Fomepizole in Toxic Alcohol Poisoning

Clinical Indications

The American College of Emergency Physicians recommends fomepizole as the first-line antidote for toxic alcohol poisoning due to its simplicity of use, reduction in medication errors, and anticipated safety in children 1

The standard dosing of fomepizole is 15 mg/kg loading dose followed by 10 mg/kg every 12 hours until alcohol concentrations are <30 mg/dL, with dosage adjustment required during extracorporeal treatment as fomepizole is dialyzable 2
The European Society of Intensive Care Medicine recommends adjusting the dosage of fomepizole during extracorporeal treatment to maintain effective inhibition of alcohol dehydrogenase 2

The Society of Critical Care Medicine recommends hemodialysis in patients with severe metabolic acidosis (anion gap >27 mmol/L) despite fomepizole treatment 3
The American Society of Nephrology recommends hemodialysis in patients with high ethylene glycol concentration (>50 mmol/L or >310 mg/dL) despite fomepizole treatment 4

Fomepizole is preferred over ethanol due to its more predictable pharmacokinetics, lack of need for blood level monitoring, and no risk of hypoglycemia 1

The International Society of Nephrology recommends monitoring anion gap to evaluate treatment effectiveness, with cessation of extracorporeal treatment recommended once anion gap is <18 mmol/L 2

Fomepizole is the preferred first-line antidote for methanol poisoning, with a simpler dosing regimen and more predictable pharmacokinetics compared to ethanol, according to the American College of Medical Toxicology 5, 6, 7, 8, 9
The American College of Medical Toxicology recommends fomepizole due to its superior safety profile, ease of use, and reduction in medication errors compared to ethanol 5, 6, 7, 8, 9
Fomepizole has anticipated improved safety in children, and may reduce or eliminate the need for hemodialysis when given early, as stated by the American Academy of Clinical Toxicology 5, 6, 7, 8, 9

Ethanol may be used as an alternative ADH inhibitor only when fomepizole is unavailable, but it requires compounding of a 10% solution and necessitates blood level monitoring, according to the American College of Medical Toxicology 5, 6, 7, 8, 9
The use of ethanol as an antidote has a higher risk of medication errors during preparation and administration, as noted by the American Academy of Clinical Toxicology 5, 6, 7, 8, 9