Treatment Of Toxic Element Poisoning

Removal of the poisoned individual from the environmental source (or vice versa) responsible for the toxic metal contamination and supportive care are generally all that is required for decontamination. In some cases, however, chelation therapy using organic compounds to bind and remove metals from the body may be warranted. Because chelation therapy may pose life-threatening side effects, due to the simultaneous chelation of essential elements such as calcium, care must be taken to manage the administration of chelation therapy (53-56). In any case, monitoring the elimination of toxic element exposure and confirmation of effective decontamination are useful when the appropriate laboratory specimen is utilized. For lead and iron, blood is a good specimen for monitoring decontamination, whereas urine is preferred for monitoring decontamination of mercury and most other toxic elements.

Chelation therapy to treat children with blood lead concentrations of 20-44 ^g/dL showed no benefit (57), but is recommended for children with blood lead levels >45 ^g/dL using the compound dimercaptosuccinic acid (DMSA). Chelation therapy should be considered for adults with blood lead levels above 60 ^g/dL and is recommended when blood levels exceed 80 ^g/dL. When blood levels exceed 70 ^g/dL, both DMSA and EDTA may be utilized. Dimercaprol (British Anti-Lewisite, BAL) is also occasionally utilized. Blood lead levels should be monitored not only to insure the subject has been removed from exposure, but also to identify the potential rebound in blood lead levels that could occur as lead from body stores are redistributed (58). In cases of iron overload, both therapeutic phlebotomy and iron chelation therapy have been utilized. Treatment with the chelators deferoxamine and deferiprone has been shown to be effective in reducing tissue injury especially in those who suffer from transfusional iron overload (59,60).

In cases of poisoning with other metals, the role of chelation therapy is less well established. Chelation of arsenic with BAL, D-penicillamine, 2-3 dimercaptopropane sulfate, or DMSA can serve to accelerate the reduction of acute symptoms, but does little to ameliorate the effects of chronic exposure (61). Aggressive chelation treatment of mercury poisoning may accelerate its removal from the body. Both arsenic and mercury decontamination can be monitored with urine. However, the efficacy of such treatment is controversial and may not outweigh the risks to the patient. The need for chelation therapy should be evaluated case by case (62,63). Chelation therapy for cadmium exposure is most useful for acute exposures and should be modestly pursued due to the overload to the kidneys that results from liberating body stores with the chelator (64). For aluminum toxicity, the most effective treatment appears to be removal of sources of aluminum exposure, although treatment with deferoxamine has been utilized.

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