Ethyl Glucuronide, Ethyl Sulfate, and Ethanol in Urine after Intensive Exposure to High Ethanol Content Mouthwash

Abstract

To determine the degree of ethanol absorption and the resultant formation and urinary excretion of its conjugated metabolites following intensive use of high ethanol content mouthwash, 10 subjects gargled with Listerine(®) antiseptic 4 times daily for 3¼ days. First morning void urine specimens were collected on each of the four study days and post-gargle specimens were collected at 2, 4, and 6 h after the final gargle of the study. Urine ethanol, ethyl glucuronide (EtG), ethyl sulfate (EtS), and creatinine were measured. Ethanol was below the positive threshold of 20 mg/dL in all of the urine specimens. EtG was undetectable in all pre-study urine specimens, but two pre-study specimens had detectable EtS (6 and 82 ng/mL; 16 and 83 μg/g creatinine). Only one specimen contained detectable EtG (173 ng/mL; 117 μg/g creatinine). EtS was detected in the urine of seven study subjects, but was not detected in the single specimen that had detectable EtG. The maximum EtS concentrations were 104 ng/mL and 112 μg/g creatinine (in different subjects). Three subjects produced a total of eight (non-baseline) urinary EtS concentrations above 50 ng/mL or 50 μg/g creatinine and three EtS concentrations exceeding 100 ng/mL or 100 μg/g creatinine. In patients being monitored for ethanol use by urinary EtG and EtS concentrations, currently accepted EtG and EtS cutoffs of 500 ng/mL are adequate to distinguish between ethanol consumption and four times daily use of high ethanol content mouthwash.

Ethyl Glucuronide and Ethyl Sulfate Assays in Clinical Trials, Interpretation, and Limitations: Results of a Dose Ranging Alcohol Challenge Study and 2 Clinical Trials

“…EtG/EtS testing is no exception. In our study, the concentrations of EtG and EtS observed at 12 hrs post consumption were, with the exception of some anecdotal reports much higher than those reported with even strong extraneous exposure (e.g., hand sanitizers), wherein concentrations rarely exceed usual cut-offs (Bertholf et al, 2011, Costantino et al, 2006, Hoiseth et al, 2010, Musshoff et al, 2010, Reisfield et al, 2011b, Reisfield et al, 2011a). Some healthcare workers, who are exposed to alcohol containing hand washes repeatedly throughout the day, might be positive if tested shortly thereafter, which could be addressed by allowing a 12 hr or greater interval before testing.…”

“…Concerns about false positives consequent to extraneous exposure to ethanol containing products may have impeded wider acceptance of this potentially valuable tool for clinical research and care (Bertholf et al, 2011, Costantino et al, 2006, Hoiseth et al, 2010, Musshoff et al, 2010, Reisfield et al, 2011b, Reisfield et al, 2011a, Rosano and Lin, 2008, SAMHSA, 2006). …”

Assessment of Exposure to Alcohol Vapor from Alcohol-Based Hand Rubs

“…Repeated exposure to alcohols could lead to passive alcoholization, possibly inducing adverse biochemical effects [3]. Despite the increasing use of ABHRs as part of hand hygiene programs, only a few studies have assessed the issue of alcohol absorption following hand disinfection [8,9,10,11,12]. The studies conducted on ethanol-based hand rubs reported that repeated hand rubbing led to blood ethanol concentrations below those known to be harmful in humans [9,10].…”

“…As with ethanol-based hand rubs, the authors found that the amounts absorbed via inhalation and/or dermal contact were very low and probably unlikely to induce adverse health effects. Reisfield et al [11,12] found that intensive use of ethanol-based sanitizer and mouthwash induces an increase in concentrations of urinary ethanol biomarkers (ethyl glucuronide and ethyl sulfate), leading to false-positive results related to ethanol consumption.…”

Commercial Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS) Testing is Not Vulnerable to Incidental Alcohol Exposure in Pregnant Women

“…Further, they are reported to remain detectable in urine for 1 – 2 days or longer (Palmer, 2009). However, reports of over-sensitivity to incidental alcohol exposure through hand sanitizer (Reisfield, Goldberger, Crews, et al, 2011), trace amounts of alcohol in some foods (Musshoff, Albermann, & Madea, 2010), and mouthwash (Costantino, Digregorio, Korn, Spayd, & Rieders, 2006; Reisfield, Goldberger, Pesce, et al, 2011) have led to suggestions in a recent SAMHSA review for more research regarding cutoff values that balance sensitivity and specificity in research contexts (Substance Abuse and Mental Health Services Administration, 2012). This 2012 SAMHSA review also noted substantial need for research regarding the role of individual factors such as gender, age, or medical condition to aid in interpretation of these biomarkers.…”