk for severe acetaminophen toxicity.
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Affiliation(s)
- Lesley Pepin
- Rocky Mountain Poison and Drug Safety, Denver, Colorado
| | | | - Andrew Fontes
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Kennon Heard
- Rocky Mountain Poison and Drug Safety, Denver, Colorado
- University of Colorado Hospital, Aurora, Colorado
| | - Brian F Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Andrew A Monte
- Rocky Mountain Poison and Drug Safety, Denver, Colorado
- University of Colorado Hospital, Aurora, Colorado
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12
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Alqurashi GI, Alqurashi FS, Alhusayni KM, Falemban AH, Alhindi YZ, Alsanosi SM, Alzahrani AR, Al-Ghamdi SS, Ayoub N. Case Reports Study on Methanol Poisoning in King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia. J Clin Med 2023; 12:4282. [PMID: 37445316 DOI: 10.3390/jcm12134282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/28/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Methanol poisoning is a challenging issue due to its inducing acute multiple organ failures, and especially due to a lack of preparedness, available antidotes, and management protocols. The current study presents six cases of methanol poisoning that attended the emergency department of King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia, between March and November 2022. All of the patients suffered from severe metabolic acidosis and visual impairment following the ingestion of homemade alcoholic beverages and colonia. Three patients were comatose, suffered from post-cardiac pulmonary arrest, and, finally, died, while the other three were non-comatose and discharged from the ICU after improvement. Management was based on clinical symptoms and other laboratory findings due to a shortage of methanol level measurement resources. The antidote, fomepizole, was not given to all of the cases due to its deficiency, and ethanol was given only to one patient due to difficulties in administering it without monitoring its concentration. Methanol poisoning and its outbreak provide insights into the dangers of hazardous homemade alcohol and other pharmaceutical preparations that might be adulterated with methanol, particularly to the shortage of suitable diagnostic testing and antidotes in addition to poor resources for management of intoxicated patients in some regions of Saudi Arabia.
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Affiliation(s)
- Ghadi I Alqurashi
- Pharmacy Department, King Abdulaziz Hospital, Taif 26521, Saudi Arabia
- Saudi Toxicology Society, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Fahad S Alqurashi
- Pharmacy Department, King Abdulaziz Hospital, Taif 26521, Saudi Arabia
| | | | - Alaa H Falemban
- Saudi Toxicology Society, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Yosra Z Alhindi
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Safaa M Alsanosi
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Abdullah R Alzahrani
- Saudi Toxicology Society, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Saeed S Al-Ghamdi
- Saudi Toxicology Society, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Nahla Ayoub
- Saudi Toxicology Society, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
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13
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Dear JW. Fomepizole should not be used more liberally in paracetamol overdose. Br J Clin Pharmacol 2023; 89:599-601. [PMID: 36471568 PMCID: PMC10107630 DOI: 10.1111/bcp.15596] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 12/12/2022] Open
Abstract
Fomepizole is a promising new treatment for preventing liver injury following paracetamol (acetaminophen) overdose. However, we need robust clinical trials to be performed to demonstrate its effect on clinical outcomes that are important to our patients and important to healthcare providers. Until such trials are performed, the toxicology community should learn the lessons from the COVID pandemic-potential novel therapeutic options may be theoretically appealing, but their effectiveness needs to be assessed in robust clinical trials before they are used in clinical practice.
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Affiliation(s)
- James W Dear
- Pharmacology, Therapeutics and Toxicology, Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK
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14
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Filip AB, Mullins ME. Fomepizole should be used more liberally in paracetamol overdose. Br J Clin Pharmacol 2023; 89:594-598. [PMID: 36471569 DOI: 10.1111/bcp.15594] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022] Open
Abstract
Growing clinical and basic science data support the use of fomepizole as an adjunct to N-acetylcysteine in paracetamol poisoning. This safe antidote may be helpful in severely poisoned patients.
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Affiliation(s)
- Ari B Filip
- Arkansas Poison and Drug Information Center, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas, USA
| | - Michael E Mullins
- Department of Emergency Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
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15
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Azharuddin S, Ogbebor O, Shuster M, Smith B, Arshad H, Cheema T. Toxicological Emergencies. Crit Care Nurs Q 2023; 46:82-99. [PMID: 36415069 DOI: 10.1097/cnq.0000000000000439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Poisoning, drug overdose, and adverse drug effects continue to be a common encounter, especially in the intensive care unit (ICU). Patients are often critically ill or have a potential to rapidly deteriorate and warrant ICU admission. Adults suffering from overdoses rarely give a complete and accurate description of the quantity or type of medications ingested. In most adult cases, multiple substances are involved. A tentative diagnosis in most overdose and poisoning cases can be made by physical examination and simple laboratory tests (electrolyte panel, creatinine, serum osmolarity, urinalysis, etc). Supportive care, with particular attention to airway management, oxygenation, and circulation, is the mainstay of treatment. Basic treatment principles include limiting the amount of toxin absorbed, enhancing the elimination of ingested toxin, and preventing the conversion of non-toxic compounds to toxic metabolites. Drugs or poisons, where specific antidotes or effective therapies exist (especially acetaminophen, salicylates, methanol, ethylene glycol, and digitalis), should be aggressively sought and treated after initial stabilization has been accomplished. For those drugs or poisons where specific quantitative tests are available, levels should be obtained before treatment and may be repeated as clinically indicated.
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Affiliation(s)
- Syed Azharuddin
- Division of Pulmonary and Critical Care Medicine, (Drs Azharuddin, Ogbebor, Arshad, and Cheema and Ms Smith), Division of Infectious Disease (Dr Ogbebor), Allegheny Health Network, Pittsburgh, Pennsylvania and Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania (Dr Shuster)
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16
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McEnery B, Scalzo A, Maliakkal J. Methanol toxicity in a pediatric patient treated with fomepizole and hemodialysis. CEN Case Rep 2022; 12:195-199. [PMID: 36307578 PMCID: PMC10151443 DOI: 10.1007/s13730-022-00744-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 10/03/2022] [Indexed: 11/07/2022] Open
Abstract
Methanol toxicity is an important cause of toxic alcohol exposure resulting in morbidity and mortality in both adult and pediatric populations. Methanol is metabolized into formaldehyde and formic acid: toxic metabolites that can cause altered mental status, visual disturbances, multisystem organ failure, and death. Recognition of methanol intoxication and rapid treatment are critical for the prevention of long-term sequelae. We present the case of a 16-year-old male with a past medical history of depression who intentionally ingested windshield wiper fluid containing methanol. Based on the patient's osmolal gap, he was estimated to have a serum methanol level of 374 mg/dL; a send-out laboratory measurement later revealed a serum methanol level of 436 mg/dL. Therapy included two hemodialysis treatments as well as fomepizole and supportive care. The patient recovered remarkably with no long-term sequelae. This case demonstrates the effectiveness of swift recognition and treatment of methanol ingestion. Optimization of methods of measuring serum methanol and evidence-based guidelines for therapy are needed to improve the care of patients with methanol intoxication.
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17
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Garibashvili T, Roeder M, Pfluegler C, Breckner M, Amann K, Heckmann JG. Ethylene glycol poisoning. Pract Neurol 2022; 22:507-508. [PMID: 36207126 DOI: 10.1136/pn-2022-003498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2022] [Indexed: 11/04/2022]
Affiliation(s)
| | - Maximilian Roeder
- Department of Internal Medicine I, Nephrological Section, Klinikum Landshut gGmbH, Landshut, Germany
| | - Carolin Pfluegler
- Department of Internal Medicine II, Intensive Care Unit, Klinikum Landshut gGmbH, Landshut, Germany
| | - Martin Breckner
- Department of Radioology, Klinikum Landshut gGmbH, Landshut, Germany
| | - Kerstin Amann
- Department of Nephropathology, Erlangen University Hospital, Erlangen, Germany
| | - Josef G Heckmann
- Department of Neurology, Klinikum Landshut gGmbH, Landshut, Germany
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18
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Al Isawi WA, Jawor ML, Hartman CK, Mezei G. Evaluation of the interaction of nanojars with biomolecules found in human body fluids. Polyhedron 2022. [DOI: 10.1016/j.poly.2022.115914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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19
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Filip AB, Berg SE, Mullins ME, Schwarz ES. Fomepizole as an adjunctive therapy for acetaminophen poisoning: cases reported to the toxicology investigators consortium (ToxIC) database 2015-2020. Clin Toxicol (Phila) 2022; 60:1006-1011. [PMID: 35510880 DOI: 10.1080/15563650.2022.2070071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Fomepizole inhibits formation of toxic acetaminophen (APAP) metabolites and may prevent or reverse mitochondrial toxicity. Given these mechanisms, it may be beneficial in patients with severe APAP toxicity. Current patterns of use for this indication are not well-studied. METHODS This is a secondary analysis of patients enrolled in the Toxicology Investigators Consortium (ToxIC) database from January 2015 to July 2020. We queried cases in which APAP was listed as an ingested agent and fomepizole was also administered. We excluded cases in which APAP was not the primary agent, N-acetylcysteine (NAC) was not administered, or fomepizole was explicitly administered for another indication. Additionally, we sent a survey to each ToxIC site that administered fomepizole for APAP toxicity to better understand when, why, and how they were using it for this indication. RESULTS Twenty-five cases of fomepizole administration following an APAP ingestion met our inclusion criteria. There were one to four cases per year between 2015 and 2019 and eight cases in 2020. Seventeen of 25 (68%) cases were for a known acute ingestion. Eighteen of 25 (72%) patients developed hepatotoxicity (AST or ALT > 1000 IU/L) and 10 of 25 (40%) developed coagulopathy (PT > 15s). This was an ill patient population, with 18 of 25 (72%) developing metabolic acidosis (pH <7.20), 12 of 25 (48%) were intubated, 9 of 25 (36%) receiving vasopressors, and 6 of 25 (24%) receiving continuous renal replacement therapy. Overall, mortality was 24%. CONCLUSION The use of fomepizole is increasing in frequency in a small subset of critically ill and acutely APAP-poisoned patients.
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Affiliation(s)
- Ari B Filip
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sarah E Berg
- The Toxikon Consortium, Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael E Mullins
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Evan S Schwarz
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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- American College of Medical Toxicology, Phoenix, AZ, USA
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20
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The Roles of Antidotes in Emergency Situations. Emerg Med Clin North Am 2022; 40:381-394. [DOI: 10.1016/j.emc.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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21
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Baj J, Forma A, Kobak J, Tyczyńska M, Dudek I, Maani A, Teresiński G, Buszewicz G, Januszewski J, Flieger J. Toxic and Nutritional Optic Neuropathies—An Updated Mini-Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19053092. [PMID: 35270784 PMCID: PMC8910489 DOI: 10.3390/ijerph19053092] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/27/2022] [Accepted: 03/03/2022] [Indexed: 12/20/2022]
Abstract
Optic neuropathies constitute a group of conditions with various etiologies and might be caused by different factors; we can distinguish the genetic and acquired causes of optic neuropathies. Even though the symptoms are not highly specific, this condition is primarily characterized by unilateral or bilateral vision loss with worsening color detection. The loss may be acute or gradual depending on the causation. In this article, we included a specification of toxic optic neuropathy (TON) mainly triggered by alcohol abuse and also the usage of other substances, including drugs or methanol, as well as intoxication by metals, organic solvents, or carbon dioxide. Nutritional deficiencies, vitamin absorption disorder, and anemia, which usually appear during excessive alcohol intake, and their effect on the etiology of the optic neuropathy have been likewise discussed.
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Affiliation(s)
- Jacek Baj
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland; (J.B.); (A.M.)
| | - Alicja Forma
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
- Correspondence:
| | - Joanna Kobak
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Magdalena Tyczyńska
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Iga Dudek
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Amr Maani
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland; (J.B.); (A.M.)
| | - Grzegorz Teresiński
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Grzegorz Buszewicz
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Jacek Januszewski
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Jolanta Flieger
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4A, 20-093 Lublin, Poland;
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22
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Link SL, Rampon G, Osmon S, Scalzo AJ, Rumack BH. Fomepizole as an adjunct in acetylcysteine treated acetaminophen overdose patients: a case series. Clin Toxicol (Phila) 2021; 60:472-477. [PMID: 34709101 DOI: 10.1080/15563650.2021.1996591] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Acetaminophen (N-acetyl-para-aminophenol or APAP) is the leading cause of acute liver failure worldwide. Standard therapy for APAP overdose is with IV N-acetylcysteine (NAC). However, overdose patients treated with NAC can still incur hepatotoxicity in some circumstances. Fomepizole has proven safety in methanol and ethylene glycol poisoning and is a potent CYP2E1 and c-Jun-N-terminal Kinase (JNK) inhibitor that is effective even in the metabolic phase. METHODS We present a prospective case series of 14 consecutive, high-risk patients who had elevated APAP levels after overdose who were treated with fomepizole as an adjunct to standard IV-NAC. The attending toxicologist utilized clinical judgement to determine the use of fomepizole, especially if APAP levels persisted due to altered half-life or risk factors for toxicity. RESULTS There were no unfavorable outcomes in any patient, which were better than expected. CONCLUSIONS This case series has demonstrated the safety of fomepizole in high-risk APAP overdose. The efficacy of fomepizole needs to be further elucidated through controlled clinical trials on a larger scale. In massive APAP overdoses, fomepizole should be considered as an adjunct due to the known failure rate of NAC and the safety profile of fomepizole.
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Affiliation(s)
- Stephanie L Link
- Saint Louis University Pulmonary and Critical Care Medicine, St. Louis, MO, USA
| | - Garrett Rampon
- University of Kansas Pulmonary and Critical Care Medicine, Kansas City, MO, USA
| | - Stephen Osmon
- Former Saint Louis University Pulmonary and Critical Care Medicine, St. Louis, MO, USA
| | - Anthony J Scalzo
- Saint Louis University Division of Toxicology, St. Louis, MO, USA
| | - Barry H Rumack
- Departments of Emergency Medicine and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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23
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Alkhazarji KIA, Naser RAA, Zghair FS. Histological changes in the kidney and liver associated with administration of ethylene glycol in domestic pigeons (Columba liviadomestica ). TIKRIT JOURNAL FOR AGRICULTURAL SCIENCES 2021; 21:106-111. [DOI: 10.25130/tjas.21.3.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
In order to illustrate the histological changes in kidney and liver associated with water drinking of ethylene glycol (EG) in domestic pigeons (Columba liviadomestica), 24 adult birds, weighing 350- 400 grams, aged 9-12 months were used, for the period from 5/2/2021- 16/3/2021 at Diyala University - College of Veterinary Medicine. They divided into two equal groups. One group control and other group gives EG with water at concentration 8.5ml/L for three weeks. Histological results illustrated normal structures of kidney and liver in the domestic pigeons of control group. It was observed histological alteration in both organs in the group which received EG such as degeneration of tubular epithelium, cellular infiltration, congestion in kidney, while detect increase inflammatory cell, degeneration, and precipitated materials in the lumen of central vein in liver. It concluded that the EG causes toxic injury to the renal and hepatic tissue in domestic pigeons.
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24
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Lao YE, Vartdal T, Froeyshov S, Latimer B, Kvaerner C, Mataric M, Holm P, Foreid S, Jacobsen D, McMartin K, Hovda KE. Fomepizole dosing during continuous renal replacement therapy - an observational study. Clin Toxicol (Phila) 2021; 60:451-457. [PMID: 34585641 DOI: 10.1080/15563650.2021.1980581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Fomepizole is the preferred antidote for treatment of methanol and ethylene glycol poisoning, acting by inhibiting the formation of the toxic metabolites. Although very effective, the price is high and the availability is limited. Its availability is further challenged in situations with mass poisonings. Therefore, a 50% reduced maintenance dose for fomepizole during continuous renal replacement therapy (CRRT) was suggested in 2016, based on pharmacokinetic data only. Our aim was to study whether this new dosing for fomepizole during CRRT gave plasma concentrations above the required 10 µmol/L. Secondly, we wanted to study the elimination kinetics of fomepizole during CRRT, which has never been studied before. METHODS Prospective observational study of adult patients treated with fomepizole and CRRT. We collected samples from arterial line (pre-filter) = plasma concentration, post-filter and dialysate for fomepizole measurements. Fomepizole was measured using high-pressure liquid chromatography with a reverse phase column. RESULTS Ten patients were included in the study. Seven were treated with continuous veno-venous hemodialysis (CVVHD) and three with continuous veno-venous hemodiafiltration (CVVHDF). Ninety-eight percent of the plasma samples were above the minimum plasma concentration of 10 µmol/L. Fomepizole was removed during CRRT with a median saturation/sieving coefficient of 0.85 and dialysis clearance of 28 mL/min. CONCLUSION Fomepizole was eliminated during CCRT. The new dosing recommendations for fomepizole and CRRT appeared safe, by maintaining the plasma concentration above the minimum value of 10 µmol/L. Based on these data, the fomepizole maintenance dose during CRRT could be reduced to half as compared to intermittent hemodialysis.
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Affiliation(s)
- Yvonne E Lao
- Norwegian National Unit for CBRNE Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Trond Vartdal
- Department of Internal Medicine, Baerum Hospital, Gjettum, Norway
| | - Sten Froeyshov
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Brian Latimer
- Department of Pharmacology, Toxicology and Neuroscience, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Christiane Kvaerner
- Department of Pulmonary Medicine, Akershus University Hospital, Nordbyhagen, Norway
| | - Marija Mataric
- Department of Anesthesiology and Intensive Care Medicine, Levanger Hospital, Levanger, Norway
| | - Peter Holm
- Intensive Care Unit, Ostfold Hospital Kalnes, Graalum, Norway
| | - Siri Foreid
- Departement of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Dag Jacobsen
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kenneth McMartin
- Department of Pharmacology, Toxicology and Neuroscience, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Knut Erik Hovda
- Norwegian National Unit for CBRNE Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
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Ramachandran A, Jaeschke H. Oxidant Stress and Acetaminophen Hepatotoxicity: Mechanism-Based Drug Development. Antioxid Redox Signal 2021; 35:718-733. [PMID: 34232786 PMCID: PMC8558076 DOI: 10.1089/ars.2021.0102] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Significance: Acetaminophen (APAP) is one of the quantitively most consumed drugs worldwide. Although safe at therapeutic doses, intentional or unintentional overdosing occurs frequently causing severe liver injury and even liver failure. In the United States, 50% of all acute liver failure cases are caused by APAP overdose. However, only one antidote with a limited therapeutic window, N-acetylcysteine, is clinically approved. Thus, more effective therapeutic interventions are urgently needed. Recent Advances: Although APAP hepatotoxicity has been extensively studied for almost 50 years, particular progress has been made recently in two areas. First, there is now a detailed understanding of involvement of oxidative and nitrosative stress in the pathophysiology, with identification of the reactive species involved, their initial generation in mitochondria, amplification through the c-Jun N-terminal kinase pathway, and the mechanisms of cell death. Second, it was demonstrated in human hepatocytes and through biomarkers in vivo that the mechanisms of liver injury in animals accurately reflect the human pathophysiology, which allows the translation of therapeutic targets identified in animals to patients. Critical Issues: For progress, solid understanding of the pathophysiology of APAP hepatotoxicity and of a drug's targets is needed to identify promising new therapeutic intervention strategies and drugs, which may be applied to humans. Future Directions: In addition to further refine the mechanistic understanding of APAP hepatotoxicity and identify additional drugs with complementary mechanisms of action to prevent cell death, more insight into the mechanisms of regeneration and developing of drugs, which promote recovery, remains a future challenge. Antioxid. Redox Signal. 35, 718-733.
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Affiliation(s)
- Anup Ramachandran
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Hartmut Jaeschke
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
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26
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Dhuria NV, Haro B, Kapadia A, Lobo KA, Matusow B, Schleiff MA, Tantoy C, Sodhi JK. Recent developments in predicting CYP-independent metabolism. Drug Metab Rev 2021; 53:188-206. [PMID: 33941024 DOI: 10.1080/03602532.2021.1923728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
As lead optimization efforts have successfully reduced metabolic liabilities due to cytochrome P450 (CYP)-mediated metabolism, there has been an increase in the frequency of involvement of non-CYP enzymes in the metabolism of investigational compounds. Although there have been numerous notable advancements in the characterization of non-CYP enzymes with respect to their localization, reaction mechanisms, species differences and identification of typical substrates, accurate prediction of non-CYP-mediated clearance, with a particular emphasis with the difficulties in accounting for any extrahepatic contributions, remains a challenge. The current manuscript comprehensively summarizes the recent advancements in the prediction of drug metabolism and the in vitro to in vitro extrapolation of clearance for substrates of non-CYP drug metabolizing enzymes.
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Affiliation(s)
- Nikhilesh V Dhuria
- Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Bianka Haro
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Amit Kapadia
- California Poison Control Center, University of California San Francisco, San Diego, CA, USA
| | | | - Bernice Matusow
- Department of Drug Metabolism and Pharmacokinetics, Plexxikon Inc, Berkeley, CA, USA
| | - Mary A Schleiff
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Christina Tantoy
- Department of Drug Metabolism and Pharmacokinetics, Plexxikon Inc, Berkeley, CA, USA
| | - Jasleen K Sodhi
- Department of Drug Metabolism and Pharmacokinetics, Plexxikon Inc, Berkeley, CA, USA.,Department of Bioengineering and Therapeutic Sciences, Schools of Pharmacy and Medicine, University of California, San Francisco, CA, USA
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27
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Holzman SD, Larsen J, Kaur R, Smelski G, Dudley S, Shirazi FM. Death by hand sanitizer: syndemic methanol poisoning in the age of COVID-19. Clin Toxicol (Phila) 2021; 59:1009-1014. [PMID: 33755514 DOI: 10.1080/15563650.2021.1895202] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The advent of COVID-19 increased attention to hand hygiene in prevention of disease transmission. To meet the increased demand for hand sanitizer during the pandemic, the US FDA issued an Emergency Use Authorization allowing new manufacturers and importers to enter the market. Some of the newly introduced hand sanitizer products contained methanol in lieu of ethanol or isopropanol. We describe five patients with fatal methanol poisoning resulting from hand sanitizers improperly containing methanol. CASE SUMMARY Comparing a 5-month period from 2019 to the same time frame in 2020, the Arizona Poison and Drug Information Center has seen an increase of 124% in exposures to hand sanitizer. Of these cases, 28% involved methanol-contaminated hand sanitizer. Five of these patients died from methanol poisoning. All five cases had similar clinical features with severe high anion gap metabolic acidosis and, in four patients, elevated osmolal gap. Methanol concentrations were consistently very elevated, but these results were not available before the patients succumbed. Four of the patients received fomepizole and adjunctive care. Two patients received emergency extracorporeal therapy. All five died despite maximal treatment efforts. CONCLUSION During the pandemic in 2020, there was a proliferation of alcohol-based hand sanitizers which contained methanol. Exposure to these products, which failed to meet regulatory standards, led to increased harm and death. Challenges to treatment of methanol poisoning, especially in rural areas, include lack of access to timely laboratory measurement of methanol concentrations and lack of available emergency hemodialysis without transfer of the patient.
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Affiliation(s)
- Sarah Denise Holzman
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Jaiva Larsen
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA.,Department of Emergency Medicine, Banner University Medical Center South, Tucson, AZ, USA.,Department of Emergency Medicine, Southern Arizona VA Health Care System, Tucson, AZ, USA
| | - Ramandeep Kaur
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Geoffrey Smelski
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Steven Dudley
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Farshad Mazda Shirazi
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA.,Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.,Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
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28
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Paret N, Grenet G, Nguyen K, Vial T, Patat AM. Fomépizole : quel schéma thérapeutique recommander ? (Hors dialyse). TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2021. [DOI: 10.1016/j.toxac.2020.10.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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29
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D'Netto ME, Archibald WJ, Cajigas HR. 44-Year-Old Woman With Altered Mental Status and Tachypnea. Mayo Clin Proc 2021; 96:776-781. [PMID: 33673925 DOI: 10.1016/j.mayocp.2020.07.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Michael E D'Netto
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - William J Archibald
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Hector R Cajigas
- Advisor to residents and Consultant in Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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30
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Patel R, Mistry AM, Mistry CM. Unintentional Ethylene Glycol Poisoning in an Adolescent. Cureus 2020; 12:e11521. [PMID: 33354465 PMCID: PMC7746011 DOI: 10.7759/cureus.11521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The differential diagnosis is broad when a patient presents with an altered mental status. Ethylene glycol poisoning, a life-threatening condition, can occur as an intentional self-harm attempt or unintentional consumption. It is metabolized in the liver by a series of enzymes, and the metabolites so formed are responsible for the majority of clinical effects. The diverse range of clinical effects includes central nervous system (CNS), gastrointestinal, cardiovascular system (CVS), pulmonary as well as renal effects. The evidence of metabolic acidosis, elevated anion gap, high osmolal gap, and calcium oxalate crystals in laboratory analysis strongly suggests ethylene glycol poisoning. The treatment traditionally consists of alcohol dehydrogenase inhibitors such as fomepizole or ethanol, and in some cases, hemodialysis is needed as well.
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Affiliation(s)
- Rutul Patel
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College (NHLMMC), Ahmedabad, IND
| | - Anuja Mahesh Mistry
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College (NHLMMC), Ahmedabad, IND
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31
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4-methylpyrazole protects against acetaminophen-induced acute kidney injury. Toxicol Appl Pharmacol 2020; 409:115317. [PMID: 33157119 DOI: 10.1016/j.taap.2020.115317] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/27/2020] [Accepted: 10/31/2020] [Indexed: 12/14/2022]
Abstract
Acetaminophen (APAP) hepatotoxicity is the most common cause of acute liver failure in the United States, and while a significant percentage of APAP overdose patients develop kidney injury, molecular mechanisms involved in APAP-induced nephrotoxicity are relatively unknown. We have shown that 4-methylpyrazole (4MP, Fomepizole) protects against APAP-induced liver injury by inhibiting reactive metabolite formation through Cyp2E1, and analysis of data from APAP overdose patients indicated that kidney dysfunction strongly correlated with severe liver injury. Since Cyp2E1 is also expressed in the kidney, this study explored protection by 4MP against APAP-induced nephrotoxicity. Male C57BL/6 J mice were treated with either 300 or 600 mg/kg APAP with or without 4MP for 2, 6 or 24 h, followed by measurement of APAP metabolism and tissue injury. Interestingly, levels of APAP and its non-oxidative metabolites were significantly higher in kidneys when compared to the liver. APAP-protein adducts were present in both tissues within 2 h, but were absent in kidney mitochondria, unlike in the liver. While GSH depletion was seen in both tissues, activation of c-jun N-terminal kinase and its translocation to the mitochondria, which is a critical feature of APAP-induced liver injury, was not detected in the kidney. Treatment with 4MP attenuated APAP oxidative metabolite generation, GSH depletion as well as kidney injury indicating its potential use in protection against APAP-induced nephrotoxicity. In conclusion, since reactive metabolite formation seems to be common in both liver and kidney, 4MP mediated inhibition of Cyp2E1 protects against APAP-induced nephrotoxicity. However, downstream mechanisms of APAP-induced nephrotoxicity seem distinct from the liver.
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32
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Scott KA, Qureshi MH, Cox PB, Marshall CM, Bellaire BC, Wilcox M, Stuart BAR, Njardarson JT. A Structural Analysis of the FDA Green Book-Approved Veterinary Drugs and Roles in Human Medicine. J Med Chem 2020; 63:15449-15482. [PMID: 33125236 DOI: 10.1021/acs.jmedchem.0c01502] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The FDA Green Book is a list of all drug products that have been approved by the FDA for use in veterinary medicine. The Green Book, as published, lacks structural information corresponding to approved drugs. To address this gap, we have compiled the structural data for all FDA Green Book drugs approved through the end of 2019. Herein we discuss the relevance of this data set to human drugs in the context of structural classes and physicochemical properties. Analysis reveals that physicochemical properties are highly optimized and consistent with a high probability of favorable drug metabolism and pharmacokinetic properties, including good oral bioavailability for most compounds. We provide a detailed analysis of this data set organized on the basis of structure and function. Slightly over half (51%) of vet drugs are also approved in human medicine. Combination drugs are biologics are also discussed.
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Affiliation(s)
- Kevin A Scott
- Department of Chemistry and Biochemistry, University of Arizona, Tucson, Arizona 85721, United States.,Department of Pharmacology and Toxicology, University of Arizona, Tucson, Arizona 85721, United States
| | - M Haziq Qureshi
- Department of Chemistry and Biochemistry, University of Arizona, Tucson, Arizona 85721, United States
| | - Philip B Cox
- Drug Discovery Science and Technology, AbbVie Inc., 1 North Waukegan Road, North Chicago, Illinois 60064, United States
| | - Christopher M Marshall
- Department of Chemistry and Biochemistry, University of Arizona, Tucson, Arizona 85721, United States
| | - Bailey C Bellaire
- Department of Chemistry and Biochemistry, University of Arizona, Tucson, Arizona 85721, United States
| | - Michael Wilcox
- Department of Chemistry and Biochemistry, University of Arizona, Tucson, Arizona 85721, United States
| | - Bradey A R Stuart
- Department of Chemistry and Biochemistry, University of Arizona, Tucson, Arizona 85721, United States
| | - Jon T Njardarson
- Department of Chemistry and Biochemistry, University of Arizona, Tucson, Arizona 85721, United States
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33
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Gouda AS, Khattab AM, Mégarbane B. Lessons from a methanol poisoning outbreak in Egypt: Six case reports. World J Crit Care Med 2020; 9:54-62. [PMID: 32844091 PMCID: PMC7416361 DOI: 10.5492/wjccm.v9.i3.54] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/08/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Mass methanol poisonings are challenging, especially in regions with no preparedness, management guidelines and available antidotes.
CASE SUMMARY Six Ukrainian patients were referred to our emergency department in Cairo, Egypt several hours after drinking an alcoholic beverage made of 70%-ethanol disinfectant bought from a local pharmacy. All patients presented with severe metabolic acidosis and visual impairments. Two were comatose. Management was based on the clinical features and chemistry tests due to deficient resources for methanol leveling. No antidote was administered due to fomepizole unavailability and the difficulties expected to obtain ethanol and safely administer it without concentration monitoring. One patient died from multiorgan failure, another developed blindness and the four other patients rapidly improved.
CONCLUSION This methanol poisoning outbreak strongly highlights the lack of safety from hazardous pharmaceuticals sold in pharmacies and limitations due to the lack of diagnostic testing, antidote availability and staff training in countries with limited-resources such as Egypt.
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Affiliation(s)
- Ahmed S Gouda
- National Egyptian Center of Environmental and Toxicological Research, Faculty of Medicine, Cairo University, Cairo 11562, Egypt
| | - Amr M Khattab
- Department of Forensic Medicine and clinical Toxicology, Faculty of Medicine, Cairo University, Cairo 11562, Egypt
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris 75010, France
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Liu YS, Lin KY, Masur J, Barby S, Chuang R, Johnson DW, Lucyk SN, Sivilotti MLA, Yarema MC. Outcomes After Recurrent Intentional Methanol Exposures Not Treated With Alcohol Dehydrogenase Inhibitors Or Hemodialysis. J Emerg Med 2020; 58:910-916. [PMID: 32307216 DOI: 10.1016/j.jemermed.2020.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/28/2020] [Accepted: 03/18/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Relying on a treatment threshold for methanol poisoning of 20 mg/dL (6.2 mmol/L) as a stand-alone criterion may lead to unnecessary and invasive treatment because it is likely too conservative, especially for patients with repeated, intentional methanol exposures. OBJECTIVE We investigated how often patients with recurrent intentional methanol exposures above this threshold developed biochemical or overt clinical toxicity despite not being treated with either an alcohol dehydrogenase inhibitor (ADHi) or hemodialysis. METHODS We identified patients with ≥3 methanol-related emergency visits from 2002 to 2015 and selected every visit in which neither ADHi nor hemodialysis were administered despite serum methanol >20 mg/dL but neither metabolic acidosis nor end organ toxicity at presentation. The primary outcome was the incidence of visual deterioration or death. RESULTS Four patients accounted for the 17 visits that met inclusion criteria. All exposures were intentional substance misuse, and 7 of 17 were via inhalation (i.e., huffing). Initial methanol concentrations ranged from 22 mg/dL to 35 mg/dL (7-11 mmol/L). Four of these 17 visits had undetectable initial ethanol concentrations at presentation, including 1 with an initial methanol concentration of 35 mg/dL. No patients developed visual deterioration, and all were known to have survived the exposure. CONCLUSION Following recurrent, intentional methanol exposure, isolated serum methanol concentrations as high as 35 mg/dL (11 mmol/L) appear to be well-tolerated without treatment in the absence of metabolic acidosis or end-organ toxicity. To better define the methanol treatment threshold, prospective studies are warranted in which patients are followed closely while fomepizole is withheld.
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Affiliation(s)
- Yang Steven Liu
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Katie Y Lin
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joanne Masur
- Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada
| | - Shalyn Barby
- Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada
| | - Ryan Chuang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Rocky Mountain Poison and Drug Safety, Denver Health, Denver, Colorado
| | - David W Johnson
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada; Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada; Section of Clinical Pharmacology and Toxicology, Alberta Health Services, Calgary, Alberta, Canada; Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Scott N Lucyk
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada; Section of Clinical Pharmacology and Toxicology, Alberta Health Services, Calgary, Alberta, Canada
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada; Ontario Poison Centre, Toronto, Ontario, Canada
| | - Mark C Yarema
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Canada; Section of Clinical Pharmacology and Toxicology, Alberta Health Services, Calgary, Alberta, Canada; Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
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Abstract
BACKGROUND Formate is a one-carbon molecule at the crossroad between cellular and whole body metabolism, between host and microbiome metabolism, and between nutrition and toxicology. This centrality confers formate with a key role in human physiology and disease that is currently unappreciated. SCOPE OF REVIEW Here we review the scientific literature on formate metabolism, highlighting cellular pathways, whole body metabolism, and interactions with the diet and the gut microbiome. We will discuss the relevance of formate metabolism in the context of embryonic development, cancer, obesity, immunometabolism, and neurodegeneration. MAJOR CONCLUSIONS We will conclude with an outlook of some open questions bringing formate metabolism into the spotlight.
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Affiliation(s)
| | - Johannes Meiser
- Department of Oncology, Luxembourg Institute of Health, L-1526 Luxembourg, Luxembourg
| | - Alexei Vazquez
- Cancer Research UK Beatson Institute, Glasgow, UK; Institute of Cancer Sciences, University of Glasgow, Glasgow, UK.
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36
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Schicchi A, Besson H, Rasamison R, Berleur MP, Mégarbane B. Fomepizole to treat disulfiram-ethanol reaction: a case series. Clin Toxicol (Phila) 2019; 58:922-925. [PMID: 31878796 DOI: 10.1080/15563650.2019.1708091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Disulfiram-ethanol reaction (DER) due to acetaldehyde accumulation occurs after drinking ethanol during disulfiram therapy. DER may result in life-threatening toxicity requiring urgent critical care. Fomepizole, an alcohol dehydrogenase inhibitor used to treat toxic alcohol poisoning, has been suggested for treating DER by preventing the metabolism of ethanol to acetaldehyde. However, its effectiveness and safety have been poorly assessed in this setting.Cases: Ten DER patients (median age, 40 years; 7 males/3 females) were included in the study. DER features consisted of consciousness impairment (median Glasgow coma score, 13; need for mechanical ventilation, 30%) with flushing (50%), vomiting (40%), electrocardiogram abnormalities (30%) and circulatory failure requiring norepinephrine (30%). Patients were successfully treated with a single intravenous infusion of fomepizole (median dose, 7.5 mg/kg). The three patients receiving norepinephrine did not improve until fomepizole was administered. The other seven patients improved promptly following fomepizole infusion without requirement for vasopressor support. All patients fully recovered. Local pain at the injection site was the only reported adverse reaction in one patient.Conclusion: Our case series supports the effectiveness and safety of fomepizole in rapidly reversing DER-induced vasodilatation and toxicity.
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Affiliation(s)
- Azzurra Schicchi
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, University of Paris, Paris, France.,Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Istituti Clinici Scientifici Maugeri, IRCCS Maugeri Hospital and University of Pavia, Pavia, Italy
| | - Hélène Besson
- AGEPS, Pharmaceutical Establishment of Paris Hospitals, APHP, Paris, France
| | - Riana Rasamison
- AGEPS, Pharmaceutical Establishment of Paris Hospitals, APHP, Paris, France
| | | | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, University of Paris, Paris, France.,Inserm UMRS 1144, University of Paris, Paris
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37
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Rasamison R, Besson H, Berleur MP, Schicchi A, Mégarbane B. Analysis of fomepizole safety based on a 16-year post-marketing experience in France. Clin Toxicol (Phila) 2019; 58:742-747. [PMID: 31608703 DOI: 10.1080/15563650.2019.1676899] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Fomepizole has been recommended as first-line antidote to treat ethylene glycol and methanol poisoning. Despite more than 30 years of utilization, the safety of fomepizole when used clinically has not been well documented. Based on the long-standing clinical experience with fomepizole in France, we investigated its safety profile in patients treated for suspected toxic alcohol poisoning.Methods: We designed a 16-year post-marketing study to evaluate the indications for fomepizole prescriptions and to investigate its safety. Data were retrospectively collected using a standardized questionnaire sent each month by post to each French hospital that ordered fomepizole during the month before. The response rate to our survey was 59%.Results: Five hundred and thirty-six patients [188 females/348 males; age, 46 years [34-55] (median [25th-75th percentiles])] were treated with fomepizole [cumulative dose, 18.6 mg/kg [15.5-26.3] (1,268 mg [900-2,100])]. Ethylene glycol/methanol poisoning was confirmed in 275 patients (51%) while a nontoxic exposure was diagnosed in 147 patients (27%). Toxic alcohol poisoning was misdiagnosed in the remaining 114 patients (21%), before the assessment of an alternative poisoning or non-poisoning diagnosis. Fifty adverse reactions were attributed to fomepizole in 36 patients (7%) including general reactions (N = 22), local reactions (N = 22) and laboratory test impairments (N = 6). All were considered mild and transient. None required stopping fomepizole. The most frequent adverse effects were injection site pain/burning (N = 13), nausea/vomiting (N = 8), vessel puncture site inflammation (N = 7), drowsiness/confusion (N = 5) and serum aminotransferase elevation (N = 3). None of the fatalities (N = 37, 7%) or persistent symptoms on discharge (N = 9; 2%) was related to fomepizole.Conclusion: Our longitudinal cohort study supports the safety of fomepizole administered to treat presumed EG and methanol poisoning.
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Affiliation(s)
- Riana Rasamison
- AGEPS, Pharmaceutical Establishment of Paris Hospitals, APHP, Paris, France
| | - Hélène Besson
- AGEPS, Pharmaceutical Establishment of Paris Hospitals, APHP, Paris, France
| | | | - Azzurra Schicchi
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, University of Paris, Paris, France.,Poison Control Centre and National Toxicology Information Centre - Toxicology Unit, Istituti Clinici Scientifici Maugeri, IRCCS Maugeri Hospital and University of Pavia, Pavia, Italy
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, University of Paris, Paris, France.,Inserm Umrs 1144, University of Paris, Paris, France
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38
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Greenwald KE, Peak DA, Wittels K, Wilcox SR. Acute Intoxication. J Emerg Med 2019; 57:387-389. [PMID: 31296353 DOI: 10.1016/j.jemermed.2019.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/19/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Kelsy E Greenwald
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David A Peak
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen Wittels
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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39
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Formic acid up-regulates vascular tension through nitric oxide-cGMP signaling pathway. Chem Biol Interact 2019; 309:108710. [PMID: 31199930 DOI: 10.1016/j.cbi.2019.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/01/2019] [Accepted: 06/10/2019] [Indexed: 11/20/2022]
Abstract
Formic acid is a common organic acid used in many industrial processes. There is a paucity of research on the direct toxicity of formic acid and how it might affect the cardiovascular system. This study aimed to understand the effect of formic acid on vascular tension in an animal model and the underlying mechanism. Results found that the vasodilation induced by formic acid was related to the endothelium. When the dosage of formic acid was 1 mM or 5 mM, the vasodilation of endothelium-intact rings was partially suppressed by l-NAME, NS-2028 and nifedipine, and vasoconstriction caused by CaCl2 was inhibited, and the mRNA levels of eNOS, the activity of NOS (tNOS, iNOS and cNOS) and the level of NO and cGMP were significantly increased. Results also found that eNOS protein expression was significantly enhanced by 5 mM of formic acid. These results suggest formic acid can relax the aortic vessels of rats in a dose-dependent pattern. Further, the mechanism of the formic acid-induced vasodilatation likely involved the NO/cGMP pathway. Finally, the current study has revealed that vasodilation induced by high concentrations of formaldehyde may be the effect of the metabolite formic acid. This study will help further inform the etiologies of formic acid-related angiocardiopathies.
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40
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The Diagnosis and Management of Toxic Alcohol Poisoning in the Emergency Department: A Review Article. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2019; 3:e28. [PMID: 31410405 PMCID: PMC6683589 DOI: 10.22114/ajem.v0i0.153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Context: This review discusses the range of clinical presentations seen with poisonings by the major toxic alcohols--methanol, ethylene glycol, and isopropyl alcohol. It outlines a straightforward diagnostic strategy and discusses in detail the current treatment recommendations. Evidence acquisition: The authors conducted a literature search of primary and secondary sources related to the topic. For treatment recommendations, search restrictions included articles published between 2008 and 2019. For background information, search restrictions included articles written from 1990 – present. Results: This review discusses in detail how the diagnosis can be made via clinical signs, symptoms, and laboratory values as well as the most recent treatment recommendations. This paper will also discuss the limitations of the emergency department workup and how the absence of particular laboratory findings does not necessarily rule out the diagnosis. Conclusion: Poisoning with methanol, ethylene glycol, and isopropanol present diagnostic and therapeutic challenges to emergency physicians. Toxic alcohol poisonings lead to an elevated osmolar gap and, with the exception of Isopropanol, a metabolic acidosis. In order for the timely initiation of life-saving treatment, emergency physicians need a solid understanding of the pathophysiology, clinical presentation, laboratory workup, and treatment.
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41
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Stevens JS, Al-Awqati Q. Lactate dehydrogenase 5: identification of a druggable target to reduce oxaluria. J Clin Invest 2019; 129:2201-2204. [PMID: 31107247 DOI: 10.1172/jci128709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Excessive excretion of oxalate in the urine results in the formation of calcium oxalate crystals and subsequent kidney stone formation. Severe forms of hyperoxaluria, including genetic forms and those that result from ethylene glycol poisoning, can result in end-stage renal disease. Therapeutic interventions are limited and often rely on dietary intervention. In this issue of the JCI, Le Dudal and colleagues demonstrate that the lactate dehydrogenase 5 inhibitor (LDH5) stiripentol reduces urinary oxalate excretion. Importantly, stiripentol treatment of a single individual with primary hyperoxaluria reduced the urinary oxalate excretion. Together, these results support further evaluation of LDH5 as a therapeutic target for hyperoxaluria.
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42
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Liakoni E, Gugelmann H, Dempsey DA, Wiegand TJ, Havel C, Jacob P, Benowitz NL. Butanediol Conversion to Gamma-Hydroxybutyrate Markedly Reduced by the Alcohol Dehydrogenase Blocker Fomepizole. Clin Pharmacol Ther 2019; 105:1196-1203. [PMID: 30450642 DOI: 10.1002/cpt.1306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/01/2018] [Indexed: 11/07/2022]
Abstract
1,4-Butanediol (BDO)-used as solvent and abused for its euphoric effects-is converted to gamma-hydroxybutyrate (GHB) by the enzyme alcohol dehydrogenase. This double-blind, placebo-controlled crossover study with six healthy volunteers is the first to date investigating the role of the ADH inhibitor fomepizole (4-methylpyrazole (4MP)) in moderating this conversion in humans. Participants received on two different days either intravenous placebo or 15 mg/kg 4MP followed by oral administration of 25 mg/kg BDO. Pretreatment with 4MP resulted in significantly higher BDO maximal plasma concentration (P = 0.001) and area under the concentration-time curve (AUC; P = 0.028), confirming that ADH is the primary pathway for the conversion of BDO to GHB in humans. With 4MP, the mean arterial pressure was significantly lower at 105 minutes compared to baseline (P = 0.003), indicating that blood pressure lowering, observed not with a temporal relationship to 4MP administration but after the maximum BDO concentration was reached, may be an intrinsic effect of BDO.
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Affiliation(s)
- Evangelia Liakoni
- Division of Clinical Pharmacology and Experimental Therapeutics, Department of Medicine, University of California, San Francisco, California, USA
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hallam Gugelmann
- California Poison Control Center, University of California, San Francisco, California, USA
| | - Delia A Dempsey
- Division of Clinical Pharmacology and Experimental Therapeutics, Department of Medicine, University of California, San Francisco, California, USA
| | | | - Christopher Havel
- Division of Clinical Pharmacology and Experimental Therapeutics, Department of Medicine, University of California, San Francisco, California, USA
| | - Peyton Jacob
- Division of Clinical Pharmacology and Experimental Therapeutics, Department of Medicine, University of California, San Francisco, California, USA
| | - Neal L Benowitz
- Division of Clinical Pharmacology and Experimental Therapeutics, Department of Medicine, University of California, San Francisco, California, USA
- California Poison Control Center, University of California, San Francisco, California, USA
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, California, USA
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Wang C, Samaha D, Hiremath S, Sikora L, Sood MM, Kanji S, Clark EG. Outcomes after toxic alcohol poisoning: a systematic review protocol. Syst Rev 2018; 7:250. [PMID: 30593287 PMCID: PMC6309090 DOI: 10.1186/s13643-018-0926-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Toxic alcohols have been implicated in accidental ingestions and intentional exposures. Recognition of toxic alcohol poisoning is challenging. The main treatment modalities include antidotes with alcohol dehydrogenase inhibitors and dialysis. Current guidelines exist for both methanol and ethylene glycol intoxication. However, treatment consensus related to other toxic alcohols is limited. Furthermore, uncertainties regarding thresholds for when to initiate antidotes and dialysis persist. As a consequence, variations exist in the interventions utilized for management of all toxic alcohol poisonings. To our knowledge, no prior systematic review of clinical outcomes of toxic alcohols exists. The objective of this study is to summarize existing evidence on short- and long-term outcomes of patients following toxic alcohol poisonings, including methanol, ethylene glycol, isopropanol, propylene glycol, and diethylene glycol. METHODS A literature search in PubMed, MEDLINE, and EMBASE will be performed based on pre-determined criteria. There will be no restrictions on publication dates or languages. The search will be supplemented by manual scan of bibliographies of eligible studies and gray literature assessment. Observational studies and clinical trials will be included in this review. Once eligible studies have been selected based on pre-specified criteria, two investigators will extract relevant data independently and perform quality assessment per validated tools. A pooled analysis of mortality and short- and long-term secondary outcomes will be performed. Pre-specified subgroup analyses will be performed according to the type of toxic alcohol intoxication, mode of renal replacement therapy, and medical interventions received. A meta-analysis will be performed if three or more studies with similar populations, type of toxic alcohol poisoning, and outcome measures, as well as adequate quality, are identified. This review will be reported according to the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) Statement. DISCUSSION This systematic review aims to synthesize current evidence in the short- and long-term outcomes of post-toxic alcohol poisoning. The results will enhance the understanding of patient morbidity and mortality after toxic alcohol poisoning, help inform uniform concrete management guideline development, identify gaps in the current state of knowledge, and provide evidence to help implement post-treatment follow-up. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018101955.
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Affiliation(s)
- Carol Wang
- Department of Medicine, University of Ottawa, 162 Parkdale Avenue, Ottawa, Ontario K1Y 1J8 Canada
- The Ottawa Hospital – Riverside Campus, 1967 Riverside Drive, Ottawa, Ontario K1H 7W9 Canada
| | - Daniel Samaha
- The Ottawa Hospital – Riverside Campus, 1967 Riverside Drive, Ottawa, Ontario K1H 7W9 Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, 1967 Riverside Drive, Ottawa, K1H 7W9 Ontario Canada
| | - Swapnil Hiremath
- The Ottawa Hospital – Riverside Campus, 1967 Riverside Drive, Ottawa, Ontario K1H 7W9 Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, 1967 Riverside Drive, Ottawa, K1H 7W9 Ontario Canada
- The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, 451 Smyth Road, Ottawa, K1H 8M5 Ontario Canada
| | - Manish M. Sood
- The Ottawa Hospital – Riverside Campus, 1967 Riverside Drive, Ottawa, Ontario K1H 7W9 Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, 1967 Riverside Drive, Ottawa, K1H 7W9 Ontario Canada
- The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
| | - Salmaan Kanji
- The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
| | - Edward G. Clark
- The Ottawa Hospital – Riverside Campus, 1967 Riverside Drive, Ottawa, Ontario K1H 7W9 Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, 1967 Riverside Drive, Ottawa, K1H 7W9 Ontario Canada
- The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
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Giner T, Ojinaga V, Neu N, Koessler M, Cortina G. Ethylene glycol intoxication presenting with high anion gap metabolic acidosis, acute kidney injury and elevated lactate. Pediatr Int 2018; 60:194-195. [PMID: 29473303 DOI: 10.1111/ped.13477] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 10/09/2017] [Accepted: 10/20/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas Giner
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Violeta Ojinaga
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaus Neu
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Miriam Koessler
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Gerard Cortina
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
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Affiliation(s)
- Jeffrey A Kraut
- From Medical and Research Services and Division of Nephrology, Veterans Health Administration Greater Los Angeles (VHAGLA) Healthcare System, and Membrane Biology Laboratory, David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (J.A.K.); and the Division of Emergency Medicine, Washington University School of Medicine, St. Louis (M.E.M.)
| | - Michael E Mullins
- From Medical and Research Services and Division of Nephrology, Veterans Health Administration Greater Los Angeles (VHAGLA) Healthcare System, and Membrane Biology Laboratory, David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (J.A.K.); and the Division of Emergency Medicine, Washington University School of Medicine, St. Louis (M.E.M.)
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46
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Ringler S, Gmuer R, Faber K, Bleisch J, Müggler SA. [CME: Ethylene Glycol Intoxication]. PRAXIS 2018; 107:1097-1106. [PMID: 30278847 DOI: 10.1024/1661-8157/a003071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
CME: Ethylene Glycol Intoxication Abstract. Ethylene glycol is a sweet-tasting alcohol used in common antifreeze and other industrial solutions. Without appropriate therapy, intoxication with ethylene glycol can result in severe metabolic acidosis, acute renal failure, and in death. After gastrointestinal resorption, hepatic metabolism starts with oxidation by alcohol dehydrogenase and results in severe anion gap metabolic acidosis. Other metabolic products are calcium oxalate crystals, which can deposit in several tissues like the kidneys and lead to acute tubular necrosis with reversible renal failure. The crucial therapeutic step is rapid inhibition of alcohol dehydrogenase with fomepizole or ethanol to avoid the formation of toxic metabolites. Additionally, haemodialysis is the most effective way to eliminate ethylene glycol as well as its toxic metabolites. If therapy is initiated rapidly, prognosis is favorable.
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Affiliation(s)
| | - Roman Gmuer
- 1 Klinik für Innere Medizin, Spital Zollikerberg
| | - Katrin Faber
- 2 Tox Info Suisse, Assoziiertes Institut der Universität Zürich
| | - Jörg Bleisch
- 3 Nephrologie- und Dialysezentrum, Spital Zollikerberg
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Cocino C, Tagliabue P, Caldato M. The mystery of the old acid man. Intern Emerg Med 2017. [PMID: 28634721 DOI: 10.1007/s11739-017-1687-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Cristina Cocino
- Department of Clinical Sciences and Community Health, Universita degli Studi di Milano, Milan, Italy
| | - Paola Tagliabue
- UOC Rianimazione e Terapia Intensiva, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Maja Caldato
- UOC Pronto Soccoso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
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El Menyiy N, Al Waili N, Bakour M, Al-Waili H, Lyoussi B. Protective Effect of Propolis in Proteinuria, Crystaluria, Nephrotoxicity and Hepatotoxicity Induced by Ethylene Glycol Ingestion. Arch Med Res 2017; 47:526-534. [PMID: 28262194 DOI: 10.1016/j.arcmed.2016.12.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 12/13/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Propolis is a natural honeybee product with wide biological activities and potential therapeutic properties. The aim of the study is to evaluate the protective effect of propolis extract on nephrotoxicity and hepatotoxicity induced by ethylene glycol in rats. METHODS Five groups of rats were used. Group 1 received drinking water, group 2 received 0.75% ethylene-glycol in drinking water, group 3 received 0.75% ethylene-glycol in drinking water along with cystone 500 mg/kg/body weight (bw) daily, group 4 received 0.75% ethylene-glycol in drinking water along with propolis extract at a dose of 100 mg/kg/bw daily, and group 5 received 0.75% ethylene-glycol in drinking water along with propolis extract at a dose of 250 mg/kg/bw daily. The treatment continued for a total of 30 d. Urinalyses for pH, crystals, protein, creatinine, uric acid and electrolytes, and renal and liver function tests were performed. RESULTS Ethylene-glycol increased urinary pH, urinary volume, and urinary calcium, phosphorus, uric acid and protein excretion. It decreased creatinine clearance and magnesium and caused crystaluria. Treatment with propolis extract or cystone normalized the level of magnesium, creatinine, sodium, potassium and chloride. Propolis is more potent than cystone. Propolis extract alleviates urinary protein excretion and ameliorates the deterioration of liver and kidney function caused by ethylene glycol. CONCLUSIONS Propolis extract has a potential protective effect against ethylene glycol induced hepatotoxicity and nephrotoxicity and has a potential to treat and prevent urinary calculus, crystaluria and proteinuria.
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Affiliation(s)
- Nawal El Menyiy
- Laboratory Physiology-Pharmacology and Environmental Health, Faculty of Sciences DHM, University Sidi Mohamed Ben Abdallah, Fez, Morocco
| | - Noori Al Waili
- New York Medical Care for Nephrology, Richmond Hill, New York, USA.
| | - Meryem Bakour
- Laboratory Physiology-Pharmacology and Environmental Health, Faculty of Sciences DHM, University Sidi Mohamed Ben Abdallah, Fez, Morocco
| | - Hamza Al-Waili
- New York Medical Care for Nephrology, Richmond Hill, New York, USA
| | - Badiaa Lyoussi
- Laboratory Physiology-Pharmacology and Environmental Health, Faculty of Sciences DHM, University Sidi Mohamed Ben Abdallah, Fez, Morocco
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50
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Cost-effectiveness of hospital treatment and outcomes of acute methanol poisoning during the Czech Republic mass poisoning outbreak. J Crit Care 2017; 39:190-198. [DOI: 10.1016/j.jcrc.2017.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 02/25/2017] [Accepted: 03/03/2017] [Indexed: 12/21/2022]
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