MinistryofHealthand

MedicalEducation

ClinicalGuidelinefor

Treatmentof
Methanol Poisoning

SubstanceAbusePreventionandTreatmentOffice
BureauofPsychosocialHealthandAddiction
DeputyforHealth

MinistryofHealthand
MedicalEducation

ClinicalGuidelinefor

Treatmentof
Methanol Poisoning

SubstanceAbusePreventionandTreatmentOffice
BureauofPsychosocialHealthandAddiction
DeputyforHealth

CharacteristicsofDocument
Title

Clinical Guideline for Treatment of Methanol

Poisoning

Aim

To provide clinical guideline for management and

treatment of methanol poisoning mass epidemics
forgeneralphysiciansworkinginemergencyrooms
andhealthmanagers.

TargetAudience

General physicians working in emergency rooms,

physiciansworkingintoxicologyemergencyrooms,
managers of health sector and substance abuse
treatmentproviders

Guideline
Development
Group

Hossein HassanianMoghaddam1, Alireza Noroozi2,

Mahdi BalaliMood3, Mohammad Bagher Saberi
Zafarghandi4, Mohammad Abdollahi5, Mahsa
Gilanipour6,ShahinShadnia7

Editor

AlirezaNoroozi

Edition

FirstEdition

PublicationDate

Summer2009

TargetAudience

General physicians working in emergency rooms,

physiciansworkingintoxicologyemergencyrooms,
managers of health sector and substance abuse
treatmentproviders

ClinicalToxicologyFellowship,ShahidBeheshtiMedicalUniversity(SBMU)
Psychiatrist,HeadofSubstanceAbusePreventionandTreatmentOffice(SAPTO)
3
SubspecialistofClinicalToxicology,MashhadUniversityofMedicalSciences(MUMS)
4
Psychiatrist,DirectorGeneralofBureauofPsychosocialHealthandAddiction
5
ProfessorandToxicologySpecialist,TehranUniversityofMedicalSciences(TUMS)
6
Psychiatrist,OfficerofTreatment,SubstanceAbusePreventionandTreatmentOffice
(SAPTO)
7
ToxicologySpecialist,ShahidBeheshtiMedicalUniversity(SBMU)
2

Contact

Iran, Tehran, Hafez Street, Deputy for Health

Building, 4th Floor, Substance Abuse Prevention
and Treatment Office (SAPTO) Tel: 0098 21
66707063Fax:00982166700410

GuidelineDevelopmentGroup
HosseinHassanianMoghaddam
ClinicalToxicologyFellowship,ShahidBeheshtiMedicalUniversity(SBMU)

AlirezaNoroozi
Psychiatrist,HeadofSubstanceAbusePreventionandTreatmentOffice
(SAPTO)

MahdiBalaliMood
SubspecialistofClinicalToxicology,MashhadUniversityofMedicalSciences
(MUMS)

MohammadBagherSaberiZafarghandi
Psychiatrist,DirectorGeneralofBureauofPsychosocialHealthand
Addiction

MohammadAbdollahi
ProfessorandToxicologySpecialist,TehranUniversityofMedicalSciences
(TUMS)

MahsaGilanipour
Psychiatrist,OfficerofTreatment,SubstanceAbusePreventionand
TreatmentOffice(SAPTO)

ShahinShadnia
ToxicologySpecialist,ShahidBeheshtiMedicalUniversity(SBMU)

ExecutiveSummary
This is an executive summary for Clinical Guideline for Treatment of
MethanolPoisoningthathasbeenproducedforuseasaquickreference
incriticalsituations.Tostudyinmoredetails,refertothefullguidelineon
methanolpoisoning.Toreportmassepidemicsofmethanolpoisoningand
to get any technical support contact Bureau of Psychosocial Health and
Addiction Tel. No 02166707063. For emergency consultation please
contactwithDrugandPoisonInformationCenterTel.No02155422020
or09646(24hoursservice)hassanian@sbmu.ac.ir.

Duetotheepidemicofmethanolpoisoningindifferentcitiesofthe
country,allhealthprofessionalsshouldbefamiliarwithprinciplesof
diagnosisandtreatmentofmethanolpoisoning.Ontimediagnosis,
propercasefindingandstandardtreatmenthaveanessentialroleto
reduce mortality and morbidity of methanol poisoning, particularly
blindnessandotherphysicalandpsychologicaldisabilities.

The most common cause of methanol poisoning in I R Iran is

adulterationofalcoholicdrinks.

Methanol is used as a solvent in printing and copy solutions,

adhesives,paints,polishersandstabilizers.Itisalsousedforwindow
cleaners,antifreeze,asafuelinalcoholiclampandasanadditivein
gasoline.Methanolisknownasanindustrialalcoholandismixedup
with ethanol that is used for medical purposes. The so called
standardalcoholicdrinksthataresoldinblackmarketsinIranmay
have methanol. The traditional herbal extracts in the country
contain methanol due to cellulose fermentation of the stalks and
seedsoftheherbs.

Absorption,DistributionandMetabolism
Methanolasanalcoholisrapidlyabsorbedthroughgastrointestinaltract,
so the average absorption half life is 5 minutes and reaches maximum
serum concentration within 30 60 minutes and well dissolves in body
water. Methanol is not toxic by itself, but its metabolites are toxic.
Methanol metabolized in different phases mainly in the liver. The initial
enzymeinitsmetabolismisalcoholdehydrogease.

ClinicalManifestations

Clinical manifestations of poisoning with methanol alone initiate

within 0.5 4 hours of ingestion and include nausea, vomiting,
abdominal pain, confusion, drowsiness and central nervous system
suppression.Patientsusuallydonotseekhelpatthisstage.

After a latent period of 6 24 hours that depends on the dose

absorbed, decompensate metabolic acidosis occur which induces
blurredvision,photophobia,changesinvisualfield,accommodation
disorder,diplopia,blindnessandlesscommonlynistagmus.

Blurredvisionwithunalteredconsciousnessisastrongsuspiciousfor
methanolpoisoning.

Coingestion of ethanol, delayed methanol poisoning features for

more than 24 hours and sometimes up to 72 hours. The clinical
picturesthatwereobservedseveraltimesinIRIran.

Severe metabolic acidosis with anion gap and increased osmolality

stronglysuggestmethanolandorethyleneglycolpoisoning.Severity
ofclinicalmanifestationsandmortalityassociatedwellwithseverity
of central nervous system depression and metabolic acidosis, but
notwithserummethanolconcentration.

Importantdifferentialdiagnosis
Animportantpointinmanagementoftoxicalcohols,particularlymethanol
poisoning, is proper and early diagnosis. Since emergency estimation of
serummethanolconcentrationisnotavailableinmostpartsofthecountry,
clinicaldifferentialdiagnosisisveryimportant.

Time of admission and patients condition: Ethanol (alcohol in

drinks)israpidlyabsorbedandclinicalfeaturesafteroverdosesuch
as flashing, drunk, central nervous depression and gastrointestinal
dysfunction occur within 12 hours. In this poisoning, the patients
conditionisgraduallyimproved,whereasintoxicalcoholsespecially
methanol,itwillbedetoriatedoverthetime,evenafter24hours.

Drunkennessandvasodilatation:Inethanolpoisoning,thepatientis
drunk with flashing, talkative and aggression, whereas in toxic
alcohols,nosignofdrunkisobservedandastateofshockwithchill
andcoldextremitiesarenoted.

Ophthalmic manifestations: In ethanol intoxication, pupils are

usually meiotic and there is no visual defect, whereas in methanol
poisoningpupilsaremydriaticandthereisaretardornoresponse
tolight.

Smellofalcohol:Smellofalcoholislessnotedintoxicalcoholsthan
inethanolintoxication.

Convulsions and central nervous symptoms: Central nervous

symptoms,particularlyconvulsionsarethesignsofseverityoftoxic
alcoholintoxications.

Tachypneaandacademia:Acidemiaisofgoodlaboratoryfindingin
differential diagnosis of toxic alcohol and the nontoxics. The body
respondtoacidemiaistachypneaandhyperventilation.However,in

ethanol poisoning, mild acidemia may occur, but is usually self

limitedandisimprovingwithsupportivetreatment.

Serumalcoholslevels:Estimationofserumalcohollevelisprobably
important in early hours of intoxication, but practically is less
important as the time passes (hours after) and even may be
confusing. Since the toxic metabolites are responsible for the
complications, the time that patient refer to the clinic, methanol
concentration may be decreased and the toxic metabolites have
beenincreased.Inaddition,impropersamplingsuchasusingalcohol
asaskindisinfectantmayshowfalseincreaseinalcohollevel.

Blood glucose and electrolytes: There is usually hypoglycemia in

ethanol poisoning, and hyperglycemia in methanol intoxication.
Hyperkalemia due to acidosis is observed in methanol poisoning,
whereas hypokalemia due to vomiting may occur in ethanol
intoxication. These findings should be evaluated together with the
othermanifestationsandobservations.

Treatment

Incaseofmethanolintoxication,tofindotherpatientsorvictims
activelyandidentificationoftheoriginviathepatientsisvery
important,whichrequirealsointersectoralcooperations.

Initial evaluation should be towards the improving of vital signs;

airway, respiration and circulations. Thus, management should be
focused on correction of metabolic acidosis, coma and eye
complications. These could be prevented by inhibition of methanol
metabolism.

In case of metabolic acidosis, sodium bicarbonate in sufficient

amountshouldbeadministered.Basicantidotesthatmaybeuseful
indifferentphaseshavebeenshowninbelowfigure.

Methanol

ADH Formaldehyde FDH FormicAcid FTHFS CO2+H2O

Ethanolor
Fomepizole

Folinicacid
andFolicAcid

ADH:alcoholdehydrogenaseFDH:formaldehydedehydrogenaseFTHFS:10formyl

tetrahyrofolatesynthetase

The table A shows indications for ethanol and fomepizol. In case of

hemodialysis,ethanoldosesshouldbeincreaseduptotwofolds.IntableB,
algorithmofstandardtreatmentofmethanolpoisoningisillustrated.

ApproachtoMethanolPoisoningEpidemics

By definition, occurrence of more than three cases of methanol

poisoning in one area within 24 hours is suggesting of methanol
poisoningepidemics.Inthiscase,publicawarenessoftheepidemic
should be considered. Experiences of the medical sciences
Universities of IR Iran revealed that delayed public information for
morethan24hoursleadedtomoremortality.

Rapid diagnosis of methanol poisoning incidence and public

information through local media could play an important role in
prevention of methanol poisoning morbidities and mortalities.
Emergency physicians should be asked to inform the University
patients referral committee. Cooperation and education of the
committeemembersandallauthoritiesarerequired.

In order to educate and harmonies the management of methanol

poisoning,thisexecutivesummarymustbedistributedinallmedical
emergency centers and hospital libraries. Also, a day workshop for

the health professionals and staff of the emergency centers of all

hospitalsisrecommended.

TableAIndicationsofethanolandfomepizolformethanolpoisoning
Criteria
Serummethanolconcentrationof>20mg/dLor
Historyoftoxicdoseofmethanolingestionandosmolal
gap>10mOs/kgH2Oor
Historyorhighsuspicious*ofmethanolpoisoningincase
thatpatientadmitwithin72hoursofingestionandhad
twooffollowing:
A.arterialpH<7.3
B.Serumbicarbonate<20mEq/L.
C.Osmolgap>10mOsm/kgH2O

*Theauthorsofthismonographrecommendthatincaseofmethanol
poisoningepidemic,inanyclinicalsuspicious,treatmentshouldbeinitiated.

 TableBAlgorithmofMethanolPoisoningTreatment
Suspectedorconfirmedmethanolpoisoningcase

Reconsiderdiagnosis
andreassess.

No

DoespatientmeetcriteriainTableA?

Findothercasesactively*

Yes

Administer1ml/kgoffivefolddilutedalcohol 96 asloadingdoseand0.16ml/kg/has
maintenancedoseorallyorbyNGTOR
Fomepizole15mg/kgloadingdoseand10mg/kgmaintenanceevery12hrsupto4doseand
then15mg/kgevery12hrsAND
AdministerFolicAcidorFolinicAcid1mg/kgupuntil50mgevery46hours,IVinD5Wduring
3060minutes
IFMethanolserumconcentrationcouldnotbedetectedorosmolalgap<10mOsm/kgH2O,
avoidethanol/fomepizoltreatment.

No

PH<7.3

Bicarbonatenot
necessary

Yes

Administerbicarbonateto
correctPHto>7.3

PH<7.3resistanttopreliminarytreatmentsor
Visualsigns/symptomsor
Deterioratingvitalsignsdespiteintensive
supportivecareor
Renalfailureor
Electrolytedisturbancesresistanttousual
treatmentsor
Lossofconsciousnessor
Methanolserumconcentration50mg/dl**

No

ContinuetreatmentaccordingtoTableAuntil
ethanol/fomepizoleindicationwouldbecorrected

Hemodialysi

Yes

Continue untilcorrectionof
hemodialysisindication

*Theaimofcasefindingistoaccessatriskpatientswhodidnotrefertoahospital.This
could be performed via consultation with patient or the relatives confidentially. The
patientsandtheirrelativesshouldbeeducatedabouttheriskofmethanolpoisoning,and
askthemtohelpinfindingnewpossiblepatientswhomighthaveingestedtoxicalcohol.
Every suspected or confirmed methanol poisoning case should be reported to the
Universitypatientsreferralcommittee.
**Although serum methanol concentration higher than 25 mg/dL in ethanol treated
patentsisanindicationforhemodialysis,thefomepizoltreatedpatientscouldbedelayed
forhemodialysis.However,itmayprolonghospitalization.
Thisalgorithmisageneralguidefortreatment.However,itisuptothephysicianincharge
todecideforthetreatmentbasedonhis/herclinicaljudgment.