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Dimercaprol: Drug information

Dimercaprol: Drug information
(For additional information see "Dimercaprol: Pediatric drug information" and see "Dimercaprol: Patient drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: US
  • Bal in Oil [DSC]
Brand Names: Canada
  • Bal in Oil [DSC]
Pharmacologic Category
  • Antidote
Dosing: Adult

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

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

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 (CSTE 2013; Kosnett 2007). 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 (Calello 2018).

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 (Calello 2018).

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 (Calello 2018); consultation with a clinical toxicologist or expert in the treatment of heavy metal poisoning is highly recommended.

Lewisite exposure

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 (ATSDR 2021).

Mercury poisoning, inorganic, acute

Mercury poisoning, inorganic, acute: IM: 5 mg/kg initially, followed by 2.5 mg/kg 1 to 2 times/day for 10 days.

Polonium internal contamination

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 (Jefferson 2009; REMM 2021).

Dosing: Kidney Impairment: Adult

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 (Hsiao 2019).

Dosing: Hepatic Impairment: Adult

Use is contraindicated in hepatic insufficiency (except in cases of postarsenical jaundice).

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Dimercaprol: Pediatric 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

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

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 (ACCLPP 2012; CDC 2002); 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 (AAP 2005; AAP [Shenoi 2020]; Calello 2018).

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 (AAP [Shenoi 2020]; Calello 2018).

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 (AAP [Shenoi 2020]; Calello 2018).

Note: Treatment courses may be repeated; at least 2 days should lapse before retreatment (Calello 2018).

Mercury poisoning, elemental or inorganic; acute

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.

Dosing: Kidney Impairment: Pediatric

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 (Hsiao 2019).

Dosing: Hepatic Impairment: Pediatric

Use is contraindicated in hepatic insufficiency (except in cases of postarsenical jaundice).

Adverse Reactions

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%)

Contraindications

Hepatic insufficiency (unless due to arsenic poisoning).

Warnings/Precautions

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.

Dosage Forms: US

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]

Generic Equivalent Available: US

Yes

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Intramuscular:

Generic: 100 mg/mL ([DSC])

Administration: Adult

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.

Administration: Pediatric

Parenteral: Administer undiluted, deep IM; rotate injection sites; prior to administration, consider injection site anesthetic (eg, lidocaine infiltration or topical lidocaine [or with prilocaine]) (AAP [Shenoi 2020]). Keep urine alkaline to protect renal function. When used in the treatment of lead poisoning, administer in a separate site from edetate CALCIUM disodium.

Use: Labeled Indications

Antidote for gold, arsenic (except arsine), or acute inorganic mercury poisoning (not for exposure to organic mercury compounds); adjunct prior to edetate CALCIUM disodium in acute lead poisoning.

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.

Use: Off-Label: Adult

Lewisite exposure; Polonium (Po-210) internal contamination

Metabolism/Transport Effects

None known.

Drug Interactions

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 Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

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

Pregnancy Considerations

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).

Breastfeeding Considerations

It is not known if dimercaprol is present in breast milk.

Dimercaprol is not absorbed orally (HSDB 2010), which would limit the exposure to a breastfed infant. Chelation with dimercaprol for lead poisoning is not recommended in adults unless blood lead levels are >50 (Kosnett 2007). Lactating patients with confirmed blood lead levels ≥40 mcg/dL should not initiate breastfeeding; pumping and discarding breast milk is recommended until blood lead levels are <40 mcg/dL (CDC 2010). In addition, the WHO recommends avoiding using the milk from a lactating patient undergoing treatment for lead poisoning to feed a child when possible, especially children who are <1 month of age, premature, or G-6-PD deficient. If breastfeeding is required, infants should be monitored for hemolysis and jaundice (WHO 2002).

Monitoring Parameters

Renal function, urine pH, infusion-related reactions.

For lead poisoning: Blood lead levels (baseline and 7-21 days after completing chelation therapy); hemoglobin or hematocrit, iron status, free erythrocyte protoporphyrin or zinc protoporphyrin; neurodevelopmental changes.

For arsenic poisoning: Urine arsenic concentration.

Mechanism of Action

The sulfhydryl group of dimercaprol combines with ions of various heavy metals to form relatively stable, nontoxic, soluble chelates which are excreted in urine.

Pharmacokinetics (Adult Data Unless Noted)

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.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (CZ) Czech Republic: Sulfactin;
  • (FI) Finland: B.a.l.;
  • (IN) India: B a l;
  • (IT) Italy: B a l;
  • (JP) Japan: Bal | Bal afp;
  • (LT) Lithuania: Sulfactin;
  • (LV) Latvia: Sulfactin;
  • (NZ) New Zealand: B.a.l.;
  • (PL) Poland: B.a.l. | Sulfactin;
  • (SK) Slovakia: Dimercarpol;
  • (TH) Thailand: B a l
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Topic 9367 Version 131.0

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