Poison hiding in plain sight 

Catastrophic Diethylene Glycol suspected closer to home

The World Health Organisation (WHO) has on numerous times made urgent calls to action to countries to prevent, detect and respond to incidents of substandard and falsified medical products.

This while during the same period countries reported several incidents of over-the-counter cough syrups for children with confirmed or suspected contamination with high levels of Diethylene Glycol (DEG) and Ethylene Glycol (EG).

These contaminants are toxic chemicals used as industrial solvents and antifreeze agents that can be fatal even when taken in small amounts, and should never be found in medicines.

Sadly, these medications are some of the most important therapies available to prevent and treat a wide variety of health conditions. Thus, a strong and well-supported regulatory system must be in place to ensure that medications meet required standards.

Only last week Lesotho joined several other African countries in withdrawing batches of children’s cough medication, Benylin Paediatric Syrup, after the medicine was found to contain high levels of DEG.

The recalled batches are 329304 and 329303, both of which expire this month.

Benylin Paediatric Syrup is used to relieve cough and its congestive symptoms, and treatment of hay fever and other allergic conditions in children aged between two to 12 years. It is presented as a clear, bright red, raspberry-flavoured medicine.

The syrup’s toxicity was discovered following laboratory tests last week by the Nigerian health regulating body, linking the contaminant to several deaths of dozens of children in Cameroon and Gambia since 2022.

The fatalities were traced back to different cough syrups manufactured in India and Indonesia. Since prevention of DEG, and other poisonings, requires a significant effort to promote consistent adherence to medication-manufacturing best practices and regulatory enforcement of the pharmaceutical industry and drug manufacturers TEBOHO KHATEBE MOLEFI (PE) spoke to the president Pharmacy Association of Lesotho TELISO LETSATSI (TL) to get a grasp of what DEG is, and how safe we are from the medication we consume.

PE: What is DEG and what are its stages of toxicity?

TL: DEG is a colourless, odourless liquid with a sweet taste used in antifreeze solutions and as a solvent in many products which include pharmaceuticals in the concentration that is recommended. It is also used as a lubricant, plasticizer.

PE: What causes DEG toxicity?

TL: DEG can be toxic in contamination to pharmaceutical substances and when consumed systemically beyond recommended levels. This liquid has greater solubility, is easily available, more palatable and cost effective, that is why it is mostly used in most products and therefore giving rise to higher chances of increased toxicity when consumed beyond expected levels

PE: Which physical findings suggest DEG toxicity?

TL: These include severe headache, dizziness, anorexia, nausea and vomiting, central nervous system depression, diarrhoea and abdominal pain. These symptoms usually manifest within 24 hours.

PE: And what related abnormal changes in body functions, their cause and consequences (pathophysiology) are associated with ingestion of this toxic substance?

TL: When consumed, DEG causes severe and extreme systemic and neurological complications such as coma, respiratory failure, liver toxicity, kidney failure, convulsions or seizures, peripheral neuropathy and if not dealt with may give rise to death in both children and adults

PE: What are the differential diagnoses for DEG toxicity, and which conditions should be included in the differential diagnoses of this toxicity?

TL: The clinical manifestations (signs and symptoms) play significant role in initial diagnosis of DEG toxicity. These include severe headache, dizziness, anorexia, nausea and vomiting, central nervous system depression, diarrhoea and abdominal pain. These symptoms usually manifest within 24 hours after ingestion of DEG.

The doctor may request the laboratory tests to confirm which include; serum osmolality, hypoglycaemia, liver function test results, urinalysis results etc. which will confirm the final diagnosis

PE: What is the incidence of DEG toxicity in the Lesotho?

TL: As far as my knowledge and practice is concerned I have not come across the case of DEG toxicity in Lesotho; no case has been reported yet and that does not eliminate the probability as other African countries have had cases of DEG toxicity.

PE: What should be the focus of clinical history for suspected DEG toxicity?

TL: The focus should be on the severity of toxicity based on the clinical manifestations and initial measures to take to safe life.

PE: What is the role of laboratory testing in DEG toxicity diagnosis, and do we make use of such here at home?

TL: Laboratory testing is always done to confirm the severity of the toxin in the body, the effect on the systems of the body such as Respiratory tract, Central Nervous System, Renal, Hepatic, Vascular system etc. The findings will give a clear picture and therefore proper treatment based on the results. At home we only pay attention to symptoms of toxicity and take them to the health facility for further laboratory investigations.

PE: Which lab tests should be performed in symptomatic patients with DEG toxicity?

TL: The laboratory tests to confirm toxicity include; serum osmolality, hypoglycaemia, liver function test results, urinalysis, etc.

PE: Are there regional and/or national guidelines for the medical management and treatment of toxicity – if yes, what are they?

TL: As per my knowledge, we do not have guidelines in Lesotho; we always use international guidelines (FDA guidance) which explain safety at home and treatments when the patient is taken to the facility

PE: What is the initial emergency treatment of DEG?

TL: Patient stabilisation is key, secure patient’s airway, breathing and blood circulation.

PE: What is pre-hospital care, and initial considerations for emergency, for DEG toxicity?

TL: Gastrointestinal decontamination is very significant. These include activated charcoal, gastric lavage and aspiration and take the patient to the facility as soon as possible.

PE: When is treatment for suspected DEG intoxication indicated?

TL: Treatment should be initiated as soon as the DEG intoxication is suspected to safe life and reduce mortality.

PE: Which medications are used in the treatment of DGE toxicity?

TL: a. Sodium Bicarbonate to correct metabolic acidosis b. Treatment should include intravenous administration of ethanol or fomepizole as they are antidotes of DEG toxicity through the inhibition of DEG metabolism and therefore prevent the production and accumulation of toxic metabolites.

PE: How safe are we from the toxicity of the medicines we consume in the country?

TL: We cannot guarantee safety even though we have not come across cases of DEG intoxication. We should always take care of ourselves and listen to our healthcare professionals such as pharmacists when they give us medications.

PE: Is the Lesotho Medical Association doing enough to protect us?

TL: I think it is doing enough through education and counselling programmes health professionals are giving to the nations in platforms like media, facilities, etc. We provide education on various conditions and medications, side effects, toxicity and precautions.