Antidotes for poisoning by alcohols that form toxic metabolites.

The alcohols methanol, ethylene glycol and diethylene glycol share many characteristics. The most important is that the compounds themselves are relatively nontoxic but are metabolized, initially by alcohol dehydrogenase, to various toxic intermediates. These compounds are readily available worldwide in commercial products as well as in homemade alcoholic beverages, both of which lead to most of the poisonings, from either unintentional or intentional ingestion. Although relatively infrequent, toxic alcohol poisonings do unfortunately occur in outbreaks and can result in severe morbidity and mortality. These poisonings have traditionally been treated with ethanol since it competes for the active site of alcohol dehydrogenase and decreases the formation of toxic metabolites. Although ethanol can be an effective antidote, there are substantial practical problems with its use. Therefore fomepizole, a potent competitive inhibitor of alcohol dehydrogenase, was developed for a hopefully better treatment for metabolically toxic alcohol poisonings. Fomepizole has few side effects and is easy to use in practice and it may obviate the need for haemodialysis in some, but not all, patients. Hence, fomepizole has largely replaced ethanol as the toxic alcohol antidote in many countries. Nevertheless, ethanol remains an important alternative because access to fomepizole can be limited, the cost may appear excessive or the physician may prefer ethanol due to experience.

Emerging progressive atypical acute kidney injury in young children linked to ethylene glycol and diethylene glycol intoxication.

BACKGROUND: There had been a sudden surge of unusually severe and rapidly progressing acute kidney injury (AKI) incidence in Indonesia since August 2022 which did not correspond to the rise of COVID-19 incidence. We suspected this was related to ethylene glycol (EG) and diethylene glycol (DEG) intoxication. This study is aimed at describing the clinical and laboratory characteristics of AKI related to D(EG) intoxication in order to spread awareness of the possibility of intoxication in cases of rapidly progressing AKI with unknown etiology. METHODS: We conducted a cross-sectional study by collecting secondary data from the pediatric AKI registry at a national referral hospital in Jakarta, Indonesia. Data on children admitted from January to November 2022 with diagnosis of stage 3 AKI based on KDIGO criteria were included. Data regarding demographics, symptoms prior to anuria, laboratory results, infection panel including COVID-19 status, treatment administered, and mortality were analyzed. RESULTS: Sixteen patients tested positive for EG and DEG, all with history of consuming syrup-based medications. High anion gap metabolic acidosis was observed in majority of patients with mean pH 7.33 ± 0.07 and mean anion gap 15.6 ± 7.8 mEq/L. No patient had high osmolal gap (mean osmolal gap 3.46 ± 4.68). One deceased patient, who had kidney biopsy performed, showed severe damage and calcium oxalate crystals in the kidney tissue. Mortality was recorded in six patients (37.5%). CONCLUSION: Careful history taking of patient's clinical course, including consumption of syrup-based medications and laboratory findings, might aid clinicians to establish a working diagnosis of D(EG) intoxication without needing to wait for blood toxicology test. Early diagnosis and therapy are crucial to prevent substantial mortality.

A case of suicide secondary to diethylene glycol intentional ingestion.

We aimed to describe a case of acute kidney injury (AKI) with an uncommon case. We described a previously health 24 years old male that presented acute kidney injury associated with neurological and respiratory symptoms. He was initially admitted at the hospital with nausea, vomiting, blurred vision, and reduced urine output. The patient's condition got worse approximately in one week. Laboratory tests revealed high levels of nitrogenous waste, hyponatremia, metabolic acidosis with an increased anion gap, and the presence of proteinuria and hematuria. The patient experienced paresthesia, seizures, respiratory alterations, and altered consciousness. The initial diagnostic hypothesis of rapidly progressive glomerulonephritis was not confirmed. A deeper investigation of the case exposed that it could have occurred an intentional exogenous poisoning with diethylene glycol (DEG). Renal biopsy unveil findings suggestive of poison-induced nephrotoxicity, which corroborated the suspicion. Despite therapeutic efforts, the patient died due to pulmonary complications. This case report shows the need to consider DEG poisoning as a etiology of AKI, especially in patients with neurological symptoms. Laboratory and histopathological analysis were crucial for the diagnosis.

Endemic rise in cases of acute kidney injury in children in Indonesia and Gambia: what is the likely culprit and why?

A sudden rise in the cases of acute kidney injury (AKI) has been reported in Indonesia and Gambia that has been linked to the consumption of tainted syrup medications for cough, colds, pain, and fever. Preliminary investigations revealed multiple lapses in quality control during manufacturing including substitution of diethylene glycol (DEG) and ethylene glycol (EG) for the more expensive but non-toxic solvent glycerol. In this editorial report, we shed light upon the current situation and urge the investigating authorities to make those responsible accountable to regain public trust.

Diglycolic acid inhibits succinate dehydrogenase activity, depletes mitochondrial membrane potential, and induces inflammation in an SH-SY5Y neuroblastoma model of neurotoxicity in vitro.

Diethylene glycol is a toxic industrial solvent resulting in a well-defined toxidrome. Diglycolic acid (DGA) has been identified as the metabolite responsible for the nephrotoxicity and hepatotoxicity. These studies assess the mechanism of DGA-induced neurotoxicity, specifically addressing the known ability of DGA to chelate calcium (Ca2+) in solution and inhibit mitochondrial complex II. SH-SY5Y cells were seeded into 96-well plates to assess intracellular Ca2+ chelation, complex II activity, mitochondrial membrane potential (ΔΨm), ATP production, and release of inflammatory cytokines TNF-α and IL-1ß with 2-, 4-, 6-, 24-, and 48-h DGA exposure. Peak Ca2+ chelation occurred at 4 h in cells treated with 6.25-50 mM DGA; however, effects were transient. Complex II activity was significantly decreased at all DGA concentrations tested, with 12.5 mM DGA causing 80% inhibition and 25 and 50 mM DGA causing 97 and 100% inhibition, respectively. Subsequently, 12.5-50 mM DGA concentrations significantly decreased ΔΨm at all time points. 50 mM DGA significantly increased release of TNF-α and IL-1ß after 24 and 48 h with significantly decreased ATP production observed at the same time points and concentration. These studies demonstrate that the DGA-induced mechanism of SH-SY5Y cell death involves complex II inhibition leading to mitochondrial depolarization, and subsequent ATP depletion with accompanying inflammatory cytokine release. These results indicate a direct mechanism of DGA-induced neurotoxicity in vitro, similarly observed in other DEG-affected target organs.

High risk and low prevalence diseases: Toxic alcohol ingestion.

INTRODUCTION: Toxic alcohol ingestion is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of toxic alcohol ingestion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Toxic alcohols include ethylene glycol, methanol, isopropyl alcohol, propylene glycol, and diethylene glycol. These substances can be found in several settings including hospitals, hardware stores, and the household, and ingestion can be accidental or intentional. Toxic alcohol ingestion presents with various degrees of inebriation, acidemia, and end-organ damage depending on the substance. Timely diagnosis is critical to prevent irreversible organ damage or death and is based primarily on clinical history and consideration of this entity. Laboratory evidence of toxic alcohol ingestion includes worsening osmolar gap or anion-gap acidemia and end organ injury. Treatment depends on the ingestion and severity of illness but includes alcohol dehydrogenase blockade with fomepizole or ethanol and special considerations for the initiation of hemodialysis. CONCLUSIONS: An understanding of toxic alcohol ingestion can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

[An occupational acute poisoning incident of diethylene glycol monobutyl ether].

Objective: To analyze the causes and clinical characteristics of 9 cases of occupational acute poisoning with diethylene glycol monobutyl ether, and provide a basis for clinical diagnosis, treatment, prognosis, and prevention. Methods: The leakage accident of diethylene glycol monobutyl ether occurred in an electronic company in Janvary 2021, in Weihai City was analyzed. The clinical manifestations, laboratory examinations, diagnosis, treatment and prognosis of 9 cases of diethylene glycol monobutyl ether poisoning were summarized. Results: All 9 patients had moderate chemical eye burns and chemical conjunctivitis, and were immediately given symptomatic treatment. They fully recovered after 14 days. Conclusion: Patients who inhale diethylene glycol monobutyl ether for a short time have obvious eye burns, but early detection and timely treatment can achieve better prognosis.

Temperature-pressure correlations of cryoprotective additives for the design of constant volume cryopreservation protocols.

In the recent years, the use of constant volume (isochoric) cryopreservation, in medicine and biotechnology has captured more attention from the research community and now there is an increasing interest in the use of this new technology. It has been established that the thermodynamics of isochoric freezing is different from that of isobaric (constant pressure) freezing. This study provides researchers in the field experimental results for various compositions of cryoprotectants commonly used in isobaric cryopreservation, in terms of temperature-pressure-molar concentration correlation. It also reveals experimental isochoric thermodynamic data for the following cryoprotectants, commonly used in isobaric cryopreservation: dimethyl sulfoxide, trehalose, ethylene glycol and diethylene glycol. Currently, the data on the pressure-temperature correlation in an isochoric system of cryoprotectants used in isobaric cryopreservation is not available. Our new experimental results indicate that the studied concentrations for each of the CPAs, lower and expands the range of temperatures in which cryopreservation by isochoric freezing can be safely practiced. We consider that these experiments will aid researchers developing new isochoric cryopreservation protocols.

Symptomatic Diethylene Glycol Ingestion Successfully Treated with Fomepizole Monotherapy.

BACKGROUND: Diethylene glycol (DEG) is an industrial solvent with many uses, including brake fluids. It has also caused mass poisonings after use as an inappropriate substitute for propylene glycol or glycerin, though individual ingestions are rare. Like other toxic alcohols, DEG is metabolized by alcohol dehydrogenase and aldehyde dehydrogenase, with toxicity likely mediated by the resulting metabolites. Fomepizole, an alcohol dehydrogenase inhibitor, is used to prevent metabolite formation with other toxic alcohol exposures. Fomepizole is recommended for DEG poisoning, though supporting clinical evidence is limited. CASE REPORT: A 31-year-old man presented after ingestion of DEG-containing brake fluid and hydrocarbon-containing "octane booster." He was noted to be clinically intoxicated, with a mildly elevated anion gap metabolic acidosis and no osmolar gap. DEG level was later found to be elevated, consistent with his ingestion. He was treated with fomepizole alone, with resolution of metabolic acidosis and clinical findings over the next 2 days. No delayed neurologic sequelae were present at 52-day follow-up. Our case provides additional evidence supporting the use of fomepizole for DEG poisoning. Consistent with other toxic alcohols, DEG poisoning, especially early presentations, may benefit from empiric fomepizole administration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: DEG poisoning is potentially life threatening, but treatable if identified early. An ingestion can be toxic despite a normal osmolar gap, leading to false reassurance. Finally, it is rare, so emergency physicians must be made aware of its potential dangers.

Functionalized Cu-based metal oxide nanoparticles with enhanced Cd+2 adsorption capacity and their ecotoxicity assessment by molecular docking.

In the present study, synthesis of eco-friendly Cu-based metal oxides nanoparticles [CuO, Cu2O, and CuO&Cu2O nanoparticles (NPs)] without and with functionalization with Diethylene glycol (DEG) has been demonstrated. The synthesized NPs were screened for their ability to adsorb multiple heavy metal ions from an aqueous solution. Based on the maximum Cadmium (Cd+2) ion adsorption capacity, functionalized Cu2O (fCu2O) NPs were selected for the detailed characterization and batch studies. The average size of fCu2O NPs was found to be 57.4 ± 6.14 nm in comparison to NPs without capping (72.6 ± 5.19 nm). The experimental parameters viz. contact time, initial pH, and initial concentration were optimized, and the obtained results were interpreted using standard isotherms and kinetic models. The maximum Cd+2 adsorption on fCu2O NPs was observed at initial solution pH 7. The adsorption of Cd+2 was found to be decreased at acidic pH due to the protonation of functional groups present on the NPs surface. A maximum Cd+2 adsorption capacity of 204 ± 6.2 mg g-1 was obtained from the Langmuir adsorption isotherm. The crystal structure of NPs was prepared and docked with the protein targets of selected soil microbes in order to determine their ecotoxicity. The obtained results showed that NPs exhibited low affinity towards protein targets in comparison to the standard used. It suggests that NPs have less impact on the functionality of soil microbes and are thus safe for their disposal into the soil micro-environment.

Identification of Three Novel Chloroalkyl Organophosphate Triesters in House Dust Using Halogenation-Guided Nontarget Screening Combined with Suspect Screening.

Several haloalkyl organophosphate triester (OPTE) flame retardants have been restricted in some countries due to their potential health risks, but the usage of alternative haloalkyl OPTEs is of concern. In this study, we comprehensively screened for haloalkyl OPTEs in house dust using high-resolution mass spectrometry. Through halogenation-guided nontarget screening, a rare chloroalkyl OPTE, diethylene glycol bis(bis(2-chloroisopropyl)phosphate) (DEGBBCPP), was unequivocally identified (Level 1) in house dust of Beijing, North China. In addition, by screening a suspect list of 61 haloalkyl OPTEs from the EPA's CompTox Chemicals Dashboard, we tentatively identified diethylene glycol bis(bis(2-chloroethyl)phosphate) (DEGBBCEP) and ethylene bis[bis(2-chloroethyl)phosphate] (EBBCEP) (Level 2). DEGBBCPP was detected in all 45 house dust samples, and the median concentration was 98.4 ng/g (13.6-6217 ng/g), that is, approximately one-half that of tris(1,3-dichloro-2-propyl) phosphate, a traditional high-production chloroalkyl OPTE. The detection frequencies of DEGBBCEP and EBBCEP were 96% and 98%, respectively, but at relatively low median concentrations of 10.6 ng/g (from not detected to 152 ng/g) and 3.79 ng/g (from not detected to 130 ng/g), respectively. In standard house dust SRM2585, DEGBBCEP and EBBCEP were detected at 160 ± 15.7 and 1897 ± 38.8 ng/g, respectively, but DEGBBCPP was not detected. Future studies should evaluate the potential adverse health effects of these emerging flame retardants.

Individual and Combined Inhalational Sedative Effects in Mice of Low Molecular Weight Aromatic Compounds Found in Agarwood Aroma.

Agarwood is known to have a sedative effect and the less studied volatile aromatic constituents it contains may have contribution to the activity. In this study, two Kyara grade (highest-grade agarwood in Japan) samples were extracted using headspace-solid phase microextraction (HS-SPME) and analyzed through gas chromatography-mass spectrometry (GC-MS). Six low molecular weight aromatic compounds (LACs) and one structurally simple compound (diethylene glycol monoethyl ether) present in the aromas were individually evaluated for inhalational sedative activity in mice through open field test. Doses of 0.0001 g/L to 1 g/L were prepared for each compound and administered to mice (n = 6/dose/compound). Results revealed all compounds decreased spontaneous motor activity at almost all doses. Strongest sedative activity of each compound reduced total spontaneous motor activity by more than half against control, demonstrating their contribution to agarwood aroma and potential as independent sedating agents. Mixtures of compounds using their most effective dose were made and evaluated again for inhalational sedative effect. Interestingly, the combination of all compounds showed no significant effect and even caused stimulation in mice movements. This result suggests antagonistic-like interaction between the compounds, which is probably due to structural similarities. Consequently, it implies the other constituents present in agarwood, along with LACs, are also important to the overall sedative activity.

Interaction of Reactive-Dye Chromophores and DEG on Ink-Jet Printing Performance.

Digital inkjet printing has been widely used in textile industry. The quality of dye solutions and ink-jet droplets limits the ink-jet printing performance, which is very important for obtaining high-quality ink-jet printing images on fabrics. In this paper, we introduced diethylene glycol (DEG) into the dye solutions of Reactive Blue 49 and Reactive Orange 13, respectively, and investigated the interaction between dye chromophores and DEG molecules. Results indicated that the dye chromophores were featured in the aggregation. Adding DEG into the dye solution could effectively disaggregate clusters of reactive dyes, and eliminate satellite ink droplets, thus improving the resolution of the ink-jet printing image on fabrics. Under the same DEG concentration, the disaggregation effect was more obvious in Orange 13 than in Reactive Blue 49. Higher DEG concentration was required in Reactive Orange 13 solution for creating complete and stable ink drops. The surface tension and viscosity of the dye solutions were measured, and printing performance on cotton fabrics was evaluated. The interaction mechanism between dye chromophores and DEG molecules was also investigated. Results from this work are useful for high-quality ink-jet printing images on fabrics.

Double gloving of disposable nitrile gloves exposed to diethylene glycol mono-n-butyl ether.

Double gloving of disposable gloves is now commonplace in healthcare settings when extra protection is needed against aqueous solutions and especially for antineoplastic drugs in isotonic aqueous media. In the present study, an ASTM F739 2.54 cm cell with closed-loop water collection without recirculation at 35 °C in a moving tray water bath was used to test the permeation of diethylene glycol mono-n-butyl ether (DGBE) through four types of disposable nitrile gloves that were singly and doubly layered in the permeation cell. Samples were taken over 8 hr for capillary gas chromatograph-mass spectrometer quantitation. The breakthrough time (tn) at a permeation of 250 ng/cm2 increased as thickness increased for single layers, but the steady-state permeation rates Ps in µg/cm2/min did not always decrease with increasing thickness. The double-layer tn, Ps and thickness were also more variable relative to a single layer. The thinnest glove with 80 [Formula: see text]m thickness showed a tn = 0-5 min whereas its double layer was 15-20 min. The thickest glove of 132 µm exhibited a tn = 10-15 min but its double layer was tn = 45-55 min. The adjusted double-layer average tn divided by the adjusted single-layer average tn was 4.0 ± 0.8. The adjusted average single-layer Ps divided by the adjusted average double-layer Ps was 3.5 ± 0.8. Other results showed that the average glove swelling was <10%; microscopic and leak testing indicated no penetration and reflectance infrared analysis also showed no chemical changes on the inside glove surfaces. Thus, the permeations were adjudged to obey Fick's First Law of Diffusion to allow calculation of diffusion coefficients D in cm2/min. The average single-layer D divided by the average double-layer D was 1.3 ± 0.2. Double gloving in the field is therefore also probably more protective than single gloving against DGBE for the four types of disposable nitrile gloves tested.

Novel Water-Soluble Cyclotriphosphazene-Bodipy Conjugates: Synthesis, Characterization and Photophysical Properties.

In the present work, novel water-soluble cyclotriphosphazene derivatives (3b and 4b) were synthesized by 'click' reactions between cyclotriphosphazene derivative with hydrophilic glycol side groups (2) and Bodipy's (3a and 4a). All newly synthesized compounds (2, 3b and 4b) were characterized by fourier-transform infrared (FTIR), mass and NMR spectroscopy techniques and elemental analysis (EA). The photophysical properties of Bodipy substituted novel cyclotriphosphazenes (3a and 4a) were examined via UV-Vis absorption and fluorescence emission spectroscopy inside water and many organic solvents such as acetone, tetrahydrofuran, dichloromethane, dimethyl sulfoxide, etc., and the results were compared with the each other. Graphical Abstract.

Fatal poisoning with diethylene glycol in an unusual setting.

Morphological findings in cases of intoxication are relatively rare in forensic pathology. In this article we report on a 26-year-old man who drank clear fluid from a tequila bottle that was given to him by a friend. Afterwards, the clear fluid was assumed to be smoke fluid containing diethylene glycol (DEG). The man died eight days later. Macroscopic and microscopic examination of the kidneys and the liver at forensic autopsy revealed findings typical of a DEG intoxication. In addition, the clinical course showed the typical triphasic pattern of symptoms. Toxicological analysis confirmed the presence of DEG in both the original smoke fluid and the tequila bottle. In conclusion, death was due to fatal intoxication by DEG. While most DEG intoxications have been mass poisoning incidents attributed to pharmaceutical products, the present case describes an unusual example of a single decedent.

PEG 3350 Administration Is Not Associated with Sustained Elevation of Glycol Levels.

OBJECTIVE: To determine whether trace amounts of ethylene glycol (EG), diethylene glycol (DEG), or triethylene glycol (TEG) in PEG 3350 are associated with increased blood levels of EG, DEG, or TEG in children receiving daily PEG 3350 therapy. STUDY DESIGN: Blood samples were drawn from 9 children who were being treated for constipation with PEG 3350 (6-12 years old) before and every 30 minutes for 3 hours after receiving 17 g of PEG 3350. PEG 3350, tap water, and blood samples from 18 age- and sex-matched controls also were analyzed. RESULTS: Baseline blood levels of EG and TEG did not differ between control and treated groups. DEG levels (median [IQR]) were lower in the PEG 3350 group (40.13 ng/mL [36.69, 63.94] vs 92.83 ng/mL [51.06, 128.93], P = .008). After PEG 3350 dose, levels of EG (390.51 ng/mL [326.06, 624.55]) and TEG (2.21 ng/mL [0, 4.5]) peaked at 90 minutes at 1032.81 ng/mL (826.84, 1486.13) (P = .009) and 35.17 ng/mL (15.81, 45.13) (P = .0005), respectively. DEG levels did not significantly change. Standard 17-g doses of PEG 3350 in 8 oz (237 mL) of water resulted in concentrations (mean ± SD) of EG, DEG, and TEG of 1.32 ± 0.23 µg/mL, 0.18 ± 0.03 µg/mL, and 0.12 ± 0.01 µg/mL, respectively. EG, DEG, and TEG levels in public water supply were 0.07 µg/mL, 0.21 µg/mL, and 0.02 µg/mL, respectively. CONCLUSIONS: Daily PEG 3350 therapy in children was not associated with sustained elevation of EG, DEG, or TEG blood levels over levels in matched controls. Although EG and TEG levels increased after a standard dose of PEG 3350, their peak values remained well below toxic levels.

Human health assessment for long-term oral ingestion of diethylene glycol.

Diethylene glycol (DEG) is an organic chemical that is used mostly as a chemical intermediate and has minor uses as a solvent or antifreeze in consumer products; these minor uses could result in potential human exposure. Potential short and long-term human exposures also occur from misuses. The considerable reporting of DEG misuses as a substitute for other solvents in drug manufacturing and summaries of important events in the history of DEG poisonings are reviewed. Given the potential for human exposure, the disposition and toxicity of DEG were examined, and a health assessment was performed. Toxicokinetics and metabolism studies are evaluated, along with a discussion on the renal toxicity mode of action in the rat. Additionally, in-depth assessments of the key animal research studies on the toxic effects of DEG from oral ingestion for various exposure time periods are presented with determination of NOAELs and LOAELs from the long-term exposure animal studies. These are applied in the derivation of a reference dose for a non-cancer endpoint from chronic exposure, resulting in a value of 0.3 mg DEG/kg bw.

An optimized two-step derivatization method for analyzing diethylene glycol ozonation products using gas chromatography and mass spectrometry.

The ozonation of hydroxyl compounds (e.g., sugars and alcohols) gives a broad range of products such as alcohols, aldehydes, ketones, and carboxylic acids. This study developed and optimized a two-step derivatization procedure for analyzing polar products of aldehydes and carboxylic acids from the ozonation of diethylene glycol (DEG) in a non-aqueous environment using gas chromatography-mass spectrometry. Experiments based on Central Composite Design with response surface methodology were carried out to evaluate the effects of derivatization variables and their interactions on the analysis. The most desirable derivatization conditions were reported, i.e., oximation was performed at room temperature overnight with the o-(2,3,4,5,6-pentafluorobenzyl) hydroxyl amine to analyte molar ratio of 6, silylation reaction temperature of 70°C, reaction duration of 70min, and N,O-bis(trimethylsilyl)-trifluoroacetamide volume of 12.5µL. The applicability of this optimized procedure was verified by analyzing DEG ozonation products in an ultrafine condensation particle counter simulation system.

Antidotes for poisoning by alcohols that form toxic metabolites.

The alcohols, methanol, ethylene glycol and diethylene glycol, have many features in common, the most important of which is the fact that the compounds themselves are relatively non-toxic but are metabolized, initially by alcohol dehydrogenase, to various toxic intermediates. These compounds are readily available worldwide in commercial products as well as in homemade alcoholic beverages, both of which lead to most of the poisoning cases, from either unintentional or intentional ingestion. Although relatively infrequent in overall occurrence, poisonings by metabolically-toxic alcohols do unfortunately occur in outbreaks and can result in severe morbidity and mortality. These poisonings have traditionally been treated with ethanol since it competes for the active site of alcohol dehydrogenase and decreases the formation of toxic metabolites. Although ethanol can be effective in these poisonings, there are substantial practical problems with its use and so fomepizole, a potent competitive inhibitor of alcohol dehydrogenase, was developed for a hopefully better treatment for metabolically-toxic alcohol poisonings. Fomepizole has few side effects and is easy to use in practice and it may obviate the need for haemodialysis in some, but not all, patients. Hence, fomepizole has largely replaced ethanol as the toxic alcohol antidote in many countries. Nevertheless, ethanol remains an important alternative because access to fomepizole can be limited, the cost may appear excessive, or the physician may prefer ethanol due to experience.