Treat with booze or drugs?

1 Oct

While I’m known for saying that most of the useful things I’ve learnt in my career I learnt on the web, it is also true that there’s the odd nugget on the telly too.

Back in the early series when House was decent there was this episode where he saves a guy’s life by getting him pissed.

We don’t do that so much anymore.

The toxic alcohols (in very brief format)

  • methanol and ethylene glycol – often in anti-freeze or windscreen wiper fluid
  • alcohols not toxic themselves but their metabolites
    • methanol goes to formate and makes you blind
    • ethylene glycol goes to a few including glycolate and buggers your kidneys
  • patients present with a metabolic acidosis and a raised osmolar gap when the alcohols are in the blood and a raised anion gap once they’re metabolised
  • Our old friend alcohol dehydrogenase does the metabolising so if you can keep it busy with something else then the toxic alcohols can be eliminated without being metabolised
  • you can do this with alcohol but it’s understandably messy to say the least…
  • or you can use the drug fomepizole
Sciencey looking diagram…
mmm chemical structures…

From the Colorado Compendium I found these two trials:

Brent, J, K McMartin, S Phillips, K K Burkhart, J W Donovan, M Wells, and K Kulig. 1999. “Fomepizole for the treatment of ethylene glycol poisoning. Methylpyrazole for Toxic Alcohols Study Group..” The New England journal of medicine 340 (11) (March 18): 832–838. doi:10.1056/NEJM199903183401102.

Brent, J, K McMartin, S Phillips, C Aaron, K Kulig, Methylpyrazole for Toxic Alcohols Study Group. 2001. “Fomepizole for the treatment of methanol poisoning..” The New England journal of medicine 344 (6) (February 8): 424–429. doi:10.1056/NEJM200102083440605.

I was expecting these to be the landmark RCTs of the drug.

I was initially surprised to see nothing of the sort.

Both papers are prospective case-series with a whopping 19 pts in the former and 11 in the latter.

They did seem to be sick though only 3 out of the 30 died. Most got haemodialysis too.

My initial thought, this is nonsense, this is a travesty of science. And then I thought about it a bit.

I have never treated someone with a toxic alcohol poisoning. This reflects my clinical naivety and immaturity and the sheer rarity of it.

Like virtually all things tox, we have to work with a lot less than RCT level evidence. And actually that’s OK. Whenever I do finally see a sickie with a toxic alcohol poisoning, I will reach for the Fomepizole… or if it’s me that’s been poisoned then I’d prefer a Bushmills 16yr old or a Laphroaig….

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