Abstract
Disulfiram is an adjunct in the treatment of alcohol use disorders, but case reports indicate that disulfiram ethanol reactions are not always recognized in the emergency department. Our first aim is to remind of this risk with two case reports of life-threatening reactions not immediately considered by the emergency physician. The second aim is to estimate the probability that a disulfiram reaction goes unrecognized with the use of a retrospective study of patients admitted to the emergency department. Clinical files of patients admitted between October 1, 2010 and September 30, 2014 to the emergency department were retrospectively screened for the key words "ethanol use" and "disulfiram". Their diagnoses were then scored by a panel regarding the probability of an interaction. Seventy-nine patients were included, and a disulfiram-ethanol reaction was scored as either 'highly likely', 'likely' or 'possible' in 54.4% and as 'doubtful' or 'certainly not present' in 45.6% of the patients. The interrater agreement was 0.71 (95% CI: 0.64-0.79). The diagnosis was not considered or only after a delay in 44.2% of the patients with a 'possible' to 'highly likely' disulfiram interaction. One patient with a disulfiram overdose died and was considered as a 'possible' interaction. A disulfiram ethanol interaction can be life threatening and failure to consider the diagnosis in the emergency department seems frequent. Prospective studies with documentation of the intake of disulfiram and evaluation of the value of acetaldehyde as a biomarker are needed to determine the precise incidence. Improving knowledge of disulfiram interactions and adequate history taking of disulfiram intake may improve the care for patients.
Highlights
Disulfiram (DIS) is primarily used as an adjunct in the treatment of alcohol use disorders [1,2,3,4]
DIS and its active metabolite S-methyl N,N-diethylthiocarbamate sulfoxide irreversibly inhibit the enzyme aldehyde dehydrogenase which leads to the accumulation of acetaldehyde with effects known as a DIS ethanol reaction (DER) [5, 6]
It should be noted that some case reports of DER concern DIS overdoses [25, 29, 38] and that sudden death has been reported as a DER with high therapeutic doses [11, 17, 34,35,36] and in DIS intentional overdoses combined with ethanol [37, 38]
Summary
Disulfiram (DIS) is primarily used as an adjunct in the treatment of alcohol use disorders [1,2,3,4]. The aims of the present study are (1) to highlight the clinical picture of a severe DER admitted to an ED with two illustrative cases and (2) to estimate the probability that a DER goes unrecognized with the use of a retrospective study of patients admitted to the emergency department
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