Treatment of Disulfiram (Antabuse) Reaction
The treatment of disulfiram-alcohol reaction consists primarily of supportive measures including Trendelenburg positioning, oxygen administration, intravenous fluid resuscitation, and vasopressors like norepinephrine for severe hypotension.
Clinical Presentation
Disulfiram-alcohol reactions occur when a patient taking disulfiram consumes alcohol, leading to acetaldehyde accumulation. Symptoms typically include:
- Flushing and facial redness
- Headache
- Nausea and vomiting
- Sweating
- Dizziness and vertigo
- Hypotension (potentially severe)
- Tachycardia
- Confusion
- Respiratory distress
- In severe cases: cardiovascular collapse, arrhythmias, and shock
Management Algorithm
1. Initial Stabilization
- Position the patient in Trendelenburg position (head lower than feet) to improve blood pressure 1
- Administer oxygen or carbogen (95% oxygen and 5% carbon dioxide) 2
- Establish IV access for fluid administration
2. Hemodynamic Support
- IV fluid resuscitation with 0.9% saline to restore blood pressure 2, 1
- Monitor vital signs continuously
- For severe hypotension unresponsive to fluids:
3. Additional Supportive Measures
- Vitamin C in massive doses (1g) intravenously 2
- Monitor potassium levels, particularly in patients on digitalis, as hypokalemia has been reported 2
- Ephedrine sulfate may be used for blood pressure support 2
4. Specific Pharmacologic Interventions
- Fomepizole (alcohol dehydrogenase inhibitor) has shown effectiveness in rapidly reversing disulfiram-ethanol reaction-induced vasodilation and toxicity 3
- Administered as a single IV infusion (median dose 7.5 mg/kg)
- Particularly effective in patients requiring vasopressor support
5. Interventions NOT Recommended
- Iron salts, antihistamines, and phenothiazines have no established benefit 1
- Continued alcohol administration is contraindicated
Special Considerations
Severity Assessment
- Mild reactions may resolve with supportive care alone
- Severe reactions can mimic acute coronary syndrome with ECG changes and cardiac biomarker elevations 4
- Life-threatening complications include severe hypotension, arrhythmias, and cardiovascular collapse
Monitoring
- Continuous cardiac monitoring
- Frequent blood pressure measurements
- Pulse oximetry
- Electrolyte monitoring, particularly potassium
Prevention of Future Episodes
- Complete abstinence from alcohol while taking disulfiram and for at least 14 days after discontinuation 2
- Patient education about avoiding all sources of alcohol, including hidden sources in foods, medications, and personal care products
- Consider alternative medications for alcohol use disorder if appropriate:
Caution
Disulfiram-alcohol reactions can be life-threatening, particularly in patients over 50 years of age or those with pre-existing cardiovascular disease. The reaction can occur with even small amounts of alcohol and may persist for up to 2 weeks after the last dose of disulfiram 2, 6.