title: Recommendations for the role of extracorporeal treatments in the management of acute methanol poisoning: a systematic review and consensus statement.
abstract: OBJECTIVE
  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.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: 1School of Medicine, University of Queensland, Brisbane, QLD, Australia. 2Drug Health Services, Royal Prince Alfred Hospital, Sydney, NSW, Australia. 3Emergency Medicine Department/Clinical Toxicology Unit, Hospital Universitari Son Espases, Palma de Mallorca, Spain. 4Réanimation Médicale et Toxicologique, Hôpital Lariboisière, INSERM U1144, Université Paris-Diderot, Paris, France. 5Division of Nephrology, Mount Sinai Beth Israel, New York, NY. 6University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO. 7Department of Emergency Medicine, Medical Toxicology Service, McGill University Health Centre, McGill University, Montréal, QC, Canada. 8School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. 9School of Medicine, University of Pittsburgh, Pittsburgh, PA. 10Département de Microbiologie Médicale et Infectiologie, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada. 11Division of Medical Toxicology, Department of Emergency Medicine, New York University School of Medicine, New York, NY. 12University of Montreal, Verdun Hospital, Montreal, QC, Canada.
authors.forename: Darren M
authors.initials: DM
authors.lastname: Roberts
authors.forename: Christopher
authors.initials: C
authors.lastname: Yates
authors.forename: Bruno
authors.initials: B
authors.lastname: Megarbane
authors.forename: James F
authors.initials: JF
authors.lastname: Winchester
authors.forename: Robert
authors.initials: R
authors.lastname: Maclaren
authors.forename: Sophie
authors.initials: S
authors.lastname: Gosselin
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Nolin
authors.forename: Valéry
authors.initials: V
authors.lastname: Lavergne
authors.forename: Robert S
authors.initials: RS
authors.lastname: Hoffman
authors.forename: Marc
authors.initials: M
authors.lastname: Ghannoum
mesh_terms: D000138:Acidosis; D000931:Antidotes / Q000008:administration & dosage*; D015415:Biomarkers; D006801:Humans; D000432:Methanol / Q000493:pharmacokinetics / Q000506:poisoning*; D017410:Practice Guidelines as Topic; D006435:Renal Dialysis / Q000379:methods*; D012720:Severity of Illness Index
chemical_list: D000931:Antidotes; D015415:Biomarkers; D000432:Methanol