Clinical toxicology (Philadelphia, Pa.)最新文献

{"title":"Author response to: Mullins et al. comment on, \"We need a standardized North American acetylcysteine dosing regimen for the treatment of paracetamol (acetaminophen) poisoning\".","authors":"Milton Tenenbein","doi":"10.1080/15563650.2026.2679164","DOIUrl":"10.1080/15563650.2026.2679164","url":null,"abstract":"<p><strong>Introduction: </strong>I have reviewed Mullins et al's critique of my commentary \"We need a standardized North American acetylcysteine dosing regimen for the treatment of paracetamol (acetaminophen) poisoning\".</p><p><strong>Discussion: </strong>I concur regarding this need, and I agree that the original three-bag regimen should be retired. However, we disagree upon its replacement. They challenge my recommendation for a two-bag regimen, and they favour the one-bag two-step approach. The impetus for a replacement acetylcysteine regimen is to decrease the adverse effects and errors associated with the three-bag protocol. However, the one-bag two-step regimen was not designed to decrease adverse effects, and their published reports do not find a decrease of errors. And a fatal adverse effect, acetylcysteine overdose, has emerged with use experience of this regimen.</p><p><strong>Conclusions: </strong>The one-bag two-step regimen should be dismissed from the quest for a standardized North American acetylcysteine dosing regimen for the treatment of paracetamol (acetaminophen) poisoning.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"633-635"},"PeriodicalIF":3.3,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148255565","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"When eye drops turn cardiotoxic: five sequential presentations of recurrent tetrahydrozoline poisoning.","authors":"Hayley Anderson, Ingrid Berling, Michael A Downes, Geoffrey K Isbister","doi":"10.1080/15563650.2026.2703876","DOIUrl":"https://doi.org/10.1080/15563650.2026.2703876","url":null,"abstract":"","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"1-2"},"PeriodicalIF":3.3,"publicationDate":"2026-07-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148595424","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Over-the-counter drug poisoning among pediatric and adolescent patients presenting to emergency departments: a nationwide analysis of the COVID-19 impact.","authors":"Sejin Heo, Kwang Yul Jung","doi":"10.1080/15563650.2026.2703877","DOIUrl":"10.1080/15563650.2026.2703877","url":null,"abstract":"<p><strong>Introduction: </strong>Over-the-counter drug consumption rose during the COVID-19 pandemic, raising concern about a parallel increase in pediatric and adolescent over-the-counter drug poisoning. We compared over-the-counter and prescription drug poisoning patterns among patients aged 18 years or younger before, during, and after the pandemic.</p><p><strong>Methods: </strong>This retrospective analysis of the nationwide Emergency Department-based Injury In-depth Surveillance system (January 2017-December 2023) included patients aged 18 years or younger presenting with drug poisoning across pre-pandemic, pandemic, and post-pandemic periods. Incidence rate ratios (IRR) were estimated using Poisson regression with monthly emergency department visits as the offset, refitted as negative binomial when over-dispersion was present. Interrupted time series analysis evaluated over-the-counter drug poisoning trends.</p><p><strong>Results: </strong>Of 5,907 drug poisoning cases, the incidence rate of over-the-counter drug poisoning increased modestly (IRR for pandemic versus pre-pandemic 1.64, 95% CI 0.98-2.76; post-pandemic 2.10, 95% CI 1.22-3.61), whereas prescription drug poisoning rose more steeply (IRR 2.62 and 3.41, respectively). Over-the-counter drugs accounted for 31.1% of cases, with the proportion declining from 33.6% to 29.9% and 29.3% (P = 0.004), while tranquilizer (22.7% to 37.0%) and antidepressant (7.3% to 10.0%) poisoning increased.</p><p><strong>Discussion: </strong>The pandemic-related increase in drug poisoning was driven predominantly by prescription drugs used in self-harm rather than by over-the-counter drug accessibility. After accounting for the pre-existing secular trend, interrupted time series analysis showed a significant immediate decrease in over-the-counter drug poisoning at the pandemic onset, whereas prescription drug poisoning did not decline. The stable or declining over-the-counter trend may reflect existing packaging-quantity restrictions at non-pharmacy outlets in South Korea, supporting the maintenance rather than relaxation of current regulations.</p><p><strong>Conclusion: </strong>Among pediatric and adolescent patients, over-the-counter drug poisoning declined while prescription drug poisoning rose significantly across the three periods. The pandemic-related increase reflected prescription rather than over-the-counter drugs.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"1-10"},"PeriodicalIF":3.3,"publicationDate":"2026-07-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148582046","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Acute poisoning in young children: a 10-year analysis from Ramathibodi Poison Center.","authors":"Achara Tongpoo, Kitisak Sanprasert, Nastayarin Ariyaviraplorn, Phantakan Tansuwannarat, Satariya Trakulsrichai","doi":"10.1080/15563650.2026.2691834","DOIUrl":"https://doi.org/10.1080/15563650.2026.2691834","url":null,"abstract":"<p><strong>Introduction: </strong>Acute poisoning remains a significant cause of preventable pediatric morbidity worldwide. While epidemiological patterns in high-income countries are well-documented, data from low- and middle-income countries remain distinct. This study aims to identify the epidemiology, toxic agents, and risk factors associated with death in children aged less than six years in Thailand.</p><p><strong>Methods: </strong>We conducted a retrospective cohort study utilizing the Ramathibodi Poison Center Toxic Exposure Surveillance System database from January 2011 to December 2020. Multinomial logistic regression was performed to identify independent associations with clinical severity and mortality.</p><p><strong>Results: </strong>During the study period, 37,076 pediatric exposures were evaluated. The majority of exposures were unintentional (99.8%) and occurred via oral ingestion (94.7%). The most common exposure categories were general-purpose chemicals (45.8%), medications (27.5%), and pesticides (19.0%). Overall mortality was 0.3% (114 deaths). The leading causes of death were pesticides (bipyridyl), general-purpose chemicals (cyanide solution), and natural toxins (cobra venom). Regression analysis identified the newborn age group as a significant independent association of mortality (odds ratio 8.26, 95% CI 4.00-17.18) and major clinical effects (odds ratio 4.59, 95% CI 2.27-9.26). Exposure to natural toxins was strongly associated with worse outcomes (odds ratio 5.33, 95% CI 2.63-10.80) and major effects (odds ratio 15.46, 95% CI 9.04-26.44).</p><p><strong>Discussion: </strong>Our finding differs from that in high-income countries. While pediatric poisoning in high-income countries is predominantly driven by pharmaceuticals, our study population was most frequently exposed to general-purpose chemicals and pesticides. Significantly, newborns were identified as the most vulnerable group for severe outcomes and death.</p><p><strong>Conclusions: </strong>Pediatric poisoning exposures in Thailand present unique regional challenges compared to high-income nations. Preventive strategies and clinical education in this region must prioritize the mitigation of highly lethal, non-pharmaceutical agents such as paraquat, hydrocarbons, and local venomous species.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"1-8"},"PeriodicalIF":3.3,"publicationDate":"2026-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148564346","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Development and validation of a Ramathibodi Poison Center scoring system to predict follow-up necessity in hospitalized patients: a retrospective study.","authors":"Kitisak Sanprasert, Satariya Trakulsrichai, Phantakan Tansuwannarat, Panee Rittilert, Achara Tongpoo","doi":"10.1080/15563650.2026.2691830","DOIUrl":"https://doi.org/10.1080/15563650.2026.2691830","url":null,"abstract":"<p><strong>Introduction: </strong>The Ramathibodi Poison Center manages a substantial workload of 30,000-40,000 annual inquiries, placing significant strain on limited human resources. We aim to develop and validate a practical risk assessment score (Ramathibodi Poison Score) to predict in-hospital mortality among hospitalized poisoned patients, thereby facilitating evidence-based patient prioritization and resource allocation.</p><p><strong>Methods: </strong>A retrospective study used a 9-year dataset partitioned into derivation cohort (70%) and internal validation cohort (30%), while a subsequent 1-year dataset (2025) served for temporal validation. Predictors were identified using multivariable logistic regression, and coefficients were transformed into a simplified integer-based score.</p><p><strong>Results: </strong>A total of 105,342 cases were included in the primary analysis, with 5,578 cases for temporal validation. Independent predictors of mortality included pesticide exposure (the strongest predictor), unknown toxic substance, undetermined or intentional exposure, advanced age (>60 years), and male sex. The score demonstrated robust discrimination with AUC values of 0.828 (derivation), 0.831 (internal), and 0.753 (temporal). Calibration yielded an observed-to-expected (O:E) ratio of 1.000 in the derivation cohort, whereas initial temporal validation demonstrated an underestimation of mortality (O:E 1.528) due to shifting epidemiology. Following logistic recalibration, the O:E ratio in the temporal cohort was 1.000. The score stratified patients from low risk (score 0-5; 0.62% mortality, negative predictive value (NPV) 99.4%) to high risk (score ≥15; 22.22% mortality).</p><p><strong>Discussion: </strong>The score addresses existing severity score limitations by stratifying risk before clinical deterioration. The robust NPV at the low-risk threshold confirms the safety of on-demand surveillance. Furthermore, initial temporal miscalibration highlights the dynamic nature of toxicology, emphasizing the need for periodic local recalibration against emerging threats.</p><p><strong>Conclusion: </strong>The Ramathibodi Poison Score utilizes simple variables to predict mortality with robust discrimination. It safely identifies low-risk patients for de-escalated surveillance. With necessary periodic recalibration, it provides a dynamic, evidence-based framework for efficient resource allocation as an adjunct to clinical judgment.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"1-8"},"PeriodicalIF":3.3,"publicationDate":"2026-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148564369","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patterns of pharmaceutical poisoning teleconsultations in Saudi Arabia: a retrospective study of community-based toxicity calls through the national toxicology consultation services.","authors":"Abdullah A Alharbi, Mohammed A Muaddi, Meshary S Binhotan, Ahmad Y Alqassim, Ali K Alsultan, Mohammed S Arafat, Abdulrahman Aldhabib, Yasser A Alaska, Eid B Alwahbi, Siddig Ibrahim Abdelwahab, Nawfal A Aljerian, Mohammed K Alabdulaali","doi":"10.1080/15563650.2026.2699336","DOIUrl":"https://doi.org/10.1080/15563650.2026.2699336","url":null,"abstract":"<p><strong>Introduction: </strong>Pharmaceutical-related toxic exposures represent a significant global health concern. This study analyzed teleconsultation data from the national Toxicology Consultation Services hotline to understand patterns of teleconsultations for pharmaceutical toxicity cases, demographic characteristics, and management dispositions.</p><p><strong>Methods: </strong>This nationwide cross-sectional study conducted in Saudi Arabia analyzed medication-related toxicity cases reported through public calls to the national toxicology hotline in 2023. Data were analyzed for demographic patterns, therapeutic medication classifications, clinical presentations, and management decisions made by Specialist in Poison Information providers.</p><p><strong>Results: </strong>Of 19,317 teleconsultations analyzed in 2023, children younger than five years accounted for 61.4% (<i>n</i> = 11,864) of cases, with toddlers (<3 years old) demonstrating the highest population-adjusted consultation rate (68.47 per 10,000). Females had higher population-adjusted consultation rates than males (7.85 versus 4.83 per 10,000, <i>P <</i>0.001). Analgesics and anti-inflammatory agents were the most frequently implicated medications (30.4%, <i>n</i> = 5,871), predominating in pediatric exposures (up to 45.5%, <i>n</i> = 378 in infants), whereas cardiovascular agents were most common among the elderly (46%, <i>n</i> = 312). Age was significantly associated with medication category (chi-square test, <i>P <</i>0.001). Most patients were asymptomatic (97.4%, <i>n</i> = 18,821), and home observation was recommended for 71.1% (<i>n</i> = 13,741) of cases. Medication class was significantly associated with management disposition (<i>P <</i>0.001) Respiratory and cardiovascular agents had the highest hospital referral rates (49.6%, <i>n</i> = 514 and 48.5%, <i>n</i> = 724, respectively). Geographic variation was minimal, indicating nationally consistent patterns.</p><p><strong>Discussion: </strong>This nationwide analysis demonstrates distinct age-related medication toxicity patterns and highlights the role of centralized toxicology teleconsultation services in providing nationwide specialized care. The high proportion of asymptomatic cases managed through home observation likely reflects the service's capacity to optimize healthcare resource utilization while maintaining patient safety.</p><p><strong>Conclusion: </strong>These findings identify specific demographic groups to prioritize for poisoning-prevention strategies and characterize how a centralized teleconsultation service triages pharmaceutical exposures. Future studies linking teleconsultation advice to verified clinical outcomes are recommended to determine its effect on resource utilization and patient safety.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"1-11"},"PeriodicalIF":3.3,"publicationDate":"2026-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148564380","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Venom induced pressure elevation reversible syndrome: a severe pediatric rattlesnake envenomation, evidence for conservative management, and call for naming the syndrome.","authors":"Matthew Lippi, Samer Metri, Leanne Cook, Jeff Lapoint, Richard Clark, Justin Seltzer, Christian Tomaszewski, Jacob Hartung, Helen Harvey, Jeremy Hardin","doi":"10.1080/15563650.2026.2700396","DOIUrl":"https://doi.org/10.1080/15563650.2026.2700396","url":null,"abstract":"<p><p><b>Introduction</b>: Rattlesnake envenomation frequently mimics traumatic compartment syndrome, as both are characterized by severe pain, swelling, and elevated compartment pressures. Unlike traumatic compartment syndrome there have been no documented cases of ischemic limb injury after envenomated patients have received antivenom. Furthermore, there is experimental evidence that fasciotomy worsens myonecrosis. This has led medical toxicologists and surgical guidelines to shift from liberally recommending fasciotomy to near universal recommendation of antivenom alone. Despite this, fasciotomies continue to be recommended and performed on rattlesnake envenomated patients. This case highlights a pediatric patient who met objective criteria for compartment syndrome and received repeated recommendations for surgical intervention but was successfully treated with antivenom alone.<b>Case presentation</b>: A 5-year-old female presented with respiratory failure, hypotension, and a tense, ecchymotic right lower extremity without distal pulses following a rattlesnake bite. The patient met criteria for compartment syndrome and emergent fasciotomy was recommended by orthopedic surgery. After multidisciplinary discussions, surgical intervention was deferred in favor of medical management with antivenom. The patient received a total of 30 vials of Crotalidae immune F(ab')2 antivenom (Anavip®), in addition to limb elevation. Following antivenom administration, serial measurements showed a progressive decline in compartment pressures over the first 24 hours. While the initial exam was consistent with traumatic compartment syndrome, the patient improved with medical management alone and was discharged on hospital day seven. Long-term follow-up confirmed a return to unassisted ambulation without neurovascular impairment or tissue loss.<b>Discussion</b>: This case demonstrates that elevated pressures from rattlesnake envenomation can be reversed with antivenom therapy. Despite clinical similarities, traumatic compartment syndrome and venom-induced pressure elevations require different treatment strategies.<b>Conclusion</b>: We propose the term Venom Induced Pressure Elevation Reversible Syndrome (VIPERS), to clearly differentiate the diagnosis from traumatic compartment syndrome. Furthermore, to avoid unnecessary surgical intervention, any consideration for fasciotomy should involve a medical toxicologist experienced in managing rattlesnake envenomation.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"1-8"},"PeriodicalIF":3.3,"publicationDate":"2026-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148564335","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Highly concentrated hydrogen peroxide poisoning with cerebral air emboli imperceptible on CT-imagery.","authors":"Hasan Khaled Abdel Rahman, Trine Hoffmann Kaas, Mikkel Brabrand, Ole Pedersen, Paula Edeusa Cristina Hammer, Søren Mikkelsen","doi":"10.1080/15563650.2026.2698024","DOIUrl":"https://doi.org/10.1080/15563650.2026.2698024","url":null,"abstract":"","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"1-2"},"PeriodicalIF":3.3,"publicationDate":"2026-07-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148552065","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Activated charcoal palatability study: do additives improve taste, ease of swallowing, and tolerability?","authors":"Kristopher Go, Ani Krishnamohan, Angela L Chiew, Betty Chan","doi":"10.1080/15563650.2026.2699332","DOIUrl":"https://doi.org/10.1080/15563650.2026.2699332","url":null,"abstract":"<p><strong>Introduction: </strong>Activated charcoal is the most widely used gastrointestinal decontaminant in poisoning. Its clinical benefit relies on patients ingesting an adequate dose, yet poor palatability often limits compliance. Enhancing taste and ease of swallowing may improve adherence. This study examines whether mixing activated charcoal with chocolate milk, apple juice, or ice cream improves palatability and willingness to consume a full therapeutic dose.</p><p><strong>Methods: </strong>A single-centre, crossover study involved 60 healthy adults tasting activated charcoal mixed in a 4:1 charcoal-to-additive ratio with water, chocolate milk, apple juice, or ice cream, in random order, with a 15-min washout period. After each tasting, participants rated taste and ease of swallowing on a 10-point visual analogue scale and indicated willingness to consume a full 50-gram dose (250 mL). Data were analysed using repeated-measures ANOVA, Cochran's Q, and regression models.</p><p><strong>Results: </strong>Sixty volunteers participated, 29 (48.3%) male, median age 22 years (IQR: 21-23 years, range: 18-44 years). Chocolate milk had the highest mean rating 5.57 (SD: 2.28) (<i>P</i> <0.05). For ease of swallowing, ice cream had the lowest mean rating 3.55 (SD: 2.08) (<i>P</i> <0.05). Full-dose acceptance was highest with chocolate milk (58%) and lowest with ice cream (35%), with a significant difference between them (<i>P</i> = 0.03). Taste was a significant predictor of full-dose willingness for chocolate milk (OR = 1.81, <i>P</i> = 0.02). Women were more likely than men to accept a full dose with chocolate milk (OR = 3.92, <i>P</i> = 0.04).</p><p><strong>Discussion: </strong>Our findings align with previous studies showing that additives improve activated charcoal palatability, with chocolate milk preferred over apple juice, ice cream, and water. Importantly, we assessed willingness to consume a full dose, a novel and clinically relevant measure of adherence and chocolate milk showed the highest willingness.</p><p><strong>Conclusion: </strong>In this volunteer study, chocolate milk significantly improved charcoal acceptance. Taste influenced full-dose willingness across additives, suggesting a role in optimising activated charcoal administration.</p>","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"1-13"},"PeriodicalIF":3.3,"publicationDate":"2026-07-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148552091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pyridoxine/pyridoxal-5'-phosphate repletion to improve outcomes of alcohol withdrawal syndrome and promote long-term abstinence: a hypothesis.","authors":"Steven J Weintraub","doi":"10.1080/15563650.2026.2702501","DOIUrl":"10.1080/15563650.2026.2702501","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Introduction: &lt;/strong&gt;Deficiency of pyridoxal-5&lt;b&gt;'&lt;/b&gt;-phosphate, the clinically measured and active form of pyridoxine (vitamin B6), is prevalent among those with alcohol use disorder. However, unlike thiamine, pyridoxal-5&lt;b&gt;'&lt;/b&gt;-phosphate is not routinely repleted. Evidence is presented that its repletion would improve outcomes of alcohol withdrawal syndrome and promote long-term abstinence.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Pyridoxal-5′-phosphate deficiency can cause a clinically consequential glutamatergic/gabaergic signaling imbalance: &lt;/strong&gt;Excessive excitatory glutamatergic signaling and inadequate inhibitory GABAergic signaling are central to the pathophysiology of alcohol withdrawal syndrome. Pyridoxal-5'-phosphate is an essential cofactor for the rate-limiting enzyme in the conversion of glutamate to GABA, glutamic acid decarboxylase. Therefore, pyridoxal-5'-phosphate deficiency would be expected to exacerbate the signaling imbalance that underlies alcohol withdrawal syndrome, worsening symptoms and treatment response. This is supported by the finding that pyridoxal-5'-phosphate deficiency-whether in animal models or other clinical conditions, including nutritional pyridoxine insufficiency, isoniazid toxicity, and certain inborn errors of metabolism-can create a glutamatergic/GABAergic imbalance severe enough to cause anticonvulsant-refractory status epilepticus.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Mechanisms of pyridoxal-5′-phosphate deficiency in alcohol use disorder: &lt;/strong&gt;Pyridoxal-5'-phosphate deficiency in alcohol use disorder occurs in part because alcohol is oxidized by alcohol dehydrogenase to acetaldehyde, which displaces pyridoxal-5'-phosphate from binding proteins, exposing it to hydrolysis by phosphatases. Hepatic disease promotes deficiency through increased phosphatase activity. Other mechanisms, including poor nutritional intake, likely contribute.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Pyridoxal-5′-phosphate deficiency may surreptitiously precipitate or exacerbate clinical manifestations of alcohol withdrawal: &lt;/strong&gt;In a small study of individuals with alcohol use disorder, pyridoxine deficiency was more prevalent in those who had an alcohol withdrawal seizure than in those who had not. More notably, among patients treated for alcohol withdrawal with the phenothiazine promazine-an obsolete treatment now known to lower the seizure threshold in alcohol withdrawal-supplementation with pyridoxine 120 mg/day resulted in fewer seizures than pyridoxine 20 mg/day (&lt;i&gt;P&lt;/i&gt; = 0.02). These findings are consistent with animal models in which pyridoxal-5'-phosphate deficiency lowers the seizure threshold. In another study, of patients who suffered alcohol withdrawal seizures, those who progressed to delirium tremens had lower pyridoxal-5'-phosphate concentrations than those who did not (&lt;i&gt;P&lt;/i&gt; = 0.011). Finally, anxiety and confusion are manifestations of both alcohol withdrawal and pyridoxal-5'-phosphate deficiency, presumably in part due to the signaling imbalance common","PeriodicalId":520593,"journal":{"name":"Clinical toxicology (Philadelphia, Pa.)","volume":" ","pages":"1-12"},"PeriodicalIF":3.3,"publicationDate":"2026-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148552056","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}