What is the treatment for ethylene glycol (antifreeze) poisoning?

From the Guidelines

Treatment for ethylene glycol poisoning should prioritize immediate medical attention, including stabilization, antidotes such as fomepizole or ethanol, and extracorporeal treatments like hemodialysis for severe cases, as recommended by the EXTRIP workgroup 1. The primary goal is to prevent further absorption and conversion of ethylene glycol to its toxic metabolites.

• Stabilization of the patient is crucial, and inducing vomiting may be considered if the ingestion was recent.
• The use of antidotes such as fomepizole (15 mg/kg loading dose, then 10 mg/kg every 12 hours) or ethanol (loading dose of 10 mL/kg of 10% ethanol, followed by 1-2 mL/kg/hour) is essential to block alcohol dehydrogenase, preventing the conversion of ethylene glycol to its toxic metabolites 1.
• Hemodialysis should be initiated for severe poisoning, especially with significant metabolic acidosis, renal failure, or high ethylene glycol levels (>50 mg/dL), as recommended by the EXTRIP workgroup 1.
• Sodium bicarbonate may be administered to correct metabolic acidosis, and thiamine (100 mg IV) and pyridoxine (50 mg IV) should be given to promote metabolism of toxic intermediates through alternative pathways.
• Supportive care includes IV fluids, correction of electrolyte imbalances, and management of complications.
• The choice of extracorporeal treatment modality should prioritize intermittent hemodialysis over other types of ECTR, unless it is not available, in which case continuous kidney replacement therapy (CKRT) is recommended 1.
• The dosage of antidotes needs to be adjusted during ECTR, and the treatment should be guided by the measurement of glycolate and EG concentrations, which should be widely available in hospitals 1.
• The EXTRIP workgroup recommends using intermittent hemodialysis rather than any other type of ECTR for patients presenting with EG poisoning requiring ECTR, when all ECTR modalities are available 1.

From the FDA Drug Label

Treatment consists of blocking the formation of toxic metabolites using inhibitors of alcohol dehydrogenase, such as fomepizole injection, and correction of metabolic abnormalities In patients with high ethylene glycol or methanol concentrations (> 50 mg/dL), significant metabolic acidosis, or renal failure, hemodialysis should be considered to remove ethylene glycol or methanol and the respective toxic metabolites of these alcohols Fomepizole injection is indicated as an antidote for ethylene glycol (such as antifreeze) or methanol poisoning, or for use in suspected ethylene glycol or methanol ingestion, either alone or in combination with hemodialysis

The treatment for ethylene glycol (antifreeze) poisoning is fomepizole injection to block the formation of toxic metabolites, and correction of metabolic abnormalities.

• Hemodialysis should be considered in addition to fomepizole injection in cases of:
  • High ethylene glycol concentrations (> 50 mg/dL)
  • Significant metabolic acidosis
  • Renal failure
• Dosing of fomepizole injection:
  • Loading dose: 15 mg/kg
  • Maintenance doses: 10 mg/kg every 12 hours for 4 doses, then 15 mg/kg every 12 hours thereafter
  • Dosage adjustment during hemodialysis: every 4 hours 2

From the Research

Treatment Options

• The treatment for ethylene glycol (antifreeze) poisoning typically consists of supportive care, administration of an antidote, and in some cases, hemodialysis 3, 4, 5, 6, 7.
• The antidotes used to treat ethylene glycol poisoning are fomepizole and ethanol, which inhibit alcohol dehydrogenase and prevent the formation of toxic metabolites 4, 5, 6, 7.
• Fomepizole has been shown to be effective in preventing renal damage and metabolic abnormalities associated with ethylene glycol poisoning, and has advantages over ethanol in terms of validated efficacy, predictable pharmacokinetics, and lack of adverse effects 4, 5, 6.
• Ethanol, on the other hand, has been used traditionally to treat ethylene glycol poisoning, but its use has not been studied prospectively and it has not been approved by the FDA for this purpose 4.
• Hemodialysis may be necessary in cases of severe ethylene glycol poisoning, particularly if the patient has developed renal failure or metabolic acidosis 3, 5, 7.

Administration of Antidotes

• Fomepizole is typically administered intravenously every 12 hours, and treatment is continued until plasma ethylene glycol concentrations are less than 20 mg per deciliter 4, 5, 6.
• Ethanol can be administered intravenously, and its use may be considered in cases where fomepizole is not available or is contraindicated 3, 4.
• The choice of antidote and the decision to use hemodialysis should be made on a case-by-case basis, taking into account the severity of the poisoning, the patient's clinical condition, and the availability of treatment options 3, 4, 5, 6, 7.

Monitoring and Supportive Care

• Patients with ethylene glycol poisoning should be closely monitored for signs of renal failure, metabolic acidosis, and other complications, and should receive supportive care as needed 3, 4, 5, 6, 7.
• Sodium bicarbonate may be used to treat metabolic acidosis, and other supportive measures such as hydration and electrolyte replacement may be necessary 7.
• Patients with severe ethylene glycol poisoning may require intensive care and monitoring in a hospital setting 3, 5, 7.