Note: Consultation with a clinical toxicologist or an expert in the treatment of heavy metal poisoning is highly recommended. Premedication with a histamine H1 antagonist (eg, diphenhydramine) is recommended.
Arsenic or gold poisoning, acute:
Mild symptoms: Infants, Children, and Adolescents: IM: 2.5 mg/kg/dose every 6 hours for 2 days, then every 12 hours on the third day, and once daily thereafter for 10 days.
Severe symptoms: Infants, Children, and Adolescents: IM: 3 mg/kg/dose every 4 hours for 2 days then every 6 hours on the third day, then every 12 hours thereafter for 10 days.
Lead poisoning, adjunct with edetate CALCIUM disodium:
Note: For the treatment of high blood lead levels (BLL) in children, the CDC recommends chelation treatment when BLL >45 mcg/dL (Ref); however, dimercaprol is only recommended for use (in combination with edetate CALCIUM disodium) in children whose BLL ≥70 mcg/dL or in pediatric patients with lead encephalopathy (Ref).
Infants, Children, and Adolescents:
Symptomatic (without encephalopathy) or BLL ≥70 mcg/dL: IM: 3 to 4 mg/kg/dose (50 to 75 mg/m2/dose) every 4 hours for 3 to 5 days in combination with edetate CALCIUM disodium; dose and duration should be based on symptoms and blood lead levels. Note: Begin treatment with edetate CALCIUM disodium with the second dimercaprol dose (Ref).
Encephalopathy: IM: 4 mg/kg/dose (75 mg/m2/dose) every 4 hours for 5 days in conjunction with edetate CALCIUM disodium; dose and duration should be based on symptoms and blood lead levels; Note: Begin treatment with edetate CALCIUM disodium with the second dimercaprol dose (Ref).
Note: Treatment courses may be repeated; at least 2 days should lapse before retreatment (Ref).
Mercury poisoning, elemental or inorganic; acute: Infants, Children, and Adolescents: IM: 5 mg/kg initially followed by 2.5 mg/kg/dose 1 to 2 times/day for 10 days.
There are no adjustments provided in manufacturer's labeling. Use with extreme caution or discontinue if acute renal insufficiency develops during therapy. Note: Extracorporeal elimination in patients with preexisting renal disease may enhance the removal of the chelator-metal complex (Ref).
Use is contraindicated in hepatic insufficiency (except in cases of postarsenical jaundice).
(For additional information see "Dimercaprol (United States and Canada: Not available): Drug information")
Note: Consultation with a clinical toxicologist or an expert in the treatment of heavy metal poisoning is highly recommended. Premedication with a histamine H1 antagonist (eg, diphenhydramine) is recommended.
Arsenic or gold poisoning, acute:
Mild symptoms: IM: 2.5 mg/kg every 6 hours for 2 days, then every 12 hours for 1 day, followed by once daily for 10 days.
Severe symptoms: IM: 3 mg/kg every 4 hours for 2 days, then every 6 hours for 1 day, followed every 12 hours for 10 days.
Lead poisoning: Note: Available guidelines recommend chelation therapy with blood lead levels (BLL) >50 mcg/dL and significant symptoms; chelation therapy may also be indicated for most patients with BLL >80 mcg/dL and all patients with BLL ≥100 mcg/dL and/or symptoms (Ref). Selection of chelating regimen should be made in consultation with a clinical toxicologist or expert in the treatment of heavy metal poisoning.
Symptoms suggestive of encephalopathy or BLL >100 mcg/dL: IM: 3 to 4 mg/kg (50 to 75 mg/m2) every 4 hours for 3 to 5 days in conjunction with edetate CALCIUM disodium; dose and duration should be based on symptoms and BLL. Note: Begin treatment with edetate CALCIUM disodium with the second dimercaprol dose (Ref).
Encephalopathy: IM: 4 mg/kg (75 mg/m2) every 4 hours for 5 days in conjunction with edetate CALCIUM disodium. Note: Begin treatment with edetate CALCIUM disodium with the second dimercaprol dose (Ref).
Note: Treatment courses may be repeated, but 2-week intervals between courses is generally recommended because lead re-equilibrates between the extravascular storage sites (eg, bone) and the vascular compartment. High initial BLL (eg, >100 mcg/dL) or presence of lead encephalopathy may indicate the need for more prompt re-treatment (Ref); consultation with a clinical toxicologist or expert in the treatment of heavy metal poisoning is highly recommended.
Lewisite exposure (off-label use): IM: 3 to 5 mg/kg/dose every 4 hours for 4 doses; adjustments can be made depending upon severity of exposure (Ref).
Mercury poisoning, inorganic, acute: IM: 5 mg/kg initially, followed by 2.5 mg/kg 1 to 2 times/day for 10 days.
Polonium (Po-210) internal contamination (off-label use): IM: 2.5 mg/kg/dose 4 times daily for 2 days, then twice daily on day 3, then once daily on days 4 through 10 for a total treatment duration of 10 days (Ref).
There are no dosage adjustments provided in the manufacturer's labeling. Use with extreme caution or discontinue if acute renal insufficiency develops during therapy.
Note: Extracorporeal elimination in patients with preexisting renal disease may enhance the removal of the chelator-metal complex (Ref).
Use is contraindicated in hepatic insufficiency (except in cases of postarsenical jaundice).
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Frequency not always defined.
Cardiovascular: Chest pain, hypertension (dose-related), tachycardia (dose-related)
Central nervous system: Anxiety, burning sensation (lips, mouth, throat), headache, nervousness, paresthesia (hand)
Dermatologic: Diaphoresis
Gastrointestinal: Abdominal pain, nausea, salivation, sore throat, vomiting
Genitourinary: Burning sensation of the penis
Hematologic & oncologic: Leukopenia (polymorphonuclear)
Infection: Abscess
Local: Pain at injection site
Neuromuscular & skeletal: Weakness
Ophthalmic: Blepharospasm, conjunctivitis, lacrimation
Renal: Renal insufficiency (acute)
Respiratory: Pharyngeal edema, rhinorrhea, throat irritation
Miscellaneous: Fever (children ~30%)
Hepatic insufficiency (unless due to arsenic poisoning).
Concerns related to adverse effects:
• Nephrotoxicity: Potentially a nephrotoxic drug; use with caution in patients with oliguria. Maintain an alkaline urine pH to protect the kidneys (prevents dimercaprol-metal complex breakdown). Discontinue or use with extreme caution if renal insufficiency develops during treatment. Hemodialysis may be used to remove the dimercaprol-metal chelate in patients with renal dysfunction
Special populations:
• Glucose 6-phosphate dehydrogenase deficiency: Use with caution in patients with glucose 6-phosphate dehydrogenase deficiency; may increase the risk of hemolytic anemia.
• Pediatric: Fever may occur in ~30% of children and may persist for the duration of therapy.
Disease related concerns:
• Lead poisoning: Investigate, identify, and remove sources of lead exposure prior to treatment; do not permit patients to re-enter the contaminated environment until lead abatement has been completed. Consultation with a clinical toxicologist or an expert in the treatment of heavy metal poisoning is highly recommended before initiating chelation therapy. The poison control center or local health department should be contacted for assistance with patient and family support as well as lead abatement.
Dosage form specific issues:
• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer's labeling.
• Peanut oil: Product contains peanut oil; use with caution in patients with peanut allergy; medication for the treatment of hypersensitivity reactions should be available for immediate use.
Other warnings/precautions:
• Administration: Administer all injections deep IM at different sites; not for IV administration. May cause significant pain upon injection.
• Appropriate use: Not indicated for the treatment of iron, cadmium, or selenium poisoning; use in these patients may result in the production of a toxic dimercaprol-metal complex.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intramuscular:
Bal in Oil: 100 mg/mL (3 mL [DSC]) [contains benzyl benzoate, peanut oil]
Yes
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intramuscular:
Generic: 100 mg/mL ([DSC])
Parenteral: Administer undiluted, deep IM; rotate injection sites; prior to administration, consider injection site anesthetic (eg, lidocaine infiltration or topical lidocaine [or with prilocaine]) (Ref). Keep urine alkaline to protect renal function. When used in the treatment of lead poisoning, administer in a separate site from edetate CALCIUM disodium.
Administer all injections by deep IM injection. Rotate injection sites. Maintain an alkaline urine pH to protect renal function. When used in the treatment of lead poisoning, administer in a separate site from edetate CALCIUM disodium.
Store at 20°C to 25°C (68°F to 77°F).
Pharmacy supply of emergency antidotes: Guidelines suggest that at least 2.4 g of dimercaprol be stocked, especially in hospitals in industrial areas or where there is a prevalence of heavy metal risk factors. Suggested amount is stated to be a sufficient quantity to treat 1 patient weighing 100 kg for an initial 8- to 24-hour period (Dart 2018); actual amount to be stocked should take into account site-specific and population-specific needs.
Treatment of gold, arsenic (except arsine), or acute elemental or inorganic mercury poisoning (except organic mercury compounds); adjunct prior to edetate CALCIUM disodium in acute lead poisoning (All indications: FDA approved in pediatric patients [age not specified] and adults).
Note: There may be more effective and less toxic alternatives to dimercaprol; consultation with a poison control center or an expert in the treatment of heavy metal poisoning is highly recommended. The use of dimercaprol in the management of poisoning from other heavy metals has not been validated.
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program
Iron Preparations: Dimercaprol may enhance the nephrotoxic effect of Iron Preparations. Risk X: Avoid combination
Multivitamins/Minerals (with ADEK, Folate, Iron): Dimercaprol may enhance the adverse/toxic effect of Multivitamins/Minerals (with ADEK, Folate, Iron). Specifically, Dimercaprol may enhance the nephrotoxic effect of Iron Salts. Risk X: Avoid combination
Animal reproduction studies have not been conducted. There are no adequate and well-controlled studies in pregnant women.
Lead poisoning: Lead is known to cross the placenta in amounts related to maternal plasma levels. Prenatal lead exposure may be associated with adverse events such as spontaneous abortion, preterm delivery, decreased birth weight, and impaired neurodevelopment. Some adverse outcomes may occur with maternal blood lead levels <10 mcg/dL. In addition, pregnant women exposed to lead may have an increased risk of gestational hypertension. Consider chelation therapy in pregnant women with confirmed blood lead levels ≥45 mcg/dL (pregnant women with blood lead levels ≥70 mcg/dL should be considered for chelation regardless of trimester). There are alternatives to the use of dimercaprol and consultation with experts in lead poisoning and high-risk pregnancy is recommended. Encephalopathic pregnant women should be chelated regardless of trimester (CDC 2010).
Renal function, urine pH, infusion-related reactions.
Arsenic poisoning: Urine arsenic concentration.
Lead poisoning: Blood lead levels (baseline and 7 to 21 days after completing chelation therapy); hemoglobin or hematocrit, iron status, free erythrocyte protoporphyrin, or zinc protoporphyrin; neurodevelopmental changes.
The sulfhydryl group of dimercaprol combines with ions of various heavy metals to form relatively stable, nontoxic, soluble chelates which are excreted in urine.
Absorption: IM: Rapid; Oral: Not absorbed.
Distribution: To all tissues including the brain.
Metabolism: Hepatic; rapid to inactive metabolites.
Time to peak, serum: 0.5 to 1 hour.
Excretion: Urine and feces via bile.
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