As alcohol is now becoming a common social evil among our society, we as Doctors always have to take care that our patient will avoid the alcohol during treatment.

There are some drugs for which patient should be warned strictly to avoid alcohol during treatment and even 12 hours before and after starting treatment. List of some main drugs are given below (Drugs causing Disulfiram like reactions).

Because if the patient consume even small amount of alcohol during treatment with these drugs, then he will suffer with severe distressing problems like headache, nausea, vomiting, sweating, vertigo, blurred vision, hypotension, dizziness, burning sensation, tightness in chest, mental confusion and even circulatory collapse.

The duration depends on the amount of alcohol consumed, usually it takes one to four hours.

This is a typical story with the drug Disulfiram, and as usual, we use these side effects to help “motivated” alcoholics to quit alcohol and this is known as Aversion therapy.

So, Aversion therapy is given only to (1) a motivated person and (2) That person should not be physically dependent on alcohol.

And what we do in “Aversion Therapy” ?

Well, we give Disulfiram to our motivated patient who want to quit alcohol, at a dose of 500mg/ day for one week and then 250 mg/day (Tab. Deadict 250 mg.) continued later and if our motivated person losses its control, then after consuming alcohol…….this time, no High, but lots of distressing problems will be waiting for him to fell like doom, for hours.

So, we use Disulfiram in the Aversion therapy….. but there are other drugs also which are given in different conditions and cause Disulfiram like reaction

Drugs causing Disulfiram like Reaction (Alcohol should be avoided strictly while using these)

• Metronidazole (Extensively used in amoebiasis and anaerobic bacterial infections) along with Tinidazole, Secnidazole, Ornidazole.
• Griseofulvin (Antifungal)
• Cefotetan (Second Generation Cephalosporin)
• Cefamandole (Second Generation Cephalosporin)
• Cefoperazone (Third Generation Cephalosporin)
• Chlorpropamide (Oral Antidiabetic drug belongs to sulfonylurea group)

Q. Why Disulfiram used in Aversion therapy? or Why Disulfiram cause Distressing symptoms in Alcoholics?

As we know that when a person consumes alcohol (Ethyl alcohol) then the enzyme Alcohol dehydrogenase act on it and will turn it into Acetaldehyde.

This aldehyde if not metabolized quickly then create all the distressing problems mentioned above and don’t forget that it is also responsible for the Hangover, from now onwards, if you hear salman Khan singing “ Hangover teri Yaadon Ka” then recall its not the memories of the girl responsible for his hangover, its the acetaldehyde formed due to consumption of ethyl alcohol.

So, this acetaldehyde is quickly metabolized by the Enzyme Aldehyde Dehydrogenase and convert our notorious acetaldehyde into acetic acid which is non toxic and metabolized by our body easily.

And this is the location where the Disulfiram act, it inhibit the enzyme Aldehyde Dehydrogenase and as the concentration of acetaldehyde rises in the blood the mentioned distressing symptoms occurs (also known as aldehyde syndrome).

Hope this article will help you understand the concept in a better way…

Happy Learning…….

We all have seen news about deaths of people dying suddenly, after consumption of “Poisonous” alcohol or read about this in newspapers …….

Why does this happen? why we are not able to prevent these deaths/casualties? why these all casualties belong to mainly lower socioeconomic groups?

well, lets discuss………..

The the causative agent behind this is mostly the inadvertent use of Methyl Alcohol…………..even small amount (15 ml) of methanol can cause blindness …….and 30 ml can cause death.

India, where the taxation on the Ethyl alcohol is extremely high, people of lower socioeconomic group attracted to the cheap alternatives for getting high, one of the method is locally made alcohol, this type of alcohol is illegally made in the farms without any proper temperature control and distillation methods or quality control and their whole idea is to make cheap alcohol, but sometimes, the methyl alcohol formed during the process, and the mishappening occurs………

Sometime we intentionally mix methyl alcohol in small quantity with ethyl alcohol to prevent ethyl alcohol from misuse eg. in Hand Sanitizers .

If we see the metabolism of methyl alcohol, it is similar to ethyl alcohol, at first the alcohol dehydrogenase act on methyl alcohol and the resultant is also aldehyde (formaldehyde) and later Aldehyde Dehydrogenase act on formaldehyde and Formic acid is formed.

Just like Ethyl alcohol it also follows the Zero order kinetics.

I hope you remember my last blog about Disulfiram where we discussed about metabolism of Ethyl Alcohol (https://pharmacology.life/2021/08/04/disulfiram-like-reactions/)

All the toxic effects of methyl alcohol are due to Formic Acid……..The further metabolism of formic acid is slow, later it is converted into carbon di oxide, which is folate dependent process.

The Problem started few hours after consumption methyl alcohol. The patient has Headache, Nausea, Vomiting, Pain abdomen, disorientation, hypotension and visual symptoms (Loss of visual acuity, ocular damage, dilated pupils which are non reactive)

The formic acid is specifically toxic to the Retina (Cause retinal damage and ultimately blindness, even in small amount of 15 ml)

Formic acid also cause severe acidosis, circulatory collapse, bradycardia, coma, respiratory depression and cause of death is usually due to respiratory failure.

How can we manage Patients of Methyl Alcohol Poisoning ?

1. We keep the Patient in dark room to protect eyes from light.

2.Gastric lavage with Sodium Bicarbonate and

3. IV sodium bicarbonate is used to prevent damage from Acidosis. It is one of the most important measure, as it can also help in preventing retinal damage.

4. Ethyl alcohol (10% in water) given through Nasogastric tube (I repeat, through Nasogastric tube, No IV Formulation for alcohol is available till date). it acts by saturating the aldehyde dehydrogenase, so less aldehyde dehydrogenase is available for the methyl alcohol and hence less Formic acid. (Though, think about the awkward situation where a family brings a patient of Methyl alcohol poisoning, and you are asking for alcohol and giving it to the patient by nasogastric tube)

5. Specific antidote – Fomepizole, well previously we use this name only for answering the viva questions, because in reality it was not commercially available in India. But in 2019 a Gujarat based Pharmaceutical company Zydus Cadila has launched the fomepizole injection (Thankfully, and the rate is also nearly 900 rs for 1.5 gm injection and if you are thinking why 1.5 gm, then calculate the amount of fomepizole for 60 kg patient as mentioned below)

And Fomepizole is way much better and preferred than Ethyl alcohol, because of its specific action in inhibiting aldehyde dehydrogenases. Fomepizole is used IV with loading dose of 15 mg/kg over 30 mins, followed by 10 mg/ kg every 12 hours, One more point to be noted that Fomepizole is also drug of choice in Ethylene glycol poisoning.

5.Hemodialysis can be done

6. Folate therapy– Folinic acid (Calcium leucovorin) 50 mg injected six hourly reduce formic acid level by increasing its oxidation.

Hope this information will help you to understand the current scenario of Methyl alcohol poisoning in India…………

Happy learning………………….

As we all know that Morphine is an excellent analgesic, used in acute pain conditions like trauma, cancer pain, acute myocardial infarction pain etc.

But Morphine use is contraindicated in Patients with head injury ……..WHY?

• Morphine causes marked Respiratory depression in dose dependent manner.

Due to respiratory depression there is retention of carbon di oxide

• This leads to cerebral vasodilation, which cause Increased intracranial tension, which can lead further brain damage and may be fatal.

• Morphine interfere with assessment of Head injury patient prognosis (As in assessment of head injury patients pupillary signs are important).

Morphine itself produces Miosis, Altered mental state and can cause vomiting also, which interfere with head injury assessment.

So due to all above mentioned causes, its better to avoid morphine in a patient with head injury……….

Hope you enjoyed the explanation…….. Happy learning