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Hypocalcemia in Hemodialysis Patients

15 mg/kg every 12 hr thereafter until ethylene glycol levels decrease to less than 20 mg/dL. The drug is given as a slow intravenous infusion. Fomepizole is dialyzable, and dosing adjustments are needed in patients receiving hemodialysis. If hemodialysis is begun more than 6 hr after the last dose of fomepizole, the timing of the next scheduled dose should be moved up to just prior to dialysis. If dialysis exceeds 4 hr, additional doses should be given every 4 hr during dialysis. Supplemental dosing after dialysis depends on when and whether an intradialytic dose was given. If less than 1 hr has passed between an intradialytic dose and the end of dialysis, a postdialysis dose of fomepizole is not necessary. If 1–3 hr have passed, one-half of the next scheduled dose is recommended. If more than 3 hr have passed, the next full dose should be given at the end of dialysis. Between dialysis sessions, fomepizole should be given every 12 hr. The most frequent adverse events reported with fomepizole use have been headache (12%), nausea (11%), and dizziness (7%) (1, 2). In an open-labeled, prospective, unpublished study, 16 patients with confirmed ethylene glycol poisoning were given fomepizole according to guidelines. Of the 16 patients, 14 received hemodialysis due to severe intoxication, with 12 of these having levels greater than 50 mg/ dL. Fomepizole blocked ethylene glycol metabolism, as evidenced by stable plasma glycolate and urinary oxalate levels. The majority of these patients (63%) had severe metabolic acidosis and impaired renal function on presentation. However, in patients with initially normal renal function, no deterioration in renal function was found during the trial. Another open-labeled, unpublished study (this one retrospective) in 26 patients with suspected ethylene glycol poisoning was similarly successful (unpublished product monograph). One patient with an ethylene glycol level of 345 mg/dL maintained normal renal function and survived with fomepizole. While hemodialysis theoretically is unnecessary once ethylene glycol metabolism has been blocked, it still is recommended for ethylene glycol concentrations greater than 50 mg/dL in order to avoid a protracted course for this potentially fatal poisoning. The high clearance of ethylene glycol by hemodialysis (approaching that of urea) accelerates recovery (6). Ethanol, the more traditional therapy, is more difficult to use clinically because it requires frequent monitoring of plasma ethanol levels. Even with optimal dosing, ethanol may be less effective than fomepizole. Though fomepizole is safe, effective, and extremely convenient, it does have the major disadvantage of high cost—$1,000 per vial, with four vials required for an average treatment.