Your essential guide to xylitol poisoning in dogs

Xylitol, sometimes called birch sugar, is a commonly found additive that makes sugar-free gum, candies, and other treats toxic to dogs. Photo: Bigstock/Javier Brosch The 21st century has brought diet crazes, sugar-free candies, gums, and even peanut butter to consumers around the globe. Xylitol, a commonly used natural sweetener, while touted as beneficial in most instances for humans, can have dire consequences in even small amounts when ingested by our canine friends. Familiarity with the common clinical signs and recommended treatments leads to a good prognosis despite a potential severe toxicosis risk. Low glycemic index: great for people, bad for dogs Xylitol is a sugar alcohol, aka a polyol. It is a carbohydrate naturally found in many fruits and vegetables. Considered a part of the FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols). It has been ballyhooed as an excellent substitute for sucrose and glucose in foods, candies, chewable vitamins, sugar-free gums, mouthwashes, and other foodstuffs. Other applications, such as an ingredient in dental fluoride treatments, liquid medications, and even nasal sprays, show xylitol is readily available and prevalent in a dog’s environment. Even in people, as with most things, too much of even a good thing can have adverse effects, causing GI distress, including bloating, gas, or diarrhea.1,2 The use of xylitol in such plentiful products isn’t by chance. Numerous benefits have been demonstrated, leading to its use in multiple goods and products. Examples of some of the known benefits of xylitol in human medicine and diet include:3–7 Antiplaque effects—Research suggests that this polyol lowers the risk of cavities by lowering the pathogenic Streptococcus species that develop in the oral cavity, leading to dental caries. This polyol decreases inflammation of the gingiva and may reduce inflammation in other parts of the body, though additional research is ongoing. It may improve teeth enamel mineralization. It can stimulate digestion, though this may manifest as diarrhea and may not necessarily benefit everyone. It may improve glycemic control when used in lieu of glucose, fructose, or sucrose for foods and drinks because it doesn’t contribute to the same type of blood sugar spikes as sugar. This lower glycemic index may aid in obesity management or lessen the risk of metabolic syndrome for those with obesity or at risk. It can lower the calorie content of foods when replacing sugar since xylitol has up to 40 percent fewer calories. However, as with most things in life, too much of anything can still do harm. Recent research suggests that xylitol in larger consumption may increase the risk of heart disease or stroke by negative impacts on the body’s ability to clot blood.6,8,9 Xylitol toxicosis in dogs While some people see benefits in the use of xylitol, others may develop GI upset, or as we see in dogs, much more severe concerns may arise. Xylitol is toxic to all dogs, with the risk of profound hypoglycemia and hepatic necrosis of key considerations. (Let clients know, too, some manufacturers use the term “birch sugar,” for xylitol on their labels.) The intensity of the response escalates with increased dosages. Hypoglycemia may occur in any patient with adequate intake; however, liver damage is unique. Sadly, we still do not have a clear understanding of why it occurs or any predictive means to know which patients will develop hepatic necrosis. Thus, we cannot envisage in which patients we will see liver issues arise. Unfortunately, we do not always know the amount ingested. Some products will list the amount contained in the product, but for proprietary reasons and because there are no regulations requiring it, many do not. Sugar-free gums, for example, may range from only two mg to an entire gram per piece of gum. Calculating the ingested dose is paramount to understanding what may occur in the patient clinically and to help guide treatment. This is where contacting poison control benefits you, the patient, and the client. No matter how often you have treated (or haven’t treated) this condition, each product and patient are different. Getting all the relevant information off the bat is key to a successful outcome. Further, if complications arise, follow-up calls with poison control can assist further in treatment decisions and options.10 Toxicity leading to hypoglycemia occurs at doses > 0.1 g/kg. It can lead to a severe drop in blood sugar secondary to its ability to stimulate rapid and significant insulin release in dogs. Acute liver necrosis has been associated with higher ingestion doses of > 0.5 g/kg.9 Overall, the toxicity for hypoglycemia starts at 0.075 to 0.1 g/kg. Thus, smaller breed dogs may be at risk of toxicity with even the smallest piece of gum.7 Xylitol and cats What about cats? Though research is limited, a 2018 study15 with a small sample size (six cats) showed no significant toxicity, with the liver and additional parameters remaining normal. 6 Further research is warranted. We still could see signs of GI upset, especially if enough is ingested. Thankfully, cats are more discriminate in what they choose to steal, which is rarely even a concern in most feline patients. Clinical signs Thankfully, quite often, owners are aware of ingestion. Usually, the dog gets into someone’s purse or bag, and the owner finds gum wrappers or remnants of consumed products. Other times, we may see an adventurous dog was counter surfing and got the sugar-free brownies off the counter. In dogs with known ingestion within 30 to 60 minutes, we can induce emesis, hopefully lessening the risk of side effects. Due to the rapid absorption of this polyol, inducing vomiting after that time is unlikely to yield results and could lead to aspiration or other complications.11 Clinical signs associated with blood sugar changes may develop within 30 minutes of ingestion but may be delayed up to 12 hours due to xylitol’s absorption properties. Liver damage, namely necrosis, may take longer to develop, sometimes as long as eight-12 hours or more (up to 72 hours) post-ingestion. With early recognition of toxicosis, clinical signs of liver disease usually are not noted. However, in patients without known ingestion, with delayed treatment, or that present 12+ hours after exposure, signs of liver failure may be present, including signs associated with loss of coagulation factors (internal bleeding, petechiae, ecchymoses).7,10 General signs may vary depending on the source of ingestion (if a food stuff, for example, there may be additional concerns for toxicity, e.g., chocolate-containing products). General hypoglycemia-induced signs would include:10,12 Lethargy Tremors Seizures Vomiting Collapse Weakness Liver toxic dose level signs may include:7,12 Icterus Diarrhea Low cholesterol Low blood sugar Elevated BUN Low albumin Elevated liver enzymes Signs of bleeding Treatment protocols and prognosis When known ingestion occurs within the hour, emesis may be indicated. Use caution in brachycephalic dogs, weak, lethargic animals, and those that may have already self-induced vomiting. However, emesis is only indicated if the patient has normal blood sugars on arrival. Thus:10,12 Check blood sugar levels immediately. If blood sugars are normal, there are no contraindications to inducing emesis, and the time of ingestion is known, then emesis should be induced. If the blood sugar is abnormal, administer a dextrose bolus (1 ml/kg), utilizing 50 percent dextrose, and dilute this 1:30 with 0.9 percent saline. Give IV over one to two minutes. Emesis may be considered if the patient returns to a normal blood sugar level. IV fluid therapy with dextrose support (2.5-5 percent) for a minimum of 12 hours is usually recommended, even in patients without signs of hypoglycemia or liver damage on presentation. Studies have shown that dextrose fluid support for at least 12 hours can have liver-protectant effects.13,14 This is a must for hypoglycemic patients and may be necessary for longer than 12 hours. Baseline bloodwork should be obtained, noting liver enzymes, electrolytes, and hydration status. If liver enzymes and blood sugars are normal at 12 hours, a trial off of dextrose is recommended. If the patient can maintain normal glucose levels for several hours and is eating well, discharging the patient is reasonable. S-Adenosylmethionine (SAMe)/silybin for liver support can be utilized in patients with toxicity at levels associated with liver necrosis, as this can act as a hepatoprotectant. Additional supportive care will vary depending on the type of ingestion and clinical signs and may include antiemetics, anti-nausea medications, and additional supportive care. Poison control often updates its recommendations, emphasizing the benefits and ensuring clients obtain case numbers for reference. For dogs with liver toxic level dose ingestions, liver enzymes should be re-evaluated for 24-72 hours to ensure they remain normal. This can be done via outpatient lab work. It should be noted activated charcoal should not be used for this ingestion due to its inability to bind this polyol readily. With known ingestions and prompt treatment, the overall prognosis for xylitol ingestion is excellent. Dogs who receive proper therapy prior to the onset of clinical signs and liver damage usually recover without incident. Some dogs may remain on S-Adenosylmethionine (SAMe)/silybin, (liver protectant) for a period post-discharge; however, most dogs never look back. For those who do manifest with liver necrosis, the prognosis is guarded.7 Successful outcomes While xylitol, in even small doses, can be significantly toxic to dogs, prompt client recognition and education, in addition to rapid treatment, can minimize the risk of permanent damage, and the majority of dogs do great. Knowing how to treat this common toxicity, whether in general or emergency practices, is paramount. Recognizing the need to treat and educating clients on why the specific treatments are warranted, the risk of liver damage, and the potential ill effects if left untreated are crucial to a successful outcome. Finally, utilizing resources like poison control or even local specialty/emergency hospitals, if needed, further improves patient care and client communications and assists in our ability to preserve the human-animal bond. Erica Tramuta-Drobnis, VMD, MPH, CPH, is the CEO and founder of ELTD One Health Consulting, LLC (https://eltdonehealth.com/). Dr. Tramuta-Drobnis works as a public health professional, emergency veterinarian, freelance writer, consultant, and researcher. She is passionate about One Health issues and believes pet health, food safety, agricultural health, and more can address the interconnection of human, animal, and environmental health. References Monash University. About FODMAPs and IBS. Monash University. Accessed February 24, 2025. https://www.monashfodmap.com/about-fodmap-and-ibs/ ASPCA. Updated Safety Warning on Xylitol: How to Protect Your Pets. ASPCA. May 23, 2019. Accessed February 23, 2025. https://www.aspca.org/news/updated-safety-warning-xylitol-how-protect-your-pets Wölnerhanssen BK, Meyer-Gerspach AC, Beglinger C, Islam MdS. Metabolic effects of the natural sweeteners xylitol and erythritol: A comprehensive review. Crit Rev Food Sci Nutr. 2020;60(12):1986-1998. doi:10.1080/10408398.2019.1623757 Gasmi Benahmed A, Gasmi A, Arshad M, et al. Health benefits of xylitol. Appl Microbiol Biotechnol. 2020;104(17):7225-7237. doi:10.1007/s00253-020-10708-7 Arruda PV de, Milessi TS, Alves-Ferreira J, et al. Applications of Xylitol in Food, Material, Health, and Medical Sector. In: de Almeida Felipe M das G, Chandel AK, eds. Current Advances in Biotechnological Production of Xylitol: Fermentative Production of Xylitol. Springer International Publishing; 2022:205-237. doi:10.1007/978-3-031-04942-2_10 Warner L. Xylitol: What to know about this popular sugar substitute. Harvard Health. September 4, 2024. Accessed February 24, 2025. https://www.health.harvard.edu/nutrition/xylitol-what-to-know-about-this-popular-sugar-substitute Brooks W. Xylitol Poisoning in dogs. VIN.com. June 1, 2022. https://veterinarypartner.vin.com/default.aspx?pid=19239&id=4952819 National Institute of Health (NIH). Xylitol may affect cardiovascular health. National Institutes of Health (NIH). June 25, 2024. Accessed February 24, 2025. https://www.nih.gov/news-events/nih-research-matters/xylitol-may-affect-cardiovascular-health Gómez-Fernández AR, Santacruz A, Jacobo-Velázquez DA. The complex relationship between metabolic syndrome and sweeteners. J Food Sci. 2021;86(5):1511-1531. doi:10.1111/1750-3841.15709 Lee J. Top 5 poisons to induce emesis in the veterinary poisoned patient. VETgirl. September 25, 2015. Accessed February 23, 2025. https://vetgirlontherun.com/top-5-poisons-to-induce-emesis-in-the-veterinary-poisoned-patient-vetgirl-veterinary-ce-blog/ Dunayer EK. New findings on the effects of xylitol ingestion in dogs. Vet Med. 2006;101(12):791-798. Hayes C. Xylitol Toxicosis in Dogs - Toxicology. Merck Veterinary Manual. October 2024. Accessed February 23, 2025. https://www.merckvetmanual.com/toxicology/food-hazards/xylitol-toxicosis-in-dogs Brooks W. S-AAdenosylmethionine (SAMe, Denosyl, Vetri-SAMe, Zentonil, Denamarin). VIN.com. August 8, 2017. https://veterinarypartner.vin.com/default.aspx?pid=19239&catId=154455&id=4951818 Schmid RD, Hovda LR. Acute Hepatic Failure in a Dog after Xylitol Ingestion. J Med Toxicol. 2016;12(2):201-205. doi:10.1007/s13181-015-0531-7 Jerzsele Á, Karancsi Z, Pászti-Gere E, et al. Effects of p.o. administered xylitol in cats. J Vet Pharmacol Ther. 2018;41(3):409-414. doi:10.1111/jvp.12479

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Your essential guide to xylitol poisoning in dogs

Understanding signs and treatment options to maximize success

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