Mercury Toxicity Medication: Chelating Agents, Gastrointestinal Decontaminants

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Medication

Medication Summary

As previously discussed, 2,3-dimercaptosuccinic acid (DMSA) and N -acetyl-D,L-penicillamine have been used as chelating agents in the treatment of mercury toxicity. Use chelating agents if the patient is symptomatic, systemic absorption is anticipated, or increased blood or urine levels are present. Chelating agents should be administered early in treatment.

GI decontamination may be useful only in acute, recent ingestions. Activated charcoal is indicated for GI decontamination because it binds inorganic and organic mercury compounds to some extent.

Class Summary

These agents are used to help remove a portion of the body's mercury stores. They are administered early in treatment because mercury binds to the body's ubiquitous sulfhydryl groups. Chelating agents are thought to use their thiol groups to compete with sulfhydryl groups in binding methyl mercury. The effectiveness of chelation in preventing or treating neurologic toxicity has not been well evaluated.

Succimer (Chemet)

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DMSA is used in inorganic and organic mercurials. It is considered superior to penicillamine because it has fewer adverse effects. Because of this agent's ease of use, good efficacy, and safety, initiate treatment with DMSA if good evidence indicates that significant absorption can occur (mercury levels may not be readily available). DMSA is the chelator of choice in cases of chronic or mild toxicity.

Dimercaprol (BAL)

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This is the drug of choice for the treatment of acute inorganic mercury toxicity. It is the preferred chelator for mercury salts. Dimercaprol is administered intramuscularly every 4 hours, mixed in a peanut oil base. It is excreted in urine and bile. Dimercaprol may be given to patients with renal failure. The BAL-mercury complex is dialyzable. Dimercaprol is used only in acute ingestion.

D-penicillamine (Depen, Cuprimine)

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D-penicillamine is an oral, thiol-based chelator for acute or chronic toxicity. It is less well tolerated than DMSA (succimer). D-penicillamine forms a complex with mercury and is excreted in urine; therefore, do not use it in renal failure. This agent cannot be considered a first-line drug, because DMSA is safer and more effective.

Class Summary

These agents are empirically used to minimize systemic absorption of the toxin. They may be of benefit only if they are administered within 1-2 hours of ingestion.

Activated charcoal (Actidose-Aqua, Charcoal Plus DS, EZ-Char)

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Activated charcoal has a network of pores that adsorbs 100-1000mg of drug per gram of charcoal. It does not dissolve in water.

Polyethylene glycol (CoLyte, GoLYTELY, NuLYTELY, Trilyte)

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This is a laxative with strong electrolyte and osmotic effects that has cathartic actions in the GI tract.

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Media Gallery

This is a 1-view, abdominal, upright radiograph in a male patient who intentionally ingested 8 ounces of elemental mercury. Notice how the mercury outlines the large intestine from ascending to descending. Image courtesy of Fred P. Harchelroad, MD, and Ferdinando L. Mirarchi, DO.
Patient with intentional ingestion of mercury from blood pressure instrument. Note how mercury beads can be seen deposited in lung fields. Image courtesy of Shuchi Vyas, MD.

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Author

David A Olson, MD Clinical Neurologist, Dekalb Neurology Group, Decatur, Georgia

David A Olson, MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

Nicholas Lorenzo, MD, MHA, CPE Founding Editor-in-Chief, eMedicine Neurology; Founder and CEO/CMO, PHLT Consultants; Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, MHA, CPE is a member of the following medical societies: Alpha Omega Alpha, American Association for Physician Leadership, American Academy of Neurology

Disclosure: Nothing to disclose.

Chief Editor

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS is a member of the following medical societies: American College of International Physicians, American Heart Association, American Stroke Association, American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute, National Association of Managed Care Physicians, American College of Physicians, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York AcademyofSciences, and Society for Academic Emergency Medicine

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Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Barry M Diner, MD, MPH, FACEP Assistant Clinical Professor, Department of Emergency Medicine, Emory University School of Medicine; Attending Physician, St Luke's Episcopal Hospital, Houston, Texas

Barry M Diner, MD, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Chair, Department of Emergency Medicine, Director of Medical Toxicology, Allegheny General Hospital; Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Michael E Mullins, MD Assistant Professor, Department of Emergency Medicine, Washington University School of Medicine

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians

Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David K Tan, MD, EMT-T, FAAEM Assistant Professor and Chief, EMS Section, Division of Emergency Medicine, Medical Director, Washington University EMS, Washington University in St Louis School of Medicine

David K Tan, MD, EMT-T, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and National Association of EMS Physicians

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Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

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Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

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Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mercury Toxicity Medication

Medication Summary

Chelating Agents

Class Summary

Succimer (Chemet)

Dimercaprol (BAL)

D-penicillamine (Depen, Cuprimine)

Gastrointestinal Decontaminants

Class Summary

Activated charcoal (Actidose-Aqua, Charcoal Plus DS, EZ-Char)

Polyethylene glycol (CoLyte, GoLYTELY, NuLYTELY, Trilyte)

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Mercury Toxicity Medication

Medication Summary

Chelating Agents

Class Summary

Succimer (Chemet)

Dimercaprol (BAL)

D-penicillamine (Depen, Cuprimine)

Gastrointestinal Decontaminants

Class Summary

Activated charcoal (Actidose-Aqua, Charcoal Plus DS, EZ-Char)

Polyethylene glycol (CoLyte, GoLYTELY, NuLYTELY, Trilyte)

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