Medication Summary

Chelation should be performed in patients with symptomatic arsenic toxicity, although the evidence of therapeutic benefit from chelation derives largely from animal studies. Chelation is principally useful for acute toxicity. In such cases, chelation should be started as soon as possible, because its efficacy declines rapidly with increasing time after exposure.^[28]

Class Summary

Bind heavy metals and to hasten excretion. By binding in plasma, they render heavy metals nontoxic.

Dimercaprol (BAL in Oil)

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First-line agent available in the US for treating arsenic poisoning. Often in short supply, is one of the antidotes considered essential to be stocked by every ED.

Administered IM q4h, mixed in a peanut oil base. Excreted in urine and bile. May be administered to patients with renal failure.

Succimer (DMSA)

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Licensed by the FDA for use only in childhood lead poisoning. Has been used worldwide as a heavy metal chelator and has been efficacious in treating arsenic intoxications. In the US, is only available in a bead-filled oral capsule of 100 mg.

Dimerval (DMPS)

Internationally accepted DOC for treating most heavy metal poisonings. Not licensed for use in the US and must be obtained from Helytex in Houston. Available as either a parenteral or oral form.

Emadi A, Gore SD. Arsenic trioxide - An old drug rediscovered. Blood Rev. 2010 Jul-Sep. 24(4-5):191-9. [QxMD MEDLINE Link]. [Full Text].
Lo-Coco F, Cicconi L, Breccia M. Current standard treatment of adult acute promyelocytic leukaemia. Br J Haematol. 2016 Mar. 172 (6):841-54. [QxMD MEDLINE Link].
Gensheimer KF, Rea V, Mills DA, Montagna CP, Simone K. Arsenic poisoning caused by intentional contamination of coffee at a church gathering--an epidemiological approach to a forensic investigation. J Forensic Sci. 2010 Jul. 55(4):1116-9. [QxMD MEDLINE Link]. [Full Text].
Mandal BK, Suzuki KT. Arsenic round the world: a review. Talanta. 2002 Aug 16. 58(1):201-35. [QxMD MEDLINE Link].
Sigmon C, Patch S. A pilot survey of in-service home arsenic tracked in from chromated copper arsenate-treated decks. J Environ Health. 2010 Jan-Feb. 72(6):18-22. [QxMD MEDLINE Link].
Matos RC, Vieira C, Morais S, Pereira ML, Pedrosa J. Toxicity of chromated copper arsenate: a study in mice. Environ Res. 2010 Jul. 110(5):424-7. [QxMD MEDLINE Link].
Kamchanawong S, Veerakajohnsak C. Arsenic, chromium, and copper leaching from CCA-treated wood and their potential impacts on landfill leachate in a tropical country. Environ Technol. 2010 Apr 1. 31(4):381-94. [QxMD MEDLINE Link].
Luna AL, Acosta-Saavedra LC, Lopez-Carrillo L, Conde P, Vera E, De Vizcaya-Ruiz A, et al. Arsenic alters monocyte superoxide anion and nitric oxide production in environmentally exposed children. Toxicol Appl Pharmacol. 2010 Jun 1. 245(2):244-51. [QxMD MEDLINE Link].
Raghu KG, Yadav GK, Singh R, Prathapan A, Sharma S, Bhadauria S. Evaluation of adverse cardiac effects induced by arsenic trioxide, a potent anti-APL drug. J Environ Pathol Toxicol Oncol. 2009. 28(3):241-52. [QxMD MEDLINE Link].
Balakumar P, Kaur J. Arsenic exposure and cardiovascular disorders: an overview. Cardiovasc Toxicol. 2009 Dec. 9(4):169-76. [QxMD MEDLINE Link].
Moon KA, Guallar E, Umans JG, Devereux RB, Best LG, Francesconi KA, et al. Association Between Exposure to Low to Moderate Arsenic Levels and Incident Cardiovascular Disease: A Prospective Cohort Study. Ann Intern Med. 2013 Sep 24. [QxMD MEDLINE Link].
Grau-Perez M, Kuo CC, Gribble MO, Balakrishnan P, Jones Spratlen M, Vaidya D, et al. Association of Low-Moderate Arsenic Exposure and Arsenic Metabolism with Incident Diabetes and Insulin Resistance in the Strong Heart Family Study. Environ Health Perspect. 2017 Dec 20. 125 (12):127004. [QxMD MEDLINE Link]. [Full Text].
Arsenic in drinking water may change heart structure. American Heart Association. Available at https://newsroom.heart.org/news/arsenic-in-drinking-water-may-change-heart-structure. May 7, 2019; Accessed: April 9, 2022.
Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Bronstein AC, Rivers LJ, et al. 2020 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila). 2021 Dec. 59 (12):1282-1501. [QxMD MEDLINE Link]. [Full Text].
Ayotte JD, Medalie L, Qi SL, Backer LC, Nolan BT. Estimating the High-Arsenic Domestic-Well Population in the Conterminous United States. Environ Sci Technol. 2017 Nov 7. 51 (21):12443-12454. [QxMD MEDLINE Link]. [Full Text].
Ng JC, Moore MR. Arsenic in drinking water: a natural killer in Bangladesh and beyond. An urgent alternative watershed management strategy is needed. Med J Aust. 2005 Dec 5-19. 183(11-12):562-3. [QxMD MEDLINE Link]. [Full Text].
Rodrigues EG, Bellinger DC, Valeri L, Hasan MO, Quamruzzaman Q, Golam M, et al. Neurodevelopmental outcomes among 2- to 3-year-old children in Bangladesh with elevated blood lead and exposure to arsenic and manganese in drinking water. Environ Health. 2016 Mar 12. 15:44. [QxMD MEDLINE Link].
Zablotska LB, Chen Y, Graziano JH, Parvez F, van Geen A, Howe GR, et al. Protective effects of B vitamins and antioxidants on the risk of arsenic-related skin lesions in Bangladesh. Environ Health Perspect. 2008 Aug. 116(8):1056-62. [QxMD MEDLINE Link].
Gong G, O'bryant SE. The Arsenic Exposure Hypothesis for Alzheimer Disease. Alzheimer Dis Assoc Disord. 2010 May 13. [QxMD MEDLINE Link].
Ettinger AS, Zota AR, Amarasiriwardena CJ, Hopkins MR, Schwartz J, Hu H, et al. Maternal arsenic exposure and impaired glucose tolerance during pregnancy. Environ Health Perspect. 2009 Jul. 117(7):1059-64. [QxMD MEDLINE Link]. [Full Text].
Vahter M. Effects of Arsenic on Maternal and fetal Health. Annu Rev Nutr. June 2009. 29:381-399. [QxMD MEDLINE Link]. [Full Text].
Yoshimura Y, Endo Y, Shimoda Y, Yamanaka K, Endo G. Acute Arsine Poiosning Confirmed by Speciation Analysis of Arsenic Compounds in the Plasma and urine by HPLC-ICP-MS. J Occupational Health. Nov 2011. 53:45-49. [QxMD MEDLINE Link]. [Full Text].
Robert B. Saper, Russell S. Phillips, Anusha Sehgal, Nadia Khouri, Roger B. Davis, Janet Paquin, et al. Lead, Mercury, and Arsenic in US- and Indian-Manufactured Ayurvedic Medicines Sold via the Internet. JAMA. 2008. 300:915-923. [Full Text].
Huang TC, Chao TY. Mees lines and Beau lines after chemotherapy. CMAJ. 2010 Feb 23. 182 (3):E149. [QxMD MEDLINE Link]. [Full Text].
Navarro B, Sayas MJ, Atienza A, Leon P. An unhappily married man with thick soles. Lancet. 1996 Jun 8. 347(9015):1596. [QxMD MEDLINE Link].
Hackenmueller SA, Strathmann FG. Total arsenic screening prior to fractionation enhances clinical utility and test utilization in the assessment of arsenic toxicity. Am J Clin Pathol. 2014 Aug. 142 (2):184-9. [QxMD MEDLINE Link]. [Full Text].
Dueñas-Laita A, Pérez-Miranda M, González-López MA, Martín-Escudero JC, Ruiz-Mambrilla M, Blanco-Varela J. Acute arsenic poisoning. Lancet. 2005 Jun 4-10. 365 (9475):1982. [QxMD MEDLINE Link].
Kosnett MJ. The role of chelation in the treatment of arsenic and mercury poisoning. J Med Toxicol. 2013 Dec. 9 (4):347-54. [QxMD MEDLINE Link]. [Full Text].
Muckter H, Liebl B, Reichl FX, et al. Are we ready to replace dimercaprol (BAL) as an arsenic antidote?. Hum Exp Toxicol. 1997 Aug. 16(8):460-5. [QxMD MEDLINE Link].
Andersen O, Aaseth J. A review of pitfalls and progress in chelation treatment of metal poisonings. J Trace Elem Med Biol. 2016 Dec. 38:74-80. [QxMD MEDLINE Link].

Media Gallery

"Blackwater" urine due to massive hemolysis, from a patient exposed to arsine at a gas tank cleaning operation.
Mees lines, or leukonychia, are transverse white bands with no palpable ridges that appear on the fingernails as a result of arsenic poisoning, certain cancers, and treatment with certain chemotherapy agents. Courtesy of Wikimedia Commons (Author Yannick Trottier) (https://commons.wikimedia.org/wiki/File:Mees%27_lines.jpg).

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Author

Adam Blumenberg, MD, MA Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Columbia University Medical Center, Columbia University Vagelos College of Physicians and Surgeons; Assistant Attending Physician, Department of Emergency Medicine, New York-Presbyterian Hospital

Adam Blumenberg, MD, MA is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Oregon Mycological Society

Disclosure: Own stock for: Inspira (ecmo company).

Coauthor(s)

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

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

Disclosure: Nothing to disclose.

Michael J Burns, MD Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David Vearrier, MD, MPH Professor of Emergency Medicine, Department of Emergency Medicine, University of Mississippi Medical Center

David Vearrier, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Additional Contributors

David C Lee, MD Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Steven Marcus, MD Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, Rutgers New Jersey Medical School, Rutgers University School of Biomedical and Health Sciences; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital; Consulting Staff, Department of Pediatrics, Newark Beth Israel Medical Center

Steven Marcus, MD is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Clinical Toxicology, American Academy of Pediatrics, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, Medical Society of New Jersey

Disclosure: Nothing to disclose.