Lead poisoning medical therapy: Difference between revisions

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Additionally, a comparative study of chelating agents showed that [[vitamin C]] ([[ascorbic acid]]), along with [[DMSA]], [[CDTA]] and [[DMPS]] increased survival in an animal model of [[lead intoxication]], while [[EDTA]], [[N-acetyl-L-cysteine]] ([[NAC]]) and various other agents did not.<ref>{{cite journal | author=Llobet JM, Domingo JL, Paternain JL, Corbella J | title=Treatment of acute lead intoxication. A quantitative comparison of a number of [[chelating agents]] | journal=Arch Environ Contam Toxicol | year=1990 | pages=185&ndash;9 |volume=19 | issue=2  | pmid=2322019 | doi=10.1007/BF01056085}}</ref> High serum levels of [[vitamin C]] have been associated with a decreased prevalence of elevated blood lead levels<ref>{{cite journal | author=Simon JA, Hudes ES | title=Relationship of ascorbic acid to blood lead levels | journal=JAMA | year=1999 | pages=2289&ndash;93 | volume=281 | issue=24  | pmid=10386552 |doi=10.1001/jama.281.24.2289}}</ref> and intervention with supplemental [[vitamin C]] was shown to markedly decrease [[lead levels]] in smokers (mean: 81 %). Authors hypothesize, however, that this effect might be due to an inhibition of lead absorption.<ref>{{cite journal |author=Dawson E, Evans D, Harris W, Teter M, McGanity W |title=The effect of [[ascorbic acid]] supplementation on the blood lead levels of smokers |journal=J Am Coll Nutr |volume=18 |issue=2 |pages=166&ndash;70 |year=1999 |pmid=10204833}}</ref>
Additionally, a comparative study of chelating agents showed that [[vitamin C]] ([[ascorbic acid]]), along with [[DMSA]], [[CDTA]] and [[DMPS]] increased survival in an animal model of [[lead intoxication]], while [[EDTA]], [[N-acetyl-L-cysteine]] ([[NAC]]) and various other agents did not.<ref>{{cite journal | author=Llobet JM, Domingo JL, Paternain JL, Corbella J | title=Treatment of acute lead intoxication. A quantitative comparison of a number of [[chelating agents]] | journal=Arch Environ Contam Toxicol | year=1990 | pages=185&ndash;9 |volume=19 | issue=2  | pmid=2322019 | doi=10.1007/BF01056085}}</ref> High serum levels of [[vitamin C]] have been associated with a decreased prevalence of elevated blood lead levels<ref>{{cite journal | author=Simon JA, Hudes ES | title=Relationship of ascorbic acid to blood lead levels | journal=JAMA | year=1999 | pages=2289&ndash;93 | volume=281 | issue=24  | pmid=10386552 |doi=10.1001/jama.281.24.2289}}</ref> and intervention with supplemental [[vitamin C]] was shown to markedly decrease [[lead levels]] in smokers (mean: 81 %). Authors hypothesize, however, that this effect might be due to an inhibition of lead absorption.<ref>{{cite journal |author=Dawson E, Evans D, Harris W, Teter M, McGanity W |title=The effect of [[ascorbic acid]] supplementation on the blood lead levels of smokers |journal=J Am Coll Nutr |volume=18 |issue=2 |pages=166&ndash;70 |year=1999 |pmid=10204833}}</ref>


===Disease Name===
===Lead Poisoning===
 
'''Adult'''
The two most commonly used [[chelating agents]] we use in adults are [[CaNa2EDTA]] injected and [[DMSA]] ([[Succimer]]) administered orally. 
 
**** BLL 5 to 19 mcg/dL: Discuss the health risks of chronic lead exposure. [[Lead exposure]] should be decreased. The risks at this level are higher for women who are or may become pregnant. 
**** BLL 20 to 39 mcg/dL: Decrease [[lead exposure]], due to long-term risks for effects on kidney function and cognitive function. Monitor BLL once a month.
**** BLL <40 mcg/dL : No evidence exist that [[chelation therapy]] at these levels decrease symptoms or reduces the risk of chronic disease.
**** BLL 40 to 49 mcg/dL:
*Asymptomatic patients – Decrease lead exposures.
*Symptomatic patients - [[DMSA]] ([[Succimer]]) administered orally.
**** BLL 50 to 79 mcg/dL: Remove from lead exposures. Patients with persisting BLL >50 mcg/dL and symptomatic after removal should undergo chelation therapy, unless there are contraindications.
**** BLL 80 to 100 mcg/dL: Acute symptoms, such as abdominal pain, constipation, headache, and anemia, generally respond well to lowering of BLL with chelation therapy. Patients may be very symptomatic at this level and these patients may require inpatient chelation therapy with parenteral [[CaNa2EDTA]].
**** BLL >100 mcg/dL: Inpatient chelation therapy with parenteral [[CaNa2EDTA]].
 
 
'''Pediatric'''
 
*****BLL <5 mcg/dL: Mean (BLL) for children 1-5 years old is less than 2 mcg/dL. Review risk factors for lead poisoning with parents. Repeat BLL in 6-12 months if the child is at high risk.. Ensure levels are done at 1 and 2 years of age. For children screened at age <12 months, retest in 3-6 months.


* '''1 Stage 1 - Name of stage'''
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
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***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)   
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)   
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
* 2 '''Stage 2 - Name of stage'''
** 2.1 '''Specific Organ system involved 1 '''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) ''''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==

Revision as of 21:01, 22 June 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aksiniya Stevasarova, M.D.

Overview

The mainstay of treatment for lead poisoning is chelation therapy.

Although the most important part of treating lead poisoning is decreasing exposure to lead, pharmacologic medical therapy with chelating agents to decrease the existing BLL (blood lead levels) include:

Medical Therapy

Additionally, a comparative study of chelating agents showed that vitamin C (ascorbic acid), along with DMSA, CDTA and DMPS increased survival in an animal model of lead intoxication, while EDTA, N-acetyl-L-cysteine (NAC) and various other agents did not.[1] High serum levels of vitamin C have been associated with a decreased prevalence of elevated blood lead levels[2] and intervention with supplemental vitamin C was shown to markedly decrease lead levels in smokers (mean: 81 %). Authors hypothesize, however, that this effect might be due to an inhibition of lead absorption.[3]

Lead Poisoning

Adult The two most commonly used chelating agents we use in adults are CaNa2EDTA injected and DMSA (Succimer) administered orally.

        • BLL 5 to 19 mcg/dL: Discuss the health risks of chronic lead exposure. Lead exposure should be decreased. The risks at this level are higher for women who are or may become pregnant.
        • BLL 20 to 39 mcg/dL: Decrease lead exposure, due to long-term risks for effects on kidney function and cognitive function. Monitor BLL once a month.
        • BLL <40 mcg/dL : No evidence exist that chelation therapy at these levels decrease symptoms or reduces the risk of chronic disease.
        • BLL 40 to 49 mcg/dL:
  • Asymptomatic patients – Decrease lead exposures.
  • Symptomatic patients - DMSA (Succimer) administered orally.
        • BLL 50 to 79 mcg/dL: Remove from lead exposures. Patients with persisting BLL >50 mcg/dL and symptomatic after removal should undergo chelation therapy, unless there are contraindications.
        • BLL 80 to 100 mcg/dL: Acute symptoms, such as abdominal pain, constipation, headache, and anemia, generally respond well to lowering of BLL with chelation therapy. Patients may be very symptomatic at this level and these patients may require inpatient chelation therapy with parenteral CaNa2EDTA.
        • BLL >100 mcg/dL: Inpatient chelation therapy with parenteral CaNa2EDTA.


Pediatric

          • BLL <5 mcg/dL: Mean (BLL) for children 1-5 years old is less than 2 mcg/dL. Review risk factors for lead poisoning with parents. Repeat BLL in 6-12 months if the child is at high risk.. Ensure levels are done at 1 and 2 years of age. For children screened at age <12 months, retest in 3-6 months.
          • Preferred regimen (2): drug name 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
          • Alternative regimen (1): drug name10 mg/kg PO q6h (maximum, 500 mg per day)
          • Alternative regimen (2): drug name 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
          • Alternative regimen (3): drug name 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
        • 1.1.2.2 (Specific population e.g. 'children < 8 years of age')
          • Preferred regimen (1): drug name 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
          • Alternative regimen (1): drug name 10 mg/kg PO q6h (maximum, 500 mg per day)
          • Alternative regimen (2): drug name 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
          • Alternative regimen (3): drug name 12.5 mg/kg PO q6h (maximum, 500 mg per dose)

References

  1. ↑ Llobet JM, Domingo JL, Paternain JL, Corbella J (1990). "Treatment of acute lead intoxication. A quantitative comparison of a number of chelating agents". Arch Environ Contam Toxicol. 19 (2): 185&ndash, 9. doi:10.1007/BF01056085. PMID 2322019.
  2. ↑ Simon JA, Hudes ES (1999). "Relationship of ascorbic acid to blood lead levels". JAMA. 281 (24): 2289&ndash, 93. doi:10.1001/jama.281.24.2289. PMID 10386552.
  3. ↑ Dawson E, Evans D, Harris W, Teter M, McGanity W (1999). "The effect of ascorbic acid supplementation on the blood lead levels of smokers". J Am Coll Nutr. 18 (2): 166&ndash, 70. PMID 10204833.

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