severe disulfiram-ethanol reactions

Case: 52 years old male with a history of alcohol abuse has been prescribed Disulfiram at the rehab center, is brought with chest pain, confusion, headache, and severe vomiting consistent with Disulfiram reaction. The patient did not respond to IV resuscitation, pressor support, and administration of diphenhydramine. What is the antidote? 

Answer: Fomepizole 

Disulfiram reaction is usually self-limiting and psychologically makes a person avoid alcohol. In some cases, the reaction can be severe, mostly with symptoms of chest pain, confusion, headache, flushing, and severe vomiting. It is important to rule out any cardiac event to avoid life-threatening outcomes. Once ruled out for any potential fatal situation, supportive treatment with IV fluid resuscitation, pressor support for persistent vasodilatation/hypotension, and diphenhydramine (for flushing) is enough.

Fomepizole can be used in unresolved situations. Fomepizole (4-methylpyrazole) in a single intravenous dose of 7.5 mg/kg. It blocks alcohol dehydrogenase and reverses the disulfiram reactions. Continuous cardiac monitoring is crucial in such cases.

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References:

1. Schicchi A, Besson H, Rasamison R, et al. Fomepizole to treat disulfiram-ethanol reaction: a case series. Clin Toxicol (Phila) 2020; 58:922.

2. Sande M, Thompson D, Monte AA. Fomepizole for severe disulfiram-ethanol reactions. Am J Emerg Med 2012; 30:262.e3.