Use of fomepizole in pediatric poisonings

July 21, 2010, 9:31 pm

★★½☆☆

Fomepizole for the treatment of pediatric ethylene and diethylene glycol, butoxyethanol, and methanol poisonings. Brent J  Clin Toxicol 2010;48:401-406.

Abstract

This paper reviews fourteen cases published previously in the medical literature in which patients under 18 years of age were treated with fomepizole (4-methylpyrazole).  These cases involved exposure to ethylene glycol (N=10), methanol (2), diethylene glycol (1), and butoxyethanol (1).

The author admits that with such a small number of cases, the data described here is merely anecdotal.  Despite this, and despite the fact that he does not start out with a set of clear research questions, he concludes that: “In many cases of pediatric ethylene glycol poisoning treated with fomepizole, hemodialysis may not be necessary despite high concentrations and the presence of metabolic acidosis”.  Certainly this may be true — after all, metabolic acidosis can present in varying degrees of severity, and mild cases are usually easily handled, especially if an alcohol dehydrogenase blocker is administered to prevent metabolism of ethylene glycol to its toxic (and acidotic) metabolites.

However, I’m concerned that a clinician briefly looking at the abstract might conclude that the paper demonstrates hemodialysis may not be necessary in these cases even when there is significant metabolic acidosis.  (Although I realize that the paper certainly doesn’t make this claim.)  In fact, of the cases presented here, only one had a reported pH less than 7.29; that patient was dialyzed.  I would be more comfortable with the paper if the author had modified his tentative conclusion to state that hemodialysis might not be necessary even in the presence of mild metabolic acidosis.

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