Disulfiram Toxicity Treatment & Management

Updated: Nov 01, 2019
  • Author: Samara Soghoian, MD, MA; Chief Editor: Sage W Wiener, MD  more...
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Prehospital Care

For patients with possible disulfiram-ethanol reaction (DER), provide supplemental oxygen, obtain intravenous access, and place all patients on a monitor. Administer thiamine, glucose, and naloxone to patients with altered mental status, as needed. Intravenous fluids should be instituted if hypotension, tachycardia, or severe vomiting is present.

Patients with coma or a severely altered mental status should be intubated for airway protection. The frequent occurrence of vomiting secondary to DER places these patients at high risk for aspiration.


Emergency Department Care

Emergency department treatment of disulfiram-ethanol reaction (DER) is primarily supportive. No specific antidote has been tested for efficacy in the treatment of DER or acute disulfiram overdose, though fomepizole has the theoretical benefit of blocking ethanol metabolism to acetaldehyde and may be a useful therapy in patients presenting with DER. Patients with a severely altered mental status or coma should be intubated for airway protection. The risk of aspiration in patients with DER is high.

Mild sedation with benzodiazepines may be useful in the agitated patient, and benzodiazepines may be used to treat seizures. However, sedation of patients with intractable vomiting increases the risk of aspiration and its sequelae and should be approached with caution. Benzodiazepines also have the potential to exacerbate hypotension.

In cases of intractable vomiting, phenothiazine use must be considered cautiously because their alpha-blockade effect may worsen or induce hypotension. Metoclopramide, ondansetron, or granisetron are considered the antiemetics of choice in these cases.

Intravenous fluids should be given to patients experiencing a DER to replace volume losses from emesis and third spacing of intravascular fluid. Intravenous fluids and vasopressors are indicated to support blood pressure and treat patients who are in shock.

Decontamination procedures are not likely to be beneficial once the reaction begins. Consider gastric emptying only in the hospital setting with cases of massive ethanol ingestion in which a patent and protected airway can be maintained. Inducing emesis with ipecac syrup is not recommended. Ipecac syrup contains ethanol, which could precipitate DER. Emesis may delay administration of activated charcoal, worsen the nausea and vomiting associated with disulfiram toxicity, and increase the likelihood of pulmonary aspiration if seizures and coma suddenly occur.

In acute disulfiram overdose, consider the use of activated charcoal, if available and if the patient is alert and able to drink it safely. Use of multiple- dose activated charcoal (MDAC) may be beneficial, as it can increase the rate of elimination of disulfiram and its metabolites that undergo enterohepatic recirculation. Activated charcoal is not indicated for disulfiramlike syndromes, and it is not indicated for the treatment of DER. The risk-benefit of administering charcoal to a patient with altered mental status and a high likelihood of vomiting and potential aspiration must be carefully weighed.

In severe DER, hemodialysis may be indicated to enhance the elimination of ethanol and acetaldehyde. Neither hemodialysis nor hemoperfusion has been beneficial for treatment of acute disulfiram overdose.

Fomepizole (Antizol) may be beneficial in cases of severe DER. Fomepizole is a potent inhibitor of alcohol dehydrogenase that may limit the metabolism of ethanol by this enzyme and thereby prevent further accumulation of acetaldehyde. No studies have examined the utility of fomepizole in this context; however, a theoretical benefit exists in patients taking disulfiram who present with DER after a large ethanol ingestion.

Monitor all patients with DER or acute disulfiram overdose for a minimum of 8-12 hours, even if they lack significant signs or symptoms of toxicity. Admit patients to the ICU if they demonstrate signs and symptoms of significant toxicity.



Consult with the local poison control center or a medical toxicologist. 

Prompt follow-up care with the primary care physician responsible for treating the patient's alcoholism should be arranged for all patients presenting with DER or disulfiram toxicity prior to discharge.

Refer patients with alcoholism to an alcoholic detoxification center and advise them not to drink alcohol or consume any medication or product containing alcohol for at least 2 weeks after the last dose of disulfiram.

A psychiatrist should evaluate all patients being treated for overdose before discharge.


Long-Term Monitoring

Disulfiram is usually prescribed at an initial dose of 500 mg/d for 1-2 weeks, followed by a maintenance dose of 125-500 mg/d. Close monitoring for adverse reactions is required. Liver function should be monitored for hepatotoxicity. [8]