Gambia recently faced a tragic medication-associated diethylene glycol mass poisoning (MDMP), despite the increasing scrutiny of the pharmaceutical industry at national and international levels. MDMPs are not new, and over the past 80 years, more than 14 MDMPs reported in 14 countries, often affecting children. As per The New England Journal of Medicine, these outbreaks mainly occur in resource-constrained settings, where the actual numbers of cases and people exposed to toxic but sublethal amounts of diethylene glycol (DEG) who did not seek health care are unclear.
DEG is a potent nephrotoxin that can cause chronic kidney disease in survivors of acute poisoning. Public health authorities in low- and middle-income countries (LMICs) need more resources to support core public health activities for MDMPs, such as surveillance, education of clinicians, and clinical follow-up of cases. Furthermore, clinicians in these countries lack the resources to diagnose and manage DEG poisoning, including appropriate and timely treatment options and access to extracorporeal treatments. Many countries have few laboratories that can rapidly confirm DEG ingestion.
DEG is an effective solvent for water-insoluble chemicals, and it has numerous industrial uses, including as a brake fluid, antifreeze, wallpaper stripper, lubricant, fuel, softening agent, plasticizer, and others. However, DEG as a toxic chemical is responsible for an unusually high number of poisonings, owing to its consumption as an inappropriate excipient, an inert ingredient commonly used as a diluent or vehicle for delivering one or more biologically active ingredients in a medication.
DEG poisoning is reported to cause a wide range of adverse health effects in multiple organ systems, but nephrotoxicity is its hallmark feature. The nephrotoxicity most likely originates from a DEG metabolite known as diglycolic acid (DGA). In sufficient amounts, DGA is a potent nephrotoxin that is concentrated in the proximal renal tubule, causing mitochondrial dysfunction and cell damage.
Suppose affected persons survive long enough to recover from acute poisoning. In that case, they remain at risk for neurotoxic effects that may manifest in bilateral facial paralysis, peripheral neuropathy, quadriparesis, and other neurologic signs and symptoms.
Current management therapies for DEG poisoning include inhibiting DGA production by blocking alcohol dehydrogenase enzymes using a drug such as fomepizole or ethanol. Supplemental or complementary treatment regimens include extracorporeal treatments such as hemodialysis. However, these treatment options should ideally be guided by serial measurements of blood DEG concentrations, which are not routinely available tests.
Experts emphasize the importance of evidence-based public health practices, adherence to drug-manufacturing best practices, and regulatory enforcement to prevent medication-associated diethylene glycol mass poisoning. They suggest that drug manufacturers should routinely test raw ingredients and finished product batches to ensure they meet quality standards.
Moreover, establishing post-marketing surveillance programs and encouraging reporting of adverse events can help mitigate morbidity and mortality. Experts also highlight the more significant public health problem of global inequity in resources dedicated to preventing, controlling, and managing poisoning by toxins.
The tragedy of the MDMP in Gambia highlights the need for increased resources and attention to core public health activities for MDMPs, including surveillance, education of clinicians, and clinical follow-up of cases. It also emphasizes the importance of appropriate and timely treatment options and access to extracorporeal treatments for managing DEG poisoning.