Barceloux DG, Krenzelok EP, Olson K, Watson W. American Academy of Clinical Toxicology Practice Guidelines on the Treatment of Ethylene Glycol Poisoning. Clinical Toxicology 1999; 37(5): 537-560.

This paper is an extensive review of all aspects of ethylene glycol poisoning and its treatment. Suggested indications for use of an antidote are: documented plasma ethylene glycol concentration greater than 20 mg/dL OR documented recent ingestion of a toxic quantity of ethylene glycol and an osmol gap greater than 10 mOsm/L OR a strong suspicion of ethylene glycol poisoning AND at least two of the following criteria: arterial pH less than 7.3; serum bicarbonate less than 20 mEq/L; and osmol gap greater than 10 mOsm/L; or the presence of urinary oxalate crystals. Fomepizole is indicated for the treatment of ethylene glycol poisoning unless unavailable or the patient has a hypersensitivity to fomepizole.

Brent J, McMartin K, Philips S, Burkhart KK, Donovan JW, Wells M, Kulig K. Fomepizole for the Treatment of Ethylene Glycol Poisoning. New England Journal of Medicine 1999; 340:832-838.

This prospective, multicenter clinical trial evaluated the use of fomepizole in 19 cases of ethylene glycol poisoning. In each case, the serum ethylene glycol concentration was greater than 20 mg/dL. Seventeen patients underwent hemodialysis in addition to receiving fomepizole. Nine patients suffered decreased renal function; all nine had elevated plasma creatinine and glycolate concentrations on presentation. The remaining patients experienced no evidence of subsequent renal injury. The authors concluded that administration of fomepizole early in the course of ethylene glycol poisoning inhibits the formation of toxic metabolites and thereby prevents renal injury.

Borron SW, Megarbane B, Baud FJ. Fomepizole in Treatment of Uncomplicated Ethylene Glycol Poisoning. Lancet 1999, 354:831.

This group treated 38 patients for clinical suspicion of ethylene glycol poisoning. Eleven patients subsequently were found to have serum ethylene glycol concentrations of 20 mg/dL or more. Three of these patients were dialyzed because of renal insufficiency and acidosis and one because serum ethylene glycol concentration was 831 mg/dL. One patient who presented with multiorgan failure died. Seven patients who presented with normal renal function and treated with fomepizole alone experienced no evidence of subsequent renal injury. The authors suggested that, in the absence of renal insufficiency and acidosis, fomepizole alone may be sufficient to treat patients poisoned with ethylene glycol.

Sivilotti MLA, Burns MJ, McMartin KE, Brent J. Toxicokinetics of Ethylene Glycol During Fomepizole Therapy: Implications for Management. Annals of Emergency Medicine 2000; 36:114-125.

The kinetics of ethylene glycol elimination were studied in ethylene glycol-poisoned patients treated with fomepizole. The elimination half-life was significantly longer in fomepizole-treated patients, indicating hepatic metabolism was inhibited. Without hepatic metabolism, the rate of renal ethylene glycol excretion was directly proportional to creatinine clearance. Patients with normal creatinine clearance were able to excrete ethylene glycol more rapidly than those with elevated creatinine and presumed renal injury. The authors concluded that serum creatinine in ethylene glycol-poisoned patients at the time of presentation can be used to determine which patients will require hemodialysis. In patients treated with fomepizole, a serum ethylene glycol concentration of 50 mg/dL or greater should no longer be used as sole criteria for hemodialysis.