Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – separation from exposure source

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ACUTE
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all patients
1st line – 

separation from exposure source

People who work in certain industries (e.g., battery production, heavy construction, mining, automotive repair, metal/electronic recycling) are at high risk of exposure to airborne lead.[12] Small-business workers such as painting contractors and plumbers are also at risk.[9][13]​​

For most children, deteriorating lead-based paint and soil and dust contaminated by lead paint are the primary sources.[6] However, household interventions for removal or amelioration of lead sources in children with lesser elevations of blood lead are difficult and of limited effectiveness.[42][75]​​[76]​ In the absence of primary sources, alternatives must be evaluated, particularly foods, folk medicines, lead-painted toys, and consumer products.​[10][11][15][16][18]​[72]​ The water supply may also need to be evaluated, particularly if water is acidic.[17] Some hobbies may expose the hobbyist to high levels of airborne lead.[6][13]​ 

The source of the exposure should be removed. However, if this is not possible, precautions should be introduced to protect against exposure. It may be necessary for the patient to change home or occupation in severe cases.

Consider – gastrointestinal decontamination

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ACUTE
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all patients
Consider – 

gastrointestinal decontamination

Treatment recommended for SOME patients in selected patient group

For solid lead objects known to be in the stomach (e.g., bullets, lead pellets, jewelry), removal is recommended to prevent potentially severe or fatal poisoning.

Methods of removal can include endoscopic procedures, surgery, or whole bowel irrigation. The decision on the approach should be made on each patient basis, following discussion with specialist teams.[59]

Plus – chelation therapy

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ACUTE
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all patients
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asymptomatic children with blood lead 45-69 micrograms/dL
Plus – 

chelation therapy

Treatment recommended for ALL patients in selected patient group

Chelation therapy should only be given by an expert experienced in the treatment of lead toxicity. Hospital admission is usually required.[75][79]

Monotherapy with succimer or edetate calcium disodium should be considered in an asymptomatic child if the blood lead level is between 45 and 69 micrograms/dL.[59]

The efficacy of chelation therapy should be monitored by measuring 24-hour urine. A lead-to-chelant ratio >1 microgram lead per 1 milligram chelant indicates effective lead chelation; chelation therapy should be discontinued if this is not achieved. The yield will fall with each subsequent day of chelation as the chelatable pool is depleted. The usual course of initial therapy is 5 days of edetate calcium disodium or 19 days of succimer. To evaluate for rebound (as lead stored in soft tissues and bone is released) and to determine whether additional chelation is indicated, a blood lead level should be taken 2 to 4 weeks after completion of chelation therapy.[59] This interval may be shorter in patients with high initial blood lead concentrations.[59]

Primary options

succimer: consult specialist for guidance on dose

OR

edetate calcium disodium: consult specialist for guidance on dose

Plus – chelation therapy

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ACUTE
|
all patients
|
children with blood lead ≥70 micrograms/dL or acute symptoms and <70 micrograms/dL
Plus – 

chelation therapy

Treatment recommended for ALL patients in selected patient group

Chelation therapy should only be given by an expert experienced in the treatment of lead toxicity. Hospital admission is usually required.[75][79]

Combined therapy with edetate calcium disodium and dimercaprol should be considered in a child if the blood lead level is ≥70 micrograms/dL or in a child with acute symptoms and blood lead <70 micrograms/dL. Close monitoring for signs of clinical deterioration and regular neurologic assessment is recommended.[59]

The efficacy of chelation therapy should be monitored by measuring 24-hour urine. A lead-to-chelant ratio >1 microgram lead per 1 milligram chelant indicates effective lead chelation; chelation therapy should be discontinued if this is not achieved. The yield will fall with each subsequent day of chelation as the chelatable pool is depleted. The usual course of initial therapy is 5 days of edetate calcium disodium or 19 days of succimer. To evaluate for rebound (as lead stored in soft tissues and bone is released) and to determine whether additional chelation is indicated, a blood lead level should be taken 2 to 4 weeks after completion of chelation therapy.[59] This interval may be shorter in patients with high initial blood lead concentrations.[59]

Primary options

dimercaprol: consult specialist for guidance on dose

and

edetate calcium disodium: consult specialist for guidance on dose

Plus – ICU admission + supportive care (if encephalopathy)

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ACUTE
|
all patients
|
children with blood lead ≥70 micrograms/dL or acute symptoms and <70 micrograms/dL
Plus – 

ICU admission + supportive care (if encephalopathy)

Treatment recommended for ALL patients in selected patient group

Patients with encephalopathy must be managed in an intensive care unit (ICU).[75][79]

Aggressive combined chelation therapy with parenteral edetate calcium disodium and dimercaprol is required.[82] Close monitoring for signs of clinical deterioration and regular neurological assessment is recommended.[59]

Additional supportive care is provided as clinically indicated. Measures include circulatory and electrolyte support, endotracheal intubation and mechanical ventilation, prevention and management of secondary bacterial infections, and deep venous thrombosis and gastrointestinal (ulcer) prophylaxis.

Plus – chelation therapy

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ACUTE
|
all patients
|
nonpregnant adult
Plus – 

chelation therapy

Treatment recommended for ALL patients in selected patient group

Chelation therapy should only be given by an expert experienced in the treatment of lead toxicity. Hospital admission is usually required.[75][79]

Monotherapy with succimer or edetate calcium disodium should be considered in an adult (nonpregnant) if the blood lead level is >70 micrograms/dL.[59]

The efficacy of chelation therapy should be monitored by measuring 24-hour urine. A lead-to-chelant ratio >1 microgram lead per 1 milligram chelant indicates effective lead chelation; chelation therapy should be discontinued if this is not achieved. The yield will fall with each subsequent day of chelation as the chelatable pool is depleted. The usual course of initial therapy is 5 days of edetate calcium disodium or 19 days of succimer. To evaluate for rebound (as lead stored in soft tissues and bone is released) and to determine whether additional chelation is indicated, a blood lead level should be taken 2 to 4 weeks after completion of chelation therapy.[59] This interval may be shorter in patients with high initial blood lead concentrations.[59]

Primary options

succimer: consult specialist for guidance on dose

OR

edetate calcium disodium: consult specialist for guidance on dose

Secondary options

dimercaprol: consult specialist for guidance on dose

and

edetate calcium disodium: consult specialist for guidance on dose

Tertiary options

penicillamine: consult specialist for guidance on dose

Plus – ICU admission + supportive care (if encephalopathy)

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ACUTE
|
all patients
|
nonpregnant adult
Plus – 

ICU admission + supportive care (if encephalopathy)

Treatment recommended for ALL patients in selected patient group

Patients with encephalopathy must be managed in an intensive care unit (ICU).

Aggressive combined chelation therapy with parenteral edetate calcium disodium and dimercaprol is required.[82] Close monitoring for signs of clinical deterioration and regular neurological assessment is recommended.[59]

Additional supportive care is provided as clinically indicated. Measures include circulatory and electrolyte support, endotracheal intubation and mechanical ventilation, prevention and management of secondary bacterial infections, and DVT and gastrointestinal (ulcer) prophylaxis.

Plus – chelation therapy

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ACUTE
|
all patients
|
pregnant with encephalopathy
Plus – 

chelation therapy

Treatment recommended for ALL patients in selected patient group

Women with confirmed blood lead levels of ≥45 micrograms/dL should be treated in consultation with clinicians experienced in the management of lead toxicity and high-risk pregnancy.[69]

Chelation therapy is usually contraindicated in pregnancy. Succimer is teratogenic, and the mobilization of lead produced by the other agents increases fetal lead exposure.

However, if a pregnant patient develops lead encephalitis, the risks of chelation therapy must be carefully weighed against the threat to the life of the mother and fetus posed by the encephalitis itself, and chelation therapy may still be appropriate in this setting.[59]

Primary options

dimercaprol: consult specialist for guidance on dose

and

edetate calcium disodium: consult specialist for guidance on dose

Plus – ICU admission + supportive care

Back
ACUTE
|
all patients
|
pregnant with encephalopathy
Plus – 

ICU admission + supportive care

Treatment recommended for ALL patients in selected patient group

Patients with encephalopathy must be managed in an intensive care unit (ICU).

Aggressive combined chelation therapy with parenteral edetate calcium disodium and dimercaprol is required.[82] Close monitoring for signs of clinical deterioration and regular neurological assessment is recommended.[59]

Additional supportive care is provided as clinically indicated. Measures include circulatory and electrolyte support, endotracheal intubation and mechanical ventilation, prevention and management of secondary bacterial infections, and deep venous thrombosis and gastrointestinal (ulcer) prophylaxis.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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