Ethanol Dosing for Polyethylene Glycol Intoxication
Critical Clarification: No Ethanol Indicated for PEG
Ethanol is NOT indicated for polyethylene glycol (PEG) poisoning because PEG is not metabolized by alcohol dehydrogenase and does not produce toxic metabolites requiring ADH inhibition. 1
Key Distinction Between PEG and Ethylene Glycol
Polyethylene glycol is essentially non-toxic due to its high molecular weight (absorption from intestinal mucosa is only 0.2%) and does not undergo metabolism to toxic compounds 2
Ethylene glycol poisoning requires aggressive antidotal therapy with either fomepizole or ethanol because it is metabolized by alcohol dehydrogenase to toxic metabolites (glyoxylate, glycolate, oxalate) that cause severe metabolic acidosis, renal failure, and neurological damage 3
The treatment protocols for ethylene glycol poisoning—including ADH inhibitors and hemodialysis—are not indicated for PEG exposure 1
Common Clinical Pitfall
If there is any suspicion of ethylene glycol co-ingestion (such as antifreeze exposure), you must immediately initiate aggressive treatment protocols for ethylene glycol poisoning rather than assuming isolated PEG exposure 1, 4
Red Flags Suggesting Ethylene Glycol (Not PEG):
- Anion gap >27 mmol/L indicating severe poisoning 5, 4
- Unexplained metabolic acidosis with elevated anion gap 4
- Neurological symptoms (altered mental status, seizures, coma) 5
- Signs of acute kidney injury 5
When Ethanol IS Indicated (Ethylene Glycol Poisoning Only)
If the patient has ethylene glycol poisoning (not PEG), ethanol serves as a competitive ADH inhibitor:
Ethanol is extensively removed by hemodialysis (elimination half-life during dialysis: 1.5-3.0 hours; clearance >100 mL/min), requiring dose adjustment during extracorporeal treatment 3
Dosing must be increased during hemodialysis to maintain therapeutic levels and prevent inadequate inhibition of ethylene glycol metabolism 3, 5
Fomepizole is preferred over ethanol when available, but ethanol remains an alternative ADH inhibitor 5, 6
Management of Actual PEG Exposure
For isolated PEG ingestion: