Methanol poisoning can induce death and disability. Treatment includes the administration of antidotes (
ethanol or
fomepizole and folic/
folinic acid) and consideration of extracorporeal treatment for correction of acidemia and/or enhanced elimination. The Extracorporeal Treatments in
Poisoning workgroup aimed to develop evidence-based consensus recommendations for extracorporeal treatment in
methanol poisoning.
DESIGN AND METHODS: Utilizing predetermined methods, we conducted a systematic review of the literature. Two hundred seventy-two relevant publications were identified but publication and selection biases were noted. Data on clinical outcomes and dialyzability were collated and a two-round modified Delphi process was used to reach a consensus.
RESULTS: Recommended indications for extracorporeal treatment: Severe
methanol poisoning including any of the following being attributed to
methanol:
coma,
seizures, new vision deficits,
metabolic acidosis with blood pH ≤ 7.15, persistent
metabolic acidosis despite adequate supportive measures and antidotes, serum anion gap higher than 24 mmol/L; or, serum
methanol concentration 1) greater than 700 mg/L (21.8 mmol/L) in the context of
fomepizole therapy, 2) greater than 600 mg/L or 18.7 mmol/L in the context of
ethanol treatment, 3) greater than 500 mg/L or 15.6 mmol/L in the absence of an
alcohol dehydrogenase blocker; in the absence of a
methanol concentration, the osmolal/osmolar gap may be informative; or, in the context of impaired kidney function. Intermittent
hemodialysis is the modality of choice and continuous modalities are acceptable alternatives. Extracorporeal treatment can be terminated when the
methanol concentration is <200 mg/L or 6.2 mmol/L and a clinical improvement is observed. Extracorporeal Treatments in
Poisoning inhibitors and folic/
folinic acid should be continued during extracorporeal treatment. General considerations: Antidotes and extracorporeal treatment should be initiated urgently in the context of severe
poisoning. The duration of extracorporeal treatment extracorporeal treatment depends on the type of extracorporeal treatment used and the
methanol exposure. Indications for extracorporeal treatment are based on risk factors for poor outcomes. The relative importance of individual indications for the triaging of patients for extracorporeal treatment, in the context of an epidemic when need exceeds resources, is unknown. In the absence of severe
poisoning but if the
methanol concentration is elevated and there is adequate
alcohol dehydrogenase blockade, extracorporeal treatment is not immediately required. Systemic anticoagulation should be avoided during extracorporeal treatment because it may increase the development or severity of
intracerebral hemorrhage.
CONCLUSION: Extracorporeal treatment has a valuable role in the treatment of patients with
methanol poisoning. A range of clinical indications for extracorporeal treatment is provided and
duration of therapy can be guided through the careful monitoring of
biomarkers of exposure and toxicity. In the absence of severe
poisoning, the decision to use extracorporeal treatment is determined by balancing the cost and complications of extracorporeal treatment to that of
fomepizole or
ethanol. Given regional differences in cost and availability of
fomepizole and extracorporeal treatment, these decisions must be made at a local level.