Ethanol dosing for the treatment of toxic alcohol poisoning*

To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222, or the nearest international regional poison center. Contact information for regional poison centers around the world is available at the website referenced below.^[1]

Prepare 10 percent infusion^¶^[2,3]

1. Withdraw 100 mL of fluid from 1 liter of 5 percent dextrose water (D5W)

2. Replace with 100 mL of 98 percent dehydrated alcohol (ethanol) injection solution, USP (preservative- and bacteriostat-free) to create a 10 percent ethanol solution

3. Check vials/ampules. In some countries, pharmaceutical grade 95 percent ethanol is available. Do NOT use denatured alcohol or any other type of alcohol^Δ.

4. Prior to dilution, dehydrated alcohol injection should be purified through a 0.22 micron filter because these solutions may not be pyrogen-free

Loading dose

Infuse 10 mL/kg of 10 percent ethanol over 60 minutes to raise serum ethanol concentration by about 100 mg/dL (22 mmol/L)^¶

Maintenance dose

1. Following administration of the loading dose, begin maintenance infusion of 10 percent ethanol solution at 1 mL/kg per hour

2. Titrate infusion rate to maintain serum ethanol concentration of approximately 100 mg/dL (22 mmol/L) based on serial ethanol concentrations measured initially every 1 to 2 hours

3. Actual maintenance dose requirements vary from 0.8 mL/kg per hour to 2 mL/kg per hour (and higher still during hemodialysis)^◊

4. Once serial measurements demonstrate stable ethanol serum levels of ≈ 100 mg/dL (22 mmol/L), frequency of measurements may be decreased to every 2 to 4 hours

5. Larger toxic ingestions may warrant targeting a higher serum ethanol concentration goal of up to 150 mg/dL (33 mmol/L)^§

6. Continue maintenance infusion until either serum methanol or ethylene glycol concentration is undetectable (in patients with end-organ toxicity) OR <20 mg/dL (SI units: methanol <6.2 mmol/L; ethylene glycol <3.2 mmol/L) and patient is asymptomatic and with a normal pH. Two or more days of ethanol infusion may be required, depending upon amount of ingestion, toxicity, and use of hemodialysis.

* NOTE: Fomepizole is preferred antidotal therapy. Ethanol shown in this table is an alternate option when fomepizole is unavailable or when there is a history of a severe adverse reaction due to fomepizole warranting its avoidance. Refer to topic.
¶ Prepared as above, a 10 percent (volume to volume) ethanol solution provides approximately 0.8 grams of ethanol per 10 mL. A 10 mL/kg loading dose therefore provides ≈ 0.8 grams ethanol/kg. 10 percent ethanol solution is hyperosmolar (1700 mosm/L) and can cause phlebitis. Central venous catheter administration using an infusion pump is therefore preferred when feasible.
Δ When pharmaceutical grade ethanol is not available, alcoholic beverages can be substituted; a 20 percent ethanol solution (eg, 80 proof or 40 percent [volume to volume] diluted in an equal volume of D5W) can be administered orally or via a nasogastric tube at half the volumes recommended herein for a 10 percent intravenous infusion.
◊ Rate of elimination of ethanol is subject to wide inter-individual variability and is generally increased in male patients and those who consume alcohol chronically. Typical clearance rates are 15 to 20 mg/dL/hour (3.3 to 4.3 mmol/L per hour). The half-life of ethanol increases as serum levels rise such that small adjustments to dose can produce disproportionate changes in ethanol serum concentrations. Ethanol dose requirement are increased by about 50 percent during hemodialysis.
§ The targeted ethanol serum concentration should be at least one quarter of the serum methanol or ethylene glycol concentration as measured in conventional (mg/dL) units. Refer to topic for empiric adjustment.

References:

Poison emergency center contact numbers. Liquid Glass Nanotech. Available at: https://www.liquidglassnanotech.com/poison-emergency-center-contact-numbers/ (Accessed on May 25, 2021).
Barceloux DG, Krenzelok EP, Olson K, et al. American academy of clinical toxicology practice guidelines on the treatment of ethylene glycol poisoning. J Toxicol Clin Toxicol 1999; 37:537.
Barceloux DG, Bond GR, Krenzelok EP, et al. American academy of clinical toxicology practice guidelines on the treatment of methanol poisoning. J Toxicol Clin Toxicol 2002; 40:415.

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Ethanol dosing for the treatment of toxic alcohol poisoning*