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Ethanol Injection and Topical Gel

Ethanol injection is used as an antiseptic, for tissue ablation, nerve block, and as an antidote for methanol toxicity.

Ethanol indications:

Replenishment of fluid and carbohydrate calories:
- It is used for the Replenishment of fluid and carbohydrate calories
Septal ablation for hypertrophic obstructive cardiomyopathy (HOCM) (Ablysinol only):
- It is useful in inducing controlled cardiac septal infarction and improvement of exercise capacity in patients with symptomatic hypertrophic obstructive cardiomyopathy who are not suitable for surgical myectomy.
Therapeutic nerve or ganglion block:
- In order to control intractable chronic pain, therapeutic neurolysis of nerves or ganglia is indicated in certain conditions.
Ethanol Topical use:
Antiseptic:
- It is used as a topical anti-microbicidal agent
Off Label Use of Ethanol in Adults:
- Antidote for Ethylene glycol overdose
- Antidote for Methanol overdose

Ethanol Dose in Adults

Ethanol as an Antiseptic:

Ethanol is used as an antiseptic, which means it helps kill germs and bacteria on the skin.
When it's mixed with other ingredients and labeled as "liquid denatured alcohol," it's meant to be used on the skin.
You can apply it directly to the skin 1 to 3 times a day, or as often as necessary to keep the area clean and free from germs.

Ethanol injection for Therapeutic nerve or ganglion block:

Ethanol is sometimes used in therapeutic procedures to block nerves or ganglia (clusters of nerve cells). In this case, it's in the form of a concentrated solution called dehydrated alcohol injection, which contains 98% ethanol.

The injection is given directly into the nerve or ganglion, and the dosage varies depending on where it's injected.
For example, if it's for conditions like trigeminal neuralgia (a type of facial pain), the dosage might range from 0.05 to 0.5 milliliters as a single injection per specific area.
For other conditions like certain types of back pain, the dosage might be higher, around 0.5 to 1 milliliter as a single injection.
It's important to note that large doses (over 1.5 milliliters) are rarely needed, and this procedure is typically reserved for cases where the pain is caused by cancer.
It's not typically used for other types of pain.

Replenishment of fluid and carbohydrate calories:

When someone needs to replenish fluids and carbohydrate calories, they might receive a solution called dehydrated alcohol infusion.
This solution contains a low concentration of alcohol (5%) and dextrose, which is a type of sugar (5%).

The infusion is administered slowly, typically over the course of a day, and the amount given can range from 1 to 2 liters per day.
This helps provide both fluids and calories to the body, which can be important in certain medical situations where a person may not be able to take in enough fluids or calories orally.

Ethanol injection for Septal ablation for HOCM:

Septal ablation is a medical procedure used to treat hypertrophic obstructive cardiomyopathy (HOCM), a condition where the heart muscle becomes abnormally thick, causing obstruction to blood flow.
In this procedure, a substance is injected into certain arteries of the heart to reduce the thickening of the muscle and improve blood flow.
The substance used for septal ablation is typically a highly concentrated solution, at least 95%, infused slowly into specific branches of the septal arteries.
The dosage varies depending on the anatomy of the septum (the wall dividing the left and right sides of the heart) and how quickly the contrast washes out.
A single dose usually ranges from 1 to 3 milliliters, with a maximum dose not exceeding 5 milliliters per procedure.
It's crucial to use the minimum effective dose required to achieve the desired reduction in pressure gradient in the left ventricular outflow tract.
Using smaller amounts may help reduce complications such as complete heart block and the size of the septal infarct (tissue death) that can occur as a result of the procedure.

Ethanol injection for Methanol or ethylene glycol overdose:

In cases of methanol or ethylene glycol overdose, intravenous administration of ethanol can be used as an off-label treatment. This treatment aims to maintain ethanol levels in the bloodstream to prevent the toxic effects of methanol or ethylene glycol until these substances are no longer detected or their levels drop below 20 mg/dL, and the patient is asymptomatic with corrected metabolic acidosis.

Here are the guidelines for administering absolute ethyl alcohol (98% concentration) intravenously:

Initial Dose: 600 to 700 milligrams per kilogram (mg/kg). For a 10% ethanol solution, this is equivalent to 7.6 to 8.9 milliliters per kilogram (mL/kg).
Maintenance Dose: The goal is to maintain serum ethanol levels above 100 mg/dL.
For Nondrinkers: The infusion rate is 66 mg/kg/hour, equivalent to 0.83 mL/kg/hour using a 10% solution.
For Chronic Drinkers: The infusion rate is higher, at 154 mg/kg/hour, equivalent to 1.96 mL/kg/hour using a 10% solution.

It's important to monitor the patient's serum ethanol concentrations frequently to adjust the dosage as needed, depending on the patient's physical condition and their metabolism of ethanol. If the patient has also consumed ethanol along with methanol or ethylene glycol, baseline serum ethanol concentration should be measured, and the ethyl alcohol loading dose should be adjusted to achieve a serum ethanol level of approximately 100 mg/dL. Additionally, consulting the Poison Control Center for options related to compounding IV ethanol is advisable.

Ethanol injection Dose adjustment for patients on hemodialysis:

In hemodialysis patients, dosage adjustments for ethanol administration are necessary due to altered metabolism and clearance rates. Here's how the dosage adjustments are made for maintenance and oral administration:

Maintenance Dose for Hemodialysis Patients:

For Nondrinkers: The maintenance infusion rate is 169 mg/kg/hour, equivalent to 2.13 mL/kg/hour using a 10% solution.
For Chronic Drinkers: The maintenance infusion rate is higher, at 257 mg/kg/hour, equivalent to 3.26 mL/kg/hour using a 10% solution.

Oral Administration:

Initial Dose: 600 to 700 mg/kg, equivalent to 0.78 to 0.9 mL/kg using a 98% solution. This should be diluted to a ≤20% concentration with water or juice before administration.
Maintenance Dose: The goal is to maintain serum ethanol levels above 100 mg/dL.
- For Nondrinkers: The maintenance dose is 66 mg/kg/hour, equivalent to 0.09 mL/kg/hour using a 98% solution.
- For Chronic Drinkers: The maintenance dose is 154 mg/kg/hour, equivalent to 0.20 mL/kg/hour using a 98% solution.

It's essential to administer oral ethanol precisely at 60-minute intervals due to its pharmacokinetics. Dilution of the solution is necessary to reduce the risk of gastritis. Monitoring of serum ethanol levels is crucial to ensure therapeutic effectiveness and avoid toxicity.

Ethanol injection Dosage adjustment for patients on hemodialysis:

For hemodialysis patients, dosage adjustments for ethanol administration are necessary due to altered metabolism and clearance rates. Here's how the dosage adjustments are made for maintenance:

Maintenance Dose for Hemodialysis Patients:

For Nondrinkers: The maintenance infusion rate is 169 mg/kg/hour, equivalent to 0.22 mL/kg/hour using a 98% solution.
For Chronic Drinkers: The maintenance infusion rate is higher, at 257 mg/kg/hour, equivalent to 0.33 mL/kg/hour using a 98% solution.

These dosage adjustments are essential to ensure that the levels of ethanol in the bloodstream are maintained within the therapeutic range while considering the individual's metabolic factors and the need for hemodialysis. Regular monitoring of serum ethanol levels is crucial to adjust the dosage as needed and to prevent toxicity.

Ethanol injection Dose in Children:

See institution-based protocol: Intravenous dehydrated alcohol injection is indicated

Methanol or ethylene glycol ingestion: Limited data available (Barceloux 1999; Barceloux 2002):

In the event of methanol or ethylene glycol ingestion in infants, children, and adolescents, intravenous ethanol administration can be employed as a treatment. Here are the dosage recommendations:

For Intravenous Administration:

Initial Dose: 600 to 700 milligrams per kilogram (mg/kg), equivalent to 7.6 to 8.9 milliliters per kilogram (mL/kg) using a 10% solution.
Maintenance Dose (for patients not receiving hemodialysis):
- For nondrinkers: 66 mg/kg/hour, equivalent to 0.83 mL/kg/hour using a 10% solution.
- For chronic drinkers: 154 mg/kg/hour, equivalent to 1.96 mL/kg/hour using a 10% solution.

For Oral Administration:

Initial Dose: 600 to 700 mg/kg, equivalent to 0.78 to 0.9 mL/kg using a 98% solution. It must be diluted to a concentration of 20% or less with water or juice before administration.
Maintenance Dose (for patients not receiving hemodialysis):
- For nondrinkers: 66 mg/kg/hour, equivalent to 0.09 mL/kg/hour using a 98% solution.
- For chronic drinkers: 154 mg/kg/hour, equivalent to 0.20 mL/kg/hour using a 98% solution.

The goal of therapy is to maintain serum ethanol levels above 100 mg/dL. Dosage adjustments may be necessary based on the patient's condition and response to treatment. It's important to monitor serum ethanol levels closely and adjust the dosage accordingly to ensure therapeutic effectiveness and avoid toxicity.

Central venous catheter lock: Limited data available:

For the use of dehydrated alcohol injection as a central venous catheter lock in infants, children, and adolescents, the dosing regimens vary based on the indication. Here's a summary:

For Catheter-related Bloodstream Infection (CRBSI):

Prophylaxis:
- Use 70% ethanol.
- Instill a volume equal to the internal volume of the catheter once daily with a dwell time of 2 to 14 hours.
- Withdraw ethanol at the end of the dwell time.
- Less frequent dosing (3 times per week) for a minimum of 4-hour dwell time or once-weekly dosing with a 2-hour dwell time have shown significant reductions in infection rate and catheter loss.
- Note: Decreasing the frequency of ethanol locks to less than daily may lead to increased infection rates, especially during an ethanol shortage.
Treatment:
- Use 70% ethanol.
- Instill a volume equal to the internal volume of the catheter with a dwell time of 4 to 25 hours.
- Some protocols repeat the dose once daily for 3 to 5 days.
- Dosing should be repeated for each lumen and used in combination with systemic antimicrobials.
- For fungal bloodstream infection, once-daily instillation with dwell times of 2 to 24 hours for 14 days following the patient's first negative blood culture has been successful.

Pregnancy Risk Factor: C

When a pregnant woman consumes ethanol, it can pass through the placenta to the baby, causing harmful effects.
Babies exposed to ethanol in the womb may experience withdrawal symptoms after birth, including crying, hyperactivity, tremors, and seizures.
Fetal alcohol syndrome (FAS) is a condition characterized by physical, behavioral, and cognitive abnormalities resulting from fetal ethanol exposure.
Since it's unclear what amount of ethanol is safe during pregnancy, the American Academy of Pediatrics (AAP) advises pregnant women to avoid all ethanol intake.
While using ethanol as an antidote in the second or third trimester is unlikely to cause FAS due to the short treatment duration, its use in the first trimester is controversial.
Additionally, during a medical procedure called percutaneous transluminal septal myocardial ablation, where ethanol is injected into a specific artery, significant exposure of ethanol to the fetus is not expected.
However, it's recommended to delay this procedure until after delivery whenever possible.

Use of ethanol during breastfeeding

Ethanol, found in breast milk at levels similar to those in the mother's blood, can affect breastfeeding infants adversely, potentially causing sleep disturbances, impaired motor development, or growth issues.
The rate at which ethanol clears from breast milk depends on factors like the mother's weight and the amount of ethanol consumed.
Guidelines suggest avoiding alcohol completely while breastfeeding or limiting intake to the equivalent of 0.5 grams per kilogram of the mother's weight per day.
Additionally, it's recommended to wait 90 to 120 minutes after drinking alcohol before breastfeeding.
However, during a medical procedure like percutaneous transluminal septal myocardial ablation, where ethanol is administered into a specific artery, significant exposure of ethanol to the infant through breast milk is not expected.

Dose adjustment in renal disease:

For patients undergoing hemodialysis due to methanol or ethylene glycol overdose, absolute ethyl alcohol is used as a treatment. Here are the recommended maintenance doses for intravenous (IV) and oral administration:

Intravenous Administration:

For patients who do not consume alcohol (nondrinkers), the recommended maintenance dose is 169 mg/kg/hour, which is equivalent to 2.13 mL/kg/hour using a 10% solution.
For chronic drinkers, the recommended maintenance dose is higher, at 257 mg/kg/hour, equivalent to 3.26 mL/kg/hour using a 10% solution.

Oral Administration:

For both nondrinkers and chronic drinkers, the recommended maintenance dose is the same.
It is 169 mg/kg/hour, equivalent to 0.22 mL/kg/hour using a 98% solution for nondrinkers, and 257 mg/kg/hour, equivalent to 0.33 mL/kg/hour using a 98% solution for chronic drinkers.

These dosages help to manage methanol or ethylene glycol overdose during hemodialysis, and they differ based on the patient's alcohol consumption habits. It's important to adhere to these guidelines to ensure proper treatment and patient safety.

Dose adjustment in liver disease:

In cases of hepatic impairment, specific dosage adjustments for medications may not always be provided in the manufacturer's labeling.
However, it is crucial to consider hepatic function when prescribing medications, especially those metabolized by the liver, as impaired liver function can affect drug metabolism and clearance, potentially leading to adverse effects.

Side effects of Ethanol injection:

Cardiovascular:
- Cardiac failure
- Heart block
- Myocardial necrosis (excessive)
- Ventricular fibrillation
- Ventricular tachycardia
Central nervous system:
- Hyperesthesia
- Neuritis
- Pain
- Paresthesia

Contraindications to Ethanol injection:

Ablysinol doesn't have any specific reasons listed by the manufacturer to avoid using it.
However, ethyl alcohol, a common ingredient in many products, may not be suitable for people who are allergic to it or any other parts of Ablysinol.
Also, if someone has a seizure disorder or is in a diabetic coma, they should avoid using Ablysinol.
Additionally, injecting dehydrated alcohol into the space around the brain (subarachnoid injection) isn't recommended for people taking blood thinners.

Warnings and precautions

Heart block (septal Ablation):

During percutaneous transluminal septal myocardial ablation, a procedure used to treat heart block, temporary heart block is common when alcohol is injected into a septal artery.
Around 10% of these temporary heart block cases may become permanent, requiring a permanent pacemaker.
Factors that increase the risk of needing a permanent pacemaker include having a longer baseline PQ interval (>160 msec), a slower baseline heart rate (<50 bpm), a higher baseline left ventricular outflow gradient (>70 mmHg), a longer maximum QRS duration during the first 48 hours (>155 msec), experiencing third-degree atrioventricular block during the procedure, and showing no clinical improvement between 12 to 48 hours after the procedure.

Myocardial Infarction

In cases of myocardial infarction, the use of alcohol is intended to induce a controlled heart attack for therapeutic purposes.
However, there is a risk of excessive tissue damage and subsequent heart failure associated with this procedure.
Factors that can increase this risk include using a larger volume of alcohol and injecting it into more septal branches in order to reduce the pressure gradient in the left ventricular outflow tract.

Ventricular arrhythmia (septal Ablation):

After septal ablation, a procedure used to treat certain heart conditions, there's a risk of ventricular arrhythmias such as ventricular tachycardia and ventricular fibrillation, which may require electric shock treatment (electrocardioversion) and occurs in about 1% of cases.
To monitor for these complications, continuous electrocardiographic monitoring is recommended for 48 hours following the procedure.

Diabetes:

In patients with diabetes mellitus, caution should be exercised when using ethyl alcohol-containing products.
Ethyl alcohol has the potential to lower blood sugar levels, which can be concerning for individuals with diabetes who are already managing their blood sugar levels.
Therefore, it's important for patients with diabetes to monitor their blood sugar closely when using products containing ethyl alcohol and to be aware of potential changes in their blood sugar levels.

Gout

In individuals with gout, it's important to use products containing ethyl alcohol with caution.
Ethyl alcohol consumption has been associated with an increased risk of gout attacks by raising uric acid levels in the body, which can worsen gout symptoms.
Therefore, individuals with gout should be mindful of their alcohol intake and consider limiting or avoiding the consumption of products containing ethyl alcohol to help manage their condition.

Hepatic impairment

In patients with hepatic impairment, it's important to use products containing ethyl alcohol with caution.
The liver plays a crucial role in metabolizing alcohol, and impaired liver function can affect how the body processes alcohol, leading to potential complications.
Therefore, individuals with hepatic impairment should be cautious when using products containing ethyl alcohol, and it may be necessary to adjust the dosage or frequency of use based on the severity of liver dysfunction.

Surprise!

In patients experiencing shock, the use of products containing ethyl alcohol should be approached with caution.
Ethyl alcohol can potentially exacerbate the cardiovascular effects of shock, such as low blood pressure and decreased organ perfusion, by further depressing cardiac function.
Therefore, it's important to carefully evaluate the patient's condition and consider the potential risks and benefits before administering products containing ethyl alcohol in cases of shock.

Ethanol (topical and injection): Drug Interaction

Note: Drug Interaction Categories:

Risk Factor C: Monitor When Using Combination
Risk Factor D: Consider Treatment Modification
Risk Factor X: Avoid Concomitant Use

Risk Factor C (Monitor therapy)
Acetaminophen	Alcohol (Ethyl) may enhance the hepatotoxic effect of Acetaminophen.
Acetohydroxamic Acid	Alcohol (Ethyl) may enhance the adverse/toxic effect of Acetohydroxamic Acid. Specifically, Alcohol (Ethyl) may increase the risk of Acetohydroxamic Acid associated rash.
Aminophylline	Alcohol (Ethyl) may increase the serum concentration of Aminophylline.
Azelastine (Systemic)	Alcohol (Ethyl) may enhance the sedative effect of Azelastine (Systemic).
Biperiden	Alcohol (Ethyl) may enhance the adverse/toxic effect of Biperiden.
Brexanolone	CNS Depressants may enhance the CNS depressant effect of Brexanolone.
Brimonidine (Topical)	May enhance the CNS depressant effect of CNS Depressants.
Brivaracetam	Alcohol (Ethyl) may enhance the CNS depressant effect of Brivaracetam.
Bromocriptine	Alcohol (Ethyl) may enhance the adverse/toxic effect of Bromocriptine. Bromocriptine may enhance the adverse/toxic effect of Alcohol (Ethyl).
Cannabidiol	May enhance the CNS depressant effect of CNS Depressants.
Cannabis	May enhance the CNS depressant effect of Alcohol (Ethyl).
Cefoperazone	May enhance the adverse/toxic effect of Alcohol (Ethyl).
CefoTEtan	May enhance the adverse/toxic effect of Alcohol (Ethyl).
Chloramphenicol (Systemic)	May enhance the adverse/toxic effect of Alcohol (Ethyl).
Chlorphenesin Carbamate	Alcohol (Ethyl) may enhance the adverse/toxic effect of Chlorphenesin Carbamate.
Cisapride	May enhance the adverse/toxic effect of Alcohol (Ethyl). Specifically, Alcohol (Ethyl) sedative and psychomotor effects may be enhanced. Alcohol (Ethyl) may also worsen nocturnal heartburn. Cisapride may increase the serum concentration of Alcohol (Ethyl).
CloBAZam	Alcohol (Ethyl) may enhance the CNS depressant effect of CloBAZam. Alcohol (Ethyl) may increase the serum concentration of CloBAZam.
CNS Depressants	May enhance the CNS depressant effect of Alcohol (Ethyl).
Cyproterone	Alcohol (Ethyl) may diminish the therapeutic effect of Cyproterone. More specifically, alcohol may interfere with antiandrogenic effects of Cyproterone.
Diethylpropion	Alcohol (Ethyl) may enhance the adverse/toxic effect of Diethylpropion.
Doxylamine	Alcohol (Ethyl) may enhance the CNS depressant effect of Doxylamine. Management: The manufacturer of Diclegis (doxylamine/pyridoxine), intended for use in pregnancy, specifically states that use with alcohol is not recommended
Dronabinol	May enhance the CNS depressant effect of Alcohol (Ethyl).
Efavirenz	May enhance the adverse/toxic effect of Alcohol (Ethyl). Efavirenz may decrease the serum concentration of Alcohol (Ethyl).
Esketamine	May enhance the CNS depressant effect of CNS Depressants.
Ethionamide	Alcohol (Ethyl) may enhance the adverse/toxic effect of Ethionamide. Specifically, there may be a risk for a psychotic episode/reaction.
Ezogabine	Alcohol (Ethyl) may enhance the adverse/toxic effect of Ezogabine. Alcohol (Ethyl) may increase the serum concentration of Ezogabine.
Fesoterodine	Alcohol (Ethyl) may enhance the CNS depressant effect of Fesoterodine.
Fosphenytoin	Alcohol (Ethyl) may enhance the CNS depressant effect of Fosphenytoin. Alcohol (Ethyl) may decrease the serum concentration of Fosphenytoin. This may be particularly applicable with chronic, heavy alcohol consumption. Alcohol (Ethyl) may increase the serum concentration of Fosphenytoin. This may be particularly applicable with acute, heavy alcohol consumption.
Griseofulvin	May enhance the adverse/toxic effect of Alcohol (Ethyl). A disulfiram-like reaction may occur.
HydrOXYzine	May enhance the CNS depressant effect of CNS Depressants.
Indoramin	Alcohol (Ethyl) may enhance the sedative effect of Indoramin. Alcohol (Ethyl) may increase the serum concentration of Indoramin.
ISOtretinoin (Systemic)	Alcohol (Ethyl) may enhance the adverse/toxic effect of ISOtretinoin (Systemic). Specifically, the risk for elevated triglyceride concentrations may be increased.
Kava Kava	May enhance the adverse/toxic effect of CNS Depressants.
Lofexidine	May enhance the CNS depressant effect of CNS Depressants. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs.
Magnesium Sulfate	May enhance the CNS depressant effect of CNS Depressants.
Mecamylamine	Alcohol (Ethyl) may enhance the adverse/toxic effect of Mecamylamine.
MetyroSINE	Alcohol (Ethyl) may enhance the sedative effect of MetyroSINE.
Minocycline	May enhance the CNS depressant effect of CNS Depressants.
Molsidomine	May enhance the hypotensive effect of Alcohol (Ethyl).
Morniflumate	Alcohol (Ethyl) may enhance the adverse/toxic effect of Morniflumate. Specifically, consumption of more than 3 alcoholic drinks per day may increase the risk of gastrointestinal hemorrhage during Morniflumate treatment.
Nabilone	May enhance the CNS depressant effect of Alcohol (Ethyl).
Nicorandil	Alcohol (Ethyl) may enhance the hypotensive effect of Nicorandil.
NIFEdipine	Alcohol (Ethyl) may increase the serum concentration of NIFEdipine.
Nonsteroidal Anti-Inflammatory Agents	Alcohol (Ethyl) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the risk of GI bleeding may be increased with this combination.
Oxcarbazepine	Alcohol (Ethyl) may enhance the CNS depressant effect of OXcarbazepine.
Oxybutynin	Alcohol (Ethyl) may enhance the CNS depressant effect of Oxybutynin.
Phendimetrazine	Alcohol (Ethyl) may enhance the adverse/toxic effect of Phendimetrazine.
Phentermine	Alcohol (Ethyl) may enhance the adverse/toxic effect of Phentermine.
Phenytoin	Alcohol (Ethyl) may enhance the CNS depressant effect of Phenytoin. Alcohol (Ethyl) may increase the serum concentration of Phenytoin. This may be particularly applicable with acute, heavy alcohol consumption. Alcohol (Ethyl) may decrease the serum concentration of Phenytoin. This may be particularly applicable with chronic, heavy alcohol consumption.
Phosphodiesterase 5 Inhibitors	Alcohol (Ethyl) may enhance the hypotensive effect of Phosphodiesterase 5 Inhibitors.
Pramipexole	Alcohol (Ethyl) may enhance the sedative effect of Pramipexole.
Propacetamol	Alcohol (Ethyl) may enhance the hepatotoxic effect of Propacetamol.
Propranolol	Alcohol (Ethyl) may decrease the serum concentration of Propranolol. Alcohol (Ethyl) may increase the serum concentration of Propranolol.
Quinagolide	Alcohol (Ethyl) may enhance the adverse/toxic effect of Quinagolide.
ROPINIRole	Alcohol (Ethyl) may enhance the sedative effect of ROPINIRole.
Rotigotine	Alcohol (Ethyl) may enhance the sedative effect of Rotigotine.
Rufinamide	Alcohol (Ethyl) may enhance the adverse/toxic effect of Rufinamide. Specifically, sleepiness and dizziness may be enhanced.
Sulfonylureas	May enhance the adverse/toxic effect of Alcohol (Ethyl). A flushing reaction may occur.
Tacrolimus (Topical)	May enhance the dermatologic adverse effect of Alcohol (Ethyl).
Tetrahydrocannabinol	May enhance the CNS depressant effect of Alcohol (Ethyl).
Tetrahydrocannabinol and Cannabidiol	May enhance the CNS depressant effect of CNS Depressants.
Theophylline	Alcohol (Ethyl) may increase the serum concentration of Theophylline.
Thiazide and Thiazide-Like Diuretics	Alcohol (Ethyl) may enhance the orthostatic hypotensive effect of Thiazide and Thiazide-Like Diuretics.
TraZODone	Alcohol (Ethyl) may enhance the adverse/toxic effect of TraZODone. Specifically, effects on sleepiness, dizziness, and manual dexterity may be enhanced.
Trimeprazine	May enhance the CNS depressant effect of CNS Depressants.
Trimethobenzamide	Alcohol (Ethyl) may enhance the CNS depressant effect of Trimethobenzamide.
Urapidil	Alcohol (Ethyl) may enhance the hypotensive effect of Urapidil.
Varenicline	May enhance the adverse/toxic effect of Alcohol (Ethyl). Specifically, alcohol tolerance may be decreased and the risk for neuropsychiatric adverse effects may be increased.
Vasodilators (Organic Nitrates)	Alcohol (Ethyl) may enhance the vasodilatory effect of Vasodilators (Organic Nitrates).
Verapamil	May increase the serum concentration of Alcohol (Ethyl).
Vitamin K Antagonists (eg, warfarin)	Alcohol (Ethyl) may decrease the serum concentration of Vitamin K Antagonists. More specifically, this effect has been described in heavy drinking alcoholic patients (over 250 g alcohol daily for over 3 months). The role of alcohol itself is unclear.
Risk Factor D (Consider therapy modification)
Aspirin	Alcohol (Ethyl) may enhance the adverse/toxic effect of Aspirin. Specifically, alcohol may increase the bleeding risk of aspirin. Alcohol (Ethyl) may diminish the therapeutic effect of Aspirin. Specifically, alcohol may interfere with the controlled release mechanism of extended release aspirin. Management: Monitor patients who drink 3 or more alcoholic drinks a day for increased bleeding while taking aspirin. Counsel patients about the risk of bleeding and discourage such consumption. Give extended release aspirin 2 hours before, or 1 hour after, alcohol.
Blonanserin	CNS Depressants may enhance the CNS depressant effect of Blonanserin.
Buprenorphine	Alcohol (Ethyl) may enhance the CNS depressant effect of Buprenorphine. Management: Advise patients receiving buprenorphine about the increased risk of CNS depression if they consume alcohol. Consider alternatives to buprenorphine for opioid addiction treatment in patients who are dependent on alcohol.
BuPROPion	Alcohol (Ethyl) may enhance the adverse/toxic effect of BuPROPion. Specifically, seizure threshold may be lowered. BuPROPion may enhance the adverse/toxic effect of Alcohol (Ethyl). Specifically, alcohol tolerance may decrease during treatment. Management: Patients receiving bupropion should be advised to minimize or avoid alcohol consumption due to possible lower alcohol tolerance, and lower seizure threshold associated with heavy alcohol consumption/abrupt discontinuation of heavy consumption.
Chlormethiazole	Alcohol (Ethyl) may enhance the CNS depressant effect of Chlormethiazole.
Droperidol	May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Exceptions to this monograph are discussed in further detail in separate drug interaction monographs.
Ketoconazole (Systemic)	May enhance the adverse/toxic effect of Alcohol (Ethyl). Management: Advise patients to avoid alcohol ingestion while taking ketoconazole.
Levomilnacipran	Alcohol (Ethyl) may increase the absorption of Levomilnacipran. More specifically, Alcohol (Ethyl) may cause more rapid release of Levomilnacipran from extendedrelease tablets, which could accelerate absorption early post-dose. Management: Avoid administering levomilnacipran with alcohol. The use of alcohol in patients receiving levomilnacipran is not otherwise advised against, although it may theoretically modify the central effects of one or both drugs.
Lomitapide	Alcohol (Ethyl) may enhance the hepatotoxic effect of Lomitapide. Management: Advise patients to limit alcohol consumption to 1 drink per day while receiving lomitapide.
Methotrexate	Alcohol (Ethyl) may enhance the hepatotoxic effect of Methotrexate. Management: Limit alcohol consumption in patients taking methotrexate. The use of methotrexate for the treatment of psoriasis or rheumatoid arthritis is contraindicated in patients with alcoholism or alcoholic liver disease.
Methotrimeprazine	CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Methotrimeprazine may enhance the CNS depressant effect of CNS Depressants. Management: Reduce adult dose of CNS depressant agents by 50% with initiation of concomitant methotrimeprazine therapy. Further CNS depressant dosage adjustments should be initiated only after clinically effective methotrimeprazine dose is established.
MetroNIDAZOLE (Topical)	May enhance the adverse/toxic effect of Alcohol (Ethyl). A disulfiramlike reaction may occur. Management: Warn patients and monitor for signs and symptoms of a disulfiram-like reaction if patients consume alcohol while using topical metronidazole. Some manufacturers of vaginal metronidazole products list alcohol use within 24 to 72 hours as a contraindication
Mipomersen	Alcohol (Ethyl) may enhance the hepatotoxic effect of Mipomersen. Management: Patients being treated with mipomersen should limit their consumption of alcohol to a maximum of 1 drink (or equivalent) per day.
Niacin	Alcohol (Ethyl) may enhance the adverse/toxic effect of Niacin.
Ombitasvir, Paritaprevir, Ritonavir, and Dasabuvir	Alcohol (Ethyl) may diminish the therapeutic effect of Ombitasvir, Paritaprevir, Ritonavir, and Dasabuvir. Management: Avoid alcohol consumption within 4 hours of taking the extended-release ombitasvir/paritaprevir/ritonavir/dasabuvir product. This interaction does not apply to the immediate-release ombitasvir/paritaprevir/ritonavir/dasabuvir product.
Opioid Agonists	CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.
OxyCODONE	CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug.
Pheniramine	Alcohol (Ethyl) may enhance the CNS depressant effect of Pheniramine.
Selective Serotonin Reuptake Inhibitors	Alcohol (Ethyl) may enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced. Management: Patients receiving selective serotonin reuptake inhibitors should be advised to avoid alcohol. Monitor for increased psychomotor impairment in patients who consume alcohol during treatment with selective serotonin reuptake inhibitors.
Serotonin/Norepinephrine Reuptake Inhibitors	Alcohol (Ethyl) may enhance the adverse/toxic effect of Serotonin/Norepinephrine Reuptake Inhibitors. Specifically, risks of psychomotor impairment may be enhanced. Alcohol (Ethyl) may enhance the hepatotoxic effect of Serotonin/Norepinephrine Reuptake Inhibitors. Particularly duloxetine and milnacipran. Management: Patients receiving serotonin/norepinephrine reuptake inhibitors (SNRIs) should be advised to avoid alcohol. Monitor for increased psychomotor impairment and hepatotoxicity in patients who consume alcohol during treatment with SNRIs.
Tacrolimus (Systemic)	Alcohol (Ethyl) may increase the absorption of Tacrolimus (Systemic). More specifically, the initial absorption rate may be increased, as alcohol may speed the release of tacrolimus from extended-release tablets. Management: Advise patients receiving extendedrelease tacrolimus (Astagraf XL or Envarsus XR brands) not to take the medication with alcoholic beverages.
Trospium	Alcohol (Ethyl) may enhance the CNS depressant effect of Trospium. Alcohol (Ethyl) may increase the serum concentration of Trospium. Specifically, alcohol may increase the peak (maximum) serum concentration of trospium when consumed within 2 hours of taking extendedreleasetrospium. Management: Avoid consuming any alcohol within 2 hours of taking a dose of trospium XR.
Zolpidem	CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol.
Risk Factor X (Avoid combination)
Acitretin	Alcohol (Ethyl) may enhance the teratogenic effect of Acitretin.
Agomelatine	Alcohol (Ethyl) may enhance the adverse/toxic effect of Agomelatine.
Alizapride	Alcohol (Ethyl) may enhance the sedative effect of Alizapride.
Alpha-Lipoic Acid	Alcohol (Ethyl) may diminish the therapeutic effect of Alpha-Lipoic Acid.
Amantadine	Alcohol (Ethyl) may enhance the CNS depressant effect of Amantadine. Alcohol may also cause dose-dumping for at least one extended-release amantadine product.
Amisulpride	May enhance the adverse/toxic effect of Alcohol (Ethyl).
Armodafinil	Alcohol (Ethyl) may diminish the therapeutic effect of Armodafinil.
Azelastine (Nasal)	Alcohol (Ethyl) may enhance the CNS depressant effect of Azelastine (Nasal).
Bedaquiline	Alcohol (Ethyl) may enhance the hepatotoxic effect of Bedaquiline.
Benznidazole	May enhance the adverse/toxic effect of Alcohol (Ethyl). A disulfiram-like reaction may occur.
Bromopride	May enhance the sedative effect of Alcohol (Ethyl).
Bromperidol	May enhance the CNS depressant effect of CNS Depressants.
Cefminox	May enhance the adverse/toxic effect of Alcohol (Ethyl).
CycloSERINE	Alcohol (Ethyl) may enhance the neurotoxic effect of CycloSERINE. Specifically, the risk for seizures may be increased.
Cysteamine (Systemic)	Alcohol (Ethyl) may enhance the adverse/toxic effect of Cysteamine (Systemic). Alcohol (Ethyl) may diminish the therapeutic effect of Cysteamine (Systemic).
Dapoxetine	May enhance the adverse/toxic effect of Alcohol (Ethyl).
Dexlansoprazole	Alcohol (Ethyl) may decrease the serum concentration of Dexlansoprazole.
Didanosine	Alcohol (Ethyl) may enhance the adverse/toxic effect of Didanosine. Specifically, the risk of pancreatitis may be increased.
Dimethindene (Topical)	May enhance the CNS depressant effect of Alcohol (Ethyl).
Disulfiram	May enhance the adverse/toxic effect of Alcohol (Ethyl). A disulfiram-like reaction may occur.
Eluxadoline	Alcohol (Ethyl) may enhance the adverse/toxic effect of Eluxadoline. Specifically, alcohol use may increase the risk of pancreatitis.
Flibanserin	Alcohol (Ethyl) may enhance the hypotensive effect of Flibanserin.
Flunitrazepam	Alcohol (Ethyl) may enhance the CNS depressant effect of Flunitrazepam.
Gabapentin Enacarbil	Alcohol (Ethyl) may enhance the CNS depressant effect of Gabapentin Enacarbil. Alcohol (Ethyl) may increase the absorption of Gabapentin Enacarbil. Specifically, the rate of absorption may be enhanced, as alcohol may speed the release of drug from the extended-release tablet.
GuanFACINE	Alcohol (Ethyl) may enhance the CNS depressant effect of GuanFACINE.
HYDROcodone	Alcohol (Ethyl) may enhance the CNS depressant effect of HYDROcodone. Alcohol (Ethyl) may increase the serum concentration of HYDROcodone. Management: Patients using the Zohydro ER brand of extended-release hydrocodone must not consume alcohol or alcohol-containing products due to possibly fatal outcomes. Other hydrocodone products are also expected to interact, but to a less significant degree.
Lercanidipine	Alcohol (Ethyl) may enhance the vasodilatory effect of Lercanidipine.
Levomethadone	Alcohol (Ethyl) may enhance the adverse/toxic effect of Levomethadone. Specifically, the risk for sedation, respiratory depression, coma, and death may be increased.
Levosulpiride	Alcohol (Ethyl) may enhance the CNS depressant effect of Levosulpiride.
Lormetazepam	Alcohol (Ethyl) may enhance the CNS depressant effect of Lormetazepam.
Melatonin	Alcohol (Ethyl) may enhance the adverse/toxic effect of Melatonin. Alcohol (Ethyl) may diminish the therapeutic effect of Melatonin.
Mequitazine	Alcohol (Ethyl) may enhance the CNS depressant effect of Mequitazine.
MetFORMIN	Alcohol (Ethyl) may enhance the adverse/toxic effect of MetFORMIN. Specifically, alcohol may potentiate the risk of lactic acidosis
Methadone	Alcohol (Ethyl) may enhance the CNS depressant effect of Methadone.
Methylphenidate	Alcohol (Ethyl) may enhance the adverse/toxic effect of Methylphenidate. Alcohol (Ethyl) may increase the serum concentration of Methylphenidate.
MetroNIDAZOLE (Systemic)	May enhance the adverse/toxic effect of Alcohol (Ethyl). A disulfiram-like reaction may occur.
Mianserin	May enhance the CNS depressant effect of Alcohol (Ethyl).
Mirtazapine	Alcohol (Ethyl) may enhance the CNS depressant effect of Mirtazapine.
Modafinil	Alcohol (Ethyl) may diminish the therapeutic effect of Modafinil.
Monoamine Oxidase Inhibitors	Alcohol (Ethyl) may enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors.
Nefopam	Alcohol (Ethyl) may enhance the CNS depressant effect of Nefopam.
Niclosamide	May increase the absorption of Alcohol (Ethyl).
Nilutamide	May enhance the adverse/toxic effect of Alcohol (Ethyl). Specifically, nilutamide may increase the likelihood of alcohol intolerance (eg, facial flushing, malaise, hypotension).
Orphenadrine	Alcohol (Ethyl) may enhance the CNS depressant effect of Orphenadrine.
Oxomemazine	May enhance the CNS depressant effect of CNS Depressants.
Paraldehyde	Alcohol (Ethyl) may enhance the CNS depressant effect of Paraldehyde.
Perampanel	May enhance the CNS depressant effect of Alcohol (Ethyl). Alcohol may also worsen the negative behavioral and psychiatric effects of Perampanel.
Pipamperone [INT]	May enhance the adverse/toxic effect of Alcohol (Ethyl). Specifically, sedative and psychomotor effects may be enhanced.
Piribedil	Alcohol (Ethyl) may enhance the sedative effect of Piribedil.
Prothionamide	Alcohol (Ethyl) may enhance the adverse/toxic effect of Prothionamide.
Rilmenidine	Alcohol (Ethyl) may enhance the adverse/toxic effect of Rilmenidine. Specifically, alcohol increased the CNS depressant effect of rilmenidine.
Sodium Oxybate	Alcohol (Ethyl) may enhance the CNS depressant effect of Sodium Oxybate.
Stiripentol	May enhance the sedative effect of Alcohol (Ethyl).
Sulpiride	Alcohol (Ethyl) may enhance the adverse/toxic effect of Sulpiride.
Sulthiame	May enhance the adverse/toxic effect of Alcohol (Ethyl). Specifically, concurrent use may result in a disulfiram-like reaction.
Suvorexant	Alcohol (Ethyl) may enhance the CNS depressant effect of Suvorexant.
Tapentadol	Alcohol (Ethyl) may enhance the CNS depressant effect of Tapentadol. Alcohol (Ethyl) may increase the serum concentration of Tapentadol. Specifically, alcohol may increase the maximum serum concentrations when used with extended-release tapentadol.
Thalidomide	CNS Depressants may enhance the CNS depressant effect of Thalidomide.
Tinidazole	May enhance the adverse/toxic effect of Alcohol (Ethyl). A disulfiram-like reaction may occur.
Topiramate	Alcohol (Ethyl) may enhance the CNS depressant effect of Topiramate. Alcohol (Ethyl) may increase the serum concentration of Topiramate. This applies specifically to use with the extended-release topiramate capsules (Trokendi XR). Also, topiramate concentrations may be subtherapeutic in the later portion of the dosage interval. Management: Concurrent use of alcohol within 6 hours of ingestion of extended-release topiramate (Trokendi XR) is contraindicated. Any use of alcohol with topiramate should be avoided when possible and should only be undertaken with extreme caution.
Trabectedin	Alcohol (Ethyl) may enhance the hepatotoxic effect of Trabectedin.
Zopiclone	Alcohol (Ethyl) may enhance the adverse/toxic effect of Zopiclone. Specifically, taking alcohol with zopiclone may increase the risk of complex sleep-related behaviors (eg, sleepdriving, eating food, making phone calls, leaving the house, etc.) Alcohol (Ethyl) may enhance the CNS depressant effect of Zopiclone.

Monitoring Parameters:

Septal Ablation for HOCM:

Continuous ECG Monitoring: Keep monitoring the heart's electrical activity for 48 hours after the procedure.
Watch for Signs/Symptoms: Be alert for signs of heart failure, chest pain, and irregular heart rhythms in the days following the procedure.

Antidotal Therapy:

Monitoring Blood Ethanol Levels: Check blood ethanol levels every 1 to 2 hours initially until they stabilize, then every 2 to 4 hours thereafter.
Assess Blood Glucose and Electrolytes: Monitor blood sugar levels and electrolyte balance, including serum magnesium levels.
Check Arterial pH and Blood Gases: Keep an eye on arterial pH and blood gas levels.
Monitor Methanol or Ethylene Glycol Blood Levels: Regularly check blood levels of methanol or ethylene glycol, the toxic substances involved.
Track Heart Rate and Blood Pressure: Monitor heart rate and blood pressure throughout treatment.

Administration of Ethanol injection?

Oral Administration for Ethylene Glycol or Methanol Overdose:

Dilute ethyl alcohol to a solution of ≤20% with water or juice to reduce the risk of gastritis.
Administer hourly by mouth or via nasogastric tube.
Note: Out-of-hospital management with orally administered ethanol is not typically recommended but has been shown to be effective. It's crucial to administer oral ethanol precisely at 60-minute intervals due to its pharmacokinetics.

Intravenous (IV) Administration for Ethylene Glycol or Methanol Overdose:

IV administration via a central vein is preferred.
Administer as a 10% solution in D5W.
The initial dose should be administered over 1 hour.

Treatment of Occluded Central Venous Catheter:

Instill a 70% solution with a volume equal to the internal volume of the catheter.
Assess patency at 30 to 60 minutes or as per institutional protocol.

Intraneural Injection:

Use separate needles for each of multiple injections or sites to prevent residual alcohol deposition at unintended sites.
Inject slowly after confirming the proper placement of the needle.
Proper patient positioning is crucial to control the localization of injections into the subarachnoid space.

Intracoronary Injection:

Inject small volumes over 1 to 2 minutes percutaneously into septal arterial branches.
Guide the injection based on the assessment of the gradient.

Mechanism of action of Ethanol injection:

Ethylene Glycol or Methanol Overdose (Off-label Use):

Ethyl alcohol competitively inhibits alcohol dehydrogenase, an enzyme that metabolizes ethylene glycol and methanol into their toxic forms, thus helping to prevent the formation of harmful metabolites.

Neurolysis:

Alcohol is used to destroy nerves at the injection site, effectively blocking nerve signals and providing relief from pain or other symptoms.

Septal Ablation:

Ethyl alcohol serves as a tissue toxin when injected through an intra-arterial catheter into a targeted septal vessel during septal ablation procedures. This toxin induces a controlled myocardial infarction, thinning the hypertrophied septum and improving heart function.

Absorption:

Oral: Ethyl alcohol is rapidly absorbed when taken orally, entering the bloodstream quickly after ingestion.

Distribution:

The volume of distribution (V) of ethyl alcohol ranges from 0.6 to 0.7 L/kg. However, this volume may be decreased in women compared to men.

Metabolism:

Ethyl alcohol undergoes hepatic metabolism, with 90% to 98% of it being metabolized in the liver. It is primarily metabolized to acetaldehyde or acetate.

Half-life Elimination:

The rate of elimination of ethyl alcohol is approximately 15 to 20 mg/dL/hour, with a range of 10 to 34 mg/dL/hour. This rate may be increased in individuals with alcohol use disorder (alcoholics).

Excretion: