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Intravenous Dilution Guidelines

Fomepizole (Antizol ®)

The authors make no claims of the accuracy of the information contained herein; and these suggested doses and/or guidelines are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this document shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.    PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.

Usual Diluents

NS, D5W

Standard Dilutions   [Amount of drug] [Infusion volume] [Infusion rate]

[Prescribed dose] [100ml] [30 min]

Stability / Miscellaneous

Stability data:

Drug Stability
Refrigerated
Stability
Room Temp.
Reconstituted
Vial/Powder
Notes P-Insert
Updated
Antizol - Fomepizole Stability: Antizol® diluted in 0.9% sodium chloride injection or dextrose 5% injection remains stable and sterile for at least 24 hours when stored refrigerated or at room temperature. Antizol® does not contain preservatives. Therefore, maintain sterile conditions, and after dilution do not use beyond 24 hours. Store at controlled room temperature, 20° to 25° C (68° to 77° F)

Stability: Antizol® diluted in 0.9% sodium chloride injection or dextrose 5% injection remains stable and sterile for at least 24 hours when stored refrigerated or at room temperature. Antizol® does not contain preservatives. Therefore, maintain sterile conditions, and after dilution do not use beyond 24 hours.
Solution  Solutions showing haziness, particulate matter, precipitate, discoloration, or leakage should not be used. 07 27 09

Dosing
: loading dose: 15 mg/kg, followed by 10 mg/kg q12h x 4 doses, then 15 mg/kg q12h thereafter until ethylene glycol levels <20 mg/dl.
Dialysis should be considered in addition to fomepizole in the case of renal failure, significant or worsening metabolic acidosis, or a measured ethylene glycol level >50 mg/dl. Fomepizole is dialyzable and should be given q4h during hemodialysis.

Mechanism of Action
Antizol (fomepizole) is a competitive inhibitor of alcohol dehydrogenase. Alcohol dehydrogenase catalyzes the oxidation of ethanol to acetaldehyde. Alcohol dehydrogenase also catalyzes the initial steps in the metabolism of ethylene glycol and methanol to their toxic metabolites.

Ethylene glycol, the main component of most antifreezes and coolants, is metabolized to glycoaldehyde, which undergoes subsequent sequential oxidations to yield glycolate, glyoxylate, and oxalate. Glycolate and oxalate are the metabolic by-products primarily responsible for the metabolic acidosis and renal damage seen in ethylene glycol toxicosis. The lethal dose of ethylene glycol in humans is approximately 1.4 mL/kg.

Methanol, the main component of windshield wiper fluid, is slowly metabolized via alcohol dehydrogenase to formaldehyde with subsequent oxidation via formaldehyde dehydrogenase to yield formic acid. Formic acid is primarily responsible for the metabolic acidosis and visual disturbances (e.g., decreased visual acuity and potential blindness) associated with methanol poisoning. A lethal dose of methanol in humans is approximately 1-2 mL/kg.

Fomepizole has been shown in vitro to block alcohol dehydrogenase enzyme activity in dog, monkey, and human liver. The concentration of fomepizole at which alcohol dehydrogenase is inhibited by 50% in vitro is approximately 0.1 µmol/L.

In a study of dogs given a lethal dose of ethylene glycol, three animals each were administered fomepizole, ethanol, or left untreated (control group). The three animals in the untreated group became progressively obtunded, moribund, and died. At necropsy, all three dogs had severe renal tubular damage. Fomepizole or ethanol, given 3 hours after ethylene glycol ingestion, attenuated the metabolic acidosis and prevented the renal tubular damage associated with ethylene glycol intoxication.

Several studies have demonstrated that Antizol plasma concentrations of approximately 10 µmol/L (0.82 mg/L) in monkeys are sufficient to inhibit methanol metabolism to formate, which is also mediated by alcohol dehydrogenase. Based on these results, concentrations of Antizol in humans in the range of 100 to 300 µmol/L (8.6-24.6 mg/L) have been targeted to assure adequate plasma concentrations for the effective inhibition of alcohol dehydrogenase.

In healthy volunteers, oral doses of Antizol (10-20 mg/kg) significantly reduced the rate of elimination of moderate doses of ethanol, which is also metabolized through the action of alcohol dehydrogenase.


DOSAGE AND ADMINISTRATION
Treatment Guidelines
If ethylene glycol or methanol poisoning is left untreated, the natural progression of the poisoning leads to accumulation of toxic metabolites, including glycolic and oxalic acids (ethylene glycol intoxication) and formic acid (methanol intoxication). These metabolites can induce metabolic acidosis, nausea/vomiting, seizures, stupor, coma, calcium oxaluria, acute tubular necrosis, blindness, and death. The diagnosis of these poisonings may be difficult because ethylene glycol and methanol concentrations diminish in the blood as they are metabolized to their respective metabolites. Hence, both ethylene glycol and methanol concentrations and acid base balance, as determined by serum electrolyte (anion gap) and/or arterial blood gas analysis, should be frequently monitored and used to guide treatment.

Treatment consists of blocking the formation of toxic metabolites using inhibitors of alcohol dehydrogenase, such as Antizol, and correction of metabolic abnormalities. In patients with high ethylene glycol or methanol concentrations (greater than or equal 50 mg/dL), significant metabolic acidosis, or renal failure, hemodialysis should be considered to remove ethylene glycol or methanol and the respective toxic metabolites of these alcohols.

Treatment with Antizol
Begin Antizol treatment immediately upon suspicion of ethylene glycol or methanol ingestion based on patient history and/or anion gap metabolic acidosis, increased osmolar gap, visual disturbances, or oxalate crystals in the urine, OR a documented serum ethylene glycol or methanol concentration greater than 20 mg/dL.

Hemodialysis
Hemodialysis should be considered in addition to Antizol in the case of renal failure, significant or worsening metabolic acidosis, or a measured ethylene glycol or methanol concentration of greater than or equal to 50 mg/dL. Patients should be dialyzed to correct metabolic abnormalities and to lower the ethylene glycol concentrations below 50 mg/dL.

Discontinuation of Antizol Treatment
Treatment with Antizol may be discontinued when ethylene glycol or methanol concentrations are undetectable or have been reduced below 20 mg/dL, and the patient is asymptomatic with normal pH.

Dosing of Antizol
A loading dose of 15 mg/kg should be administered, followed by doses of 10 mg/kg every 12 hours for 4 doses, then 15 mg/kg every 12 hours thereafter until ethylene glycol or methanol concentrations are undetectable or have been reduced below 20 mg/dL, and the patient is asymptomatic with normal pH. All doses should be administered as a slow intravenous infusion over 30 minutes (see Administration).

Dosage with Renal Dialysis
Antizol® (fomepizole) Injection is dialyzable and the frequency of dosing should be increased to every 4 hours during hemodialysis.

Antizol Dosing in Patients Requiring Hemodialysis
DOSE AT THE BEGINNING OF HEMODIALYSIS
If <6 hours since last Antizol dose If greater than or equal6 hours since last Antizol dose
Do not administer dose Administer next scheduled dose

DOSING DURING HEMODIALYSIS
Dose every 4 hours

DOSING AT THE TIME HEMODIALYSIS IS COMPLETED
Time between last dose and the end of hemodialysis  
<1 hour Do not administer dose at the end of hemodialysis
1–3 hours Administer 1/2 of next scheduled dose
>3 hours Administer next scheduled dose


MAINTENANCE DOSING OFF HEMODIALYSIS
Give next scheduled dose 12 hours from last dose administered

Administration
Antizol solidifies at temperatures less than 25° C (77° F). If the Antizol solution has become solid in the vial, the solution should be liquefied by running the vial under warm water or by holding in the hand. Solidification does not affect the efficacy, safety, or stability of Antizol. Using sterile technique, the appropriate dose of Antizol should be drawn from the vial with a syringe and injected into at least 100 mL of sterile 0.9% sodium chloride injection or dextrose 5% injection. Mix well. The entire contents of the resulting solution should be infused over 30 minutes. Antizol, like all parenteral products, should be inspected visually for particulate matter prior to administration.

Stability
Antizol diluted in 0.9% sodium chloride injection or dextrose 5% injection remains stable and sterile for at least 24 hours when stored refrigerated or at room temperature. Antizol does not contain preservatives. Therefore, maintain sterile conditions, and after dilution do not use beyond 24 hours. Solutions showing haziness, particulate matter, precipitate, discoloration, or leakage should not be used.

HOW SUPPLIED
Antizol is supplied as a sterile, preservative-free solution for intravenous use as:

Supplied in packages of four vials. Each vial contains 1.5 mL (1 g/mL) of fomepizole.

NDC 68727-200-02

Store at controlled room temperature, 20° to 25° C (68° to 77° F)

Distributed by:
Jazz Pharmaceuticals, Inc.
Palo Alto, CA 94304

For questions of a medical nature, call 1-888-867-7426.
Part No. ANT PI-8511
Revision Date: April 2006


Source: [package insert]
Disclaimer
The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.  PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.
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