Fomepizole to treat disulfiram-ethanol reaction: a case series

Abstract

Introduction: Disulfiram-ethanol reaction (DER) due to acetaldehyde accumulation occurs after drinking ethanol during disulfiram therapy. DER may result in life-threatening toxicity requiring urgent critical care. Fomepizole, an alcohol dehydrogenase inhibitor used to treat toxic alcohol poisoning, has been suggested for treating DER by preventing the metabolism of ethanol to acetaldehyde. However, its effectiveness and safety have been poorly assessed in this setting.

Cases: Ten DER patients (median age, 40 years; 7 males/3 females) were included in the study. DER features consisted of consciousness impairment (median Glasgow coma score, 13; need for mechanical ventilation, 30%) with flushing (50%), vomiting (40%), electrocardiogram abnormalities (30%) and circulatory failure requiring norepinephrine (30%). Patients were successfully treated with a single intravenous infusion of fomepizole (median dose, 7.5 mg/kg). The three patients receiving norepinephrine did not improve until fomepizole was administered. The other seven patients improved promptly following fomepizole infusion without requirement for vasopressor support. All patients fully recovered. Local pain at the injection site was the only reported adverse reaction in one patient.

Conclusion: Our case series supports the effectiveness and safety of fomepizole in rapidly reversing DER-induced vasodilatation and toxicity.

Keywords:

• Fomepizole
• disulfiram-ethanol reaction
• antidote
• safety
• vasodilatation

Acknowledgments

The authors would like to thank Mrs. Alison Good (Scotland, UK) for her helpful review of the manuscript.

Disclosure statement

The authors alone are responsible for the content and writing of this paper. The manuscript has been read and approved by all authors. The authors certify that the submission is not under review at any other publication. The authors certify that the authors have no other submissions and previous reports that might be regarded as overlapping with the current work. The authors declare no financial disclosures. Drs. Hélène Besson, Riana Rasamison and Marie-Pierre Berleur are reporting that they work in the French public institution, Pharmaceutical Establishment of Paris Hospitals (AGEPS) that manufactures fomepizole in France.