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Key points

  • We recommend to consult your poison centre with the use of this antidote.
  • Fomepizole is preferred over ethanol, due to its effectiveness and ease of administration.
  • For methanol poisoning, folinic acid or folic acid can also be used as adjuvants.
  • For ethylene glycol poisoning, pyridoxine and thiamine can also be used as adjuvants.
  • Methanol and ethylene glycol are dialyzable.
  • Ethanol doses required vary between patients due to weight and individual differences in elimination; dose titration is required.

+ Synonyms and other terms

  • Absolute alcohol
  • Anhydrous alcohol
  • Dehydrated alcohol
  • Ethyl alcohol

+ Indications

  • When fomepizole is not available:
  • Methanol poisoning if serum concentration is equal or greater than 6 mmol/L (19,2 mg/dL).
  • Ethylene glycol poisoning if serum concentration is equal or greater than 3 mmol/L (18,6 mg/dL).
  • Circumstances suggesting one of these poisons pending testing, i.e.:
    • Metabolic acidosis with increased anion gap and unexplained osmolar gap greater than 10.
    • History, signs or symptoms suggestive of exposure
  • On a case-by-case basis, after consulting with your poison centre for other substances metabolized by alcohol dehydrogenase, such as diethylene glycol, 1.4-butanediol, or various glycol ethers, when metabolic acidosis develops.

+ Dosage

+ Pediatric Dose

Target serum ethanol level of 22 mmol/L (1 g/L) obtained by:

  • Intravenous route :
    • Use a solution for injection diluted to a final ethanol concentration of 10% v/v (see suggested IV preparation):
      • Loading dose: 8-10 ml/kg by slow IV infusion over 30 min.
      • Maintenance dose: 1 - 2 ml/kg/h by continuous IV infusion.
    • Dose adjustment is required for hemodialysis.
  • Oral Route:
    • Use an oral solution diluted to a final ethanol concentration of 20% v/v (see suggested PO preparation):
      • Loading dose: 4 ml/kg PO/NG tube.
      • Maintenance dose: 0.4 - 0.8 ml/kg/h PO/NG tube.
      • Dose adjustment is required for hemodialysis.

+ Adult Dose

Target serum ethanol level of 22 mmol/L (1 g/L) obtained by:

  • Intravenous route :
    • Use a solution for injection diluted to a final ethanol concentration of 10% v/v (see suggested IV preparation):
      • Loading dose:  8-10 ml/kg by slow IV infusion over 30 min.
      • Maintenance dose: 1 - 2 ml/kg/h by continuous IV infusion.
    • Dose adjustment is required for hemodialysis.
  • Oral Route:
    • Use an oral solution diluted to a final ethanol concentration of 20% v/v (see suggested PO preparation):
      • Loading dose: 4 ml/kg PO/NG tube.
      • Maintenance dose: 0.4 - 0.8 ml/kg/h PO/NG tube.
      • Dose adjustment is required for hemodialysis.

+ Renal Impairment

No data suggests that the dose should be modified for short-term use.

+ Hepatic Impairment

No data suggests that the dose should be modified for short-term use.

+ Hemodialysis Patient

  • If there is ethanol in the dialysate, no change should be necessary.
  • If the dialysate does not contain ethanol:
    • Intravenous route, 10% v/v solution:
      • Maintenance dose during hemodialysis: 2 - 3.5 ml/kg/h by continuous IV infusion.
    • Oral route, 20% v/v solution:
      • Maintenance dose during hemodialysis: 1.3 - 1.8 ml/kg/h PO/NG tube.

+ Pregnancy

  • During pregnancy, the choice is between fomepizole, an antidote with an unknown risk, and ethanol, an antidote whose risks are known.
  • Ethanol is a confirmed teratogen when consumed regularly.
  • The risk of birth defects or fetal alcohol syndrome are to be considered if ethanol is administered over a long period. Refer to the centre IMAGe if necessary.
  • The effect of ethanol used in poisoning cases during pregnancy is not known. It could be similar to a slightly prolonged isolated ingestion given that the ethanol level targeted is 22 mmol/L over several hours.
  • If fomepizole is not an option, do not hesitate to use ethanol during pregnancy if the anticipated toxic effects pose a significant risk of morbidity or mortality.
  • No data suggests that the dose should be modified for short-term use.

+ Obese or Overweight Patient

No data suggests that the dose should be modified for short-term use.

+ Adverse effects

  • Central nervous system depression, possible hypoglycemia, thrombophlebitis (if administered via a peripheral vein).

+ Monitoring

  • Ethanol serum level
  • Plasma concentration of ethylene glycol or methanol
    • Conversion factors:
      • Methanol: 1 mmol/l = 3.20 mg/dL; 1 mg/dL = 0.3121 mmol/L.
      • Ethylene glycol: 1 mmol/l = 6.21 mg/dL; 1 mg/dL= 0.1611 mmol/L.
  • Hepatic and renal function
  • Serum electrolytes
  • Glucose
  • EKG
  • Blood gases
  • Anion and osmolar gaps

+ End of treatment

  • Methanol poisoning: Concentration less than 6 mmol/L and absence of metabolic acidosis (if patient is on hemodialysis, the level must be obtained at least 4 - 6 h after the end of the hemodialysis session).
  • Ethylene glycol poisoning: Concentration less than 3 mmol/L and absence of metabolic acidosis (if patient is on hemodialysis, the level must be obtained at least 4 - 6 h after the end of the hemodialysis session).
  • Poisoning with other substances: Generally several hours after the metabolic acidosis has subsided (quantitative testing may not be readily available).

+ Special Notes on Administration

Intravenous Route (IV)

  • Direct IV: Not recommended.
  • Continuous IV infusion:
  • Suggested preparation method using 99.5% - 100% v/v ethanol solution for injection:
    • Put 100 ml of 99.5% - 100% v/v ethanol solution for injection in 900 ml of D5W. Final volume: 1000 ml. Final concentration: approx. 10% v/v = 100 mg/ml.
    • Use this preparation for the loading dose and the maintenance dose.
  • Administer using a volumetric pump.
  • Ideally, ethanol should be administered by central line.
  • Note: 99.5% - 100% v/v ethanol = 790 mg/ml.

Enteral Route (PO or NG Tube)

  • Dilute ethanol in juice in order to obtain a final concentration of approximately 20% v/v (200 mg/ml).
  • Suggested preparation method using 99.5% - 100% v/v ethanol solution for injection
    • Put 20 ml of 99.5% - 100% v/v ethanol in 80 ml of juice. Final volume: 100 ml Final concentration: 20% v/v.
    • Put 50 ml of 99.5% - 100% v/v ethanol in 200 ml of juice. Final volume: 250 ml. Final concentration: 20% v/v.
    • Put 100 ml of 99.5% - 100% v/v ethanol in 400 ml of juice. Final volume: 500 ml. Final concentration: 20% v/v.
  • Suggested preparation method using 40% v/v oral solution of ethanol (e.g. vodka):
    • Put 50 ml of 40% v/v ethanol in 50 ml of juice. Final volume: 100 ml. Final concentration: 20% v/v.
    • Put 125 ml of 40% v/v ethanol in 125 ml of juice. Final volume: 250 ml. Final concentration: 20% v/v.
    • Put 250 ml of 40% v/v ethanol in 250 ml of juice. Final volume: 500 ml. Final concentration: 20% v/v.

Intraosseous Route (IO)

  • No data available.

Subcutaneous Route (SC)

  • Do not administer using this route.

Intramuscular Route (IM)

  • Do not administer using this route.

Compatibility

Partial list only. Consult the pharmacist on duty at your health care facility.

  • Compatible solutions: D5W, NS.
  • Y-site compatibility (when diluted in D5W): cimetidine, diltiazem, dobutamine, dopamine, epinephrine, esmolol, haloperidol, standard heparin, regular insulin, labetalol, sodium nitroprusside, norepinephrine, phenylephrine, procainamide, ranitidine.
  • Y-site incompatibility: No data available.

Stability

  • Store unopened vials at room temperature between 15°C and 30°C.
  • Stable 151 days at room temperature

+ Available products

  • Dehydrated ethyl alcohol USP sterile solution, 100 % v/v, 10ml vials.
    • Order directly from Gentès and Bolduc Pharmacists
    • 1-855-866-0866
    • Product code: 11615-0010

+ Amount required to treat a person weighting 70kg during 24 hours

  • At least 750 g, unless fomepizole is stocked.

+ References

Lepik, Katherine J., Adrian R. Levy, Boris G. Sobolev, Roy A. Purssell, Christopher R. DeWitt, Gunnar D. Erhardt, James R. Kennedy, Derek E. Daws, and Jane L. Brignall. 2009. “Adverse Drug Events Associated with the Antidotes for Methanol and Ethylene Glycol Poisoning: A Comparison of Ethanol and Fomepizole.” Annals of Emergency Medicine 53 (4):439–50.e10.



Roberts, Darren M., Christopher Yates, Bruno Megarbane, James F. Winchester, Robert Maclaren, Sophie Gosselin, Thomas D. Nolin, et al. 2015. “Recommendations for the Role of Extracorporeal Treatments in the Management of Acute Methanol Poisoning: A Systematic Review and Consensus Statement.” Critical Care Medicine 43 (2):461–72.



Schaeffer, Tammi H. 2016. “Ethanol.” In Critical Care Toxicology, edited by Jeffrey Brent, Keith Burkhart, Paul Dargan, Benjamin Hatten, Bruno Megarbane, and Robert Palmer, 28:1–6. Cham: Springer International Publishing.



Sivilotti, Marco L. A. 2009. “Ethanol: Tastes Great! Fomepizole: Less Filling!” Annals of Emergency Medicine 53 (4):451–53.


Last updated : 2021-08-31