Venipuncture Notes For Nplex

General Laboratory Safety Guidelines •Lab coats should be worn at all times. Remove when eating and drinking or using the washroom. •No cosmetics or fragrances while in lab area due to potential allergies or contamination •Avoid loose clothing, scarves, long hair, or dangling jewellery •No open toed shoes or sandals •Avoid rubbing eyes and wash hands frequently •Standard cleaning techniques include cleaning all surfaces minimum once per day and after exposure to blood with either 10% household bleach or 5.25% hypochloride solution. •Sharps and all body fluids disposed of in designated sharps containers •Blood and urine specimens must be kept in separate refrigerator from food, supplements or injectables. •If tuberculosis or other transmissible respiratory infection is suspected, use an N-95 mask when in close contact or drawing blood. •Do not wear jewellery under gloves. Change gloves after each patient and wash hands immediately after removing gloves. Safety When Performing Blood Draws •

Do not re-cap needle by hand. If recapping needs to occur, place cap on table and thread needle tip through cap.

Potential Complications with Laboratory Duties or when Performing Blood Draws Needle Sticks: • 20% occur when uncovering the needle – need to discard needle • 70% occur at end of draw i.e. after exposure and before disposal • 7% of all surgeries involve contamination or exposure • Concern is with blood transmissible diseases: o HIV – 6 month incubation post exposure o HCV/HBV – 1 month incubation post exposure • Post-exposure prophylaxis treatment is anti viral. • Both exposed health care provider and source of blood (patient) need to be tested at the time of exposure. Exposed should be retested 6 months later. Abrasions or Contusions: • Commonly from substances delivered in glass containers, e.g. amino acids, TPN • Also occurs from sharp edges or during intravenous treatments. Most common injury in surgery

Chemical Exposures: • Chemotherapy treatment involves caustic toxic substances that can cause damage to the tissues of the patient • Intravenous hydrochloric acid and colchicine are chemical hazards. Allergic Reactions: • Preservatives such as alcohol, sodium benzoate, or EDTA are most likely to cause allergic reactions. Other potential allergens include latex gloves and tourniquet. People at risk for latex or other allergies include patients with atopic conditions, history of long term latex exposure (health care workers) or allergies to plants in the latex family (bananas, kiwi, avocados) • 1/1,000,000 are sensitive to thiamine (B1) although it is possible this population is sensitive to the preservatives, not the B1 itself • Test patients by administering a small amount (1-2ccs) of the substance in question and watch to see if there is an allergic reaction. • Emergency kit must contain an EPI pen and oral allergy medication (Benadryl) to treat a potential anaphylaxis reaction. If reaction occurs, leave IV catheter in place in case access is needed in an unconscious patient. • Symptoms: itching or swelling at site of contact, swollen throat and eyes, dyspnea, abdominal pain or nausea, shock and death. • Avoid latex exposure by placing tourniquet over clothing, avoid using petroleum products (Vasaline) that break down latex, avoid exposing gloves to heat or UV light, use latex free products. Infection at Site of Injection • Higher risk: diabetics, HIV, and immunocompromised patients • Clean skin with enlarging circles starting at the injection site and working outwards to the perimeter with isopropyl alcohol. • Isopropyl alcohol cleans but does not disinfect. Iodine solutions (Betadine) disinfect. • Bacteria on the skin can be introduced systemically by an unclean site or nonsterile equipment. • Remove needle immediately if signs of infection are present. Send needle for culturing. Possible Conditions Associated with Venipuncture and/or Intravenous Therapy Hematoma • Occurs when needle nicks the vein or passes through. • A tight tourniquet can make a hematoma worse by increasing blood loss. Risk increased when the tourniquet is left on too long. • More common with elderly patients due to fragile veins and medications. • Treatment: o Apply pressure to the area

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o Keep arm straight with pressure applied. Bent elbows create clots that can be dislodged when arm is later straightened. o Instruct patient to avoid heavy lifting with the injured arm for 2 hours. o Apply Arnica cream to the area when bleeding has stopped. Prevention o Using proper technique. o Taking a complete medical history.

Thrombosis: • After endothelial cell trauma, platelets are attracted to the site and adhere to the vein wall. A clot reduces blood flow in the vein and increases risk for embolus. • Risk of thrombus formation with: o Use of lower extremities o Patient does not sit still during treatment o Long IV treatments (>3h) o If IV line goes dry damage may occur due to decreased lubrication to the blood vessel. • Signs and Symptoms o IV flow slows, blood may back up in IV line. o Pain and swelling at the site • Treatment o Remove needle o Apply a cold compress on site for 10 minutes o Find a new site for IV o Doctor may administer a heparin flush to break up clot. Phlebitis • Endothelial irritation, inflammation, aggregation and platelet adhesion • 27-70% of hospital patients are affected by this (sicker population, and IV in a longer period of time) • Factors that increase chances of Phlebitis o IV solution pH does not match blood o Large gage needle o Fast drip rate o Hypertonic solutions o Cancer patients at greatest risk due to multiple injections, inflamed or scarred veins, and an increased risk of clotting in some cancer types. • Signs and Symptoms o Area is red and tender to touch o IV flow slows o Patient may have a fever o Prevention • Treatment

o Remove needle o Cold compress on site for 20 minutes. May need to repeat every 20-30 minutes o Allow 3-10 days to heal before IV treatment can be resumed in the affected vein • Prevention o Slow drip rate o Solution pH o Solution tonicity o Site selection o Smaller catheter Thrombophlebitis: • Inflammation of the vein as well as a thrombus • Etiology same as phlebitis. • Signs/Symptoms o Slow or stopped flow rate o Vein tender to palpation o Vein is hard on palpation and feels like a rope or cord o Area warm to the touch with reddish lines radiating from the injection site • Treatment o Remove needle o Apply a warm compress for 20 minutes to area to dilate vein and improve circulation o Patient may require blood thinners, hospitalization • Prevention o Slow drip rate o Solution pH o Solution tonicity o Site selection o Smaller catheter o Monitor patients closely Infiltration: • Injected materials enter surrounding tissue through a defect in the vein wall usually caused by puncturing through vein on insertion or with patient movement. • Can be prevented by ensuring needle is secured in vein and patient does not move during treatment. • Signs/Symptoms o Site cool to touch o Taut skin o Edema and redness o Flow of IV slows or stops.

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o Blood back flow is absent if bag placed lower than venipuncture site. Treatment o Remove needle and apply ice if infiltration has occurred <30 minutes ago, then alternate hot/cold. o If >30 minutes apply heat to the area initially o Elevate arm o May take vein up to 7-10 days to recover before ready to be used for IV again.

Extravasation: • Injected substance seeps through vein into surrounding tissue without damage to vein wall • Higher risk in neonates, geriatric patients, cancer patients, diabetics and patients with peripheral vascular disease. • Symptoms o More painful than infiltration leading to increased tissue damage and irritation by injected/infused substances. o Blistering or necrosis. o Skin cool to touch but patient feels hot. o Flow of IV slows or stops. o Absent blood back flow. • Treatment o Remove needle o Elevate area o Apply warm compress o Administer antidote if appropriate. Cortisone can be applied or injected if colchicine has caused irritation. Venous Spasm: • May be caused by a painful insertion, anxious patients, large needles, or with certain site locations. • May also be caused by irritating or cold solutions, hyperosmolar or viscous solutions (fat soluble vitamins) or by pushing or dripping too rapidly. • Signs/Symptoms o Flow rate will decrease or stop. o Pain at injection site or along vein. • Treatment o Apply heat o Address anxiety with patient o Magnesium may reduce smooth muscle spasms o If spasm does not subside, remove needle • Prevention o Warm area with a compress o Massage vein before insertion

o Address anxiety with patient o Administer solutions slowly Speed Shock: • Occurs when solution is pushed too rapidly • Signs/Symptoms o Difficulty breathing or vertigo o Cyanosis o Headache o Chest pain o Arrhythmia o Hypotension o Shock • Treatment o Lie patient down with feet/knees above head o Leave needle in patient o Ensure adequate oxygenation and use oxygen therapy when necessary o CPR if needed • Prevention o Infuse at a slow rate and monitor patient closely Syncope • Caused by a lack of oxygen to the brain due to a vasovagal response initiated by anxiety, hypoglycemia, hypotension or dehydration • Can also be caused by medication such as insulin, beta blockers or other antihypertensive drugs • Anticonvulsants cause a relative decrease in calcium, which may leave a patient susceptible to magnesium therapy • Treatment: o Lie patient down, place cold water on their forehead or occiput o Acupressure CV24, KI1, PC9, GV26 o Smelling salts o Note in patients chart about history of fainting Catheter Emboli • Occurs when a portion of the angiocath is dislodged and travels in vein • Most commonly occurs due to poor technique • Signs/Symptoms o Intense, sudden, sharp pain o Weak, rapid pulse o Patient may become cyanotic • Treatment o Place tourniquet above injection site

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o Call EMS. Angiocath is radio-opaque and will show up on radiograph Prevention o Do not reinsert needle through angiocath once it is inserted into patient Special Considerations when Performing Intravenous Procedures

Obesity • May create difficulty in palpating or visualizing veins Mastectomy • It is common for patients to have edema and lymphadenopathy on the same side of a mastectomy, lumpectomy or lymphectomy. • If unilateral, draw blood from the other side • If bilateral, chose the side with the least amount of edema or use a butterfly in vein on hands Skin irritation at site • Avoid any skin irritations if possible including eczema and psoriasis. Edema • Avoid areas of edema due to the difficulty in finding veins, a potential contamination due to transudate, and risk of infection. Sclerosed or Damaged Veins • Can occur with patients receiving frequent IV treatments, especially chemotherapy • Insertion may be painful and difficult • If possible avoid areas of sclerosed veins which often have poor blood flow. Types of Needles, Blood Samples and Tubes Needles • Measured by length and size of bore • Gage measures the inside diameter of the bore. Smaller numbers indicate a larger bore. Larger numbers indicate a smaller bore. Measurements are based on wire sizes. • Needle length is measured in inches. • Amount of fluid is measured in mL (or cc’s). • Needle gage should be greater than 23 to avoid hemolysis. • Butterfly needles contain flexible ‘wings’ as well as a smaller gage (23) which may be more suitable for children or elderly patients. Vacutainer System

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In the past, blood was sucked out of the vein with a syringe and anticoagulants were added separately to the sample. Now blood collection tubes are a vacuum and come with required solutions already inside. Vacuum system ensures no over flow – blood flow will stop when the vacuum has been used up in each tube. Tubes have expiry dates printed on outside of tube.

Steps for Blood Collection 1. Ensure all materials are present and are not expired (Needle, tubes, alcohol wipes, tourniquet, plastic vaccutainer holder for needle, cotton balls. 2. Open needle at end containing rubber protector and screw into place on plastic vaccutainer holder. 3. Open silver end of needle and inspect for burs or irregularities along surface. 4. Recap needle by placing cap on table and threading needle into cap loosely. 5. Inspect patient for phlebotomy site. 6. Cleanse site thoroughly with separate alcohol swabs or until swabs are clean after use. 7. Put on gloves. 8. Place tourniquet 3 inches (7.5 cm) above site. 9. Insert needle into vein with bevel up. 10. Push tube onto rubber coated needle enclosed in plastic vaccutainer holder. 11. Release tourniquet when last tube begins to fill. 12. Remove needle and place cotton ball venipuncture on site. Ask patient to place pressure on cotton ball. 13. Remove needle and place into sharps container. 14. Invert tubes slowly to mix blood and solution, set in test tube holder. 15. Label tubes with patient’s name, DOB and date of service, or as required by laboratory service provider. Types of Blood Samples Whole Blood • Contains serum, plasma, and RBC • Tubes for whole blood collection contain anticoagulants to prevent blood from clotting before it is tested. • Sample lasts up to 12 hours if fresh and from 3-6 months when frozen • Tubes to be used: o All coloured tubes can be used for whole blood samples. • Tests using whole blood o CBC o Hormone levels

o Heavy metals → don’t want to clot therefore use an anticoagulant (e.g. sodium citrate, heparin in the tubes so that it won’t clot. EDTA prevents clotting but it chelates particularly Calcium, Pb) Serum • Fluid that remains after blood has clotted and then been centrifuged. Does not contain any cells. • Use tubes that separate serum from cells with a polymer solution that has a specific gravity between serum and RBCs • Tubes to be used o SST, mottle, red/grey • Tests using serum o Most commonly used tube. Plasma • Fluid component of blood that contains fibrinogen and other clotting factors • Anticoagulants are present in tubes used then blood is centrifuged. • Tubes to be used o Green • Tests using plasma o INR o PTT o IgG food sensitivity test Blood Collection Tubes • Tubes come in a variety of sizes and the tube stoppers are colour coded depending on what they are used for. • Pediatric size: 1.5 – 2 ml unless large amounts of serum are required • Order of tubes important due to potential contamination of later tubes with solutions from earlier tubes (i.e. if solution is aspirated back through needle it may be transferred to later tubes) Grey top • Contains sodium chloride, potassium oxalate, or sodium fluoride. • May also contain lithium idoacetate or heparin. • Use o Fasting glucose Green top • Contains sodium heparin or lithium heparin (anticoagulant). • Uses o BUN o Ionized calcium

o Electrolytes o ALCAT food sensitivity test o INR Lavender/Purple/ Light Blue top: • Contains buffered sodium citrate or EDTA. • Volume dependent tubes and must be filled to not skew lab results. • These tubes cannot be frozen because cells in sample will lyse. • Uses o CBC (with differential) o INR o PPT o Hormones (hGC) Red Top • Does not contain anticoagulants which causes blood to clot. • Serum is collected after centrifugation. • If serum is pink it contains lysed cells and cannot be used. Royal Blue top • Contains sodium heparin or EDTA • Uses o Trace elements o Nutritional chemistry o Toxicology tests Brown Top • Contains heparin • Uses o Test for lead poisoning Black top • Contains buffered sodium citrate\ • Uses o ESR Yellow tube • Contains a growth medium to culture microbes or acid citrate dextrose (ACD) to test for blood banking • Each microbe requires a different growth medium and so the doctor must have an idea of which organism is being tested for when requisitioning for the test • Usually in hospitals only

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Always drawn first to avoid false positive results Use o Septicemia o DNA/paternity testing o HLA

Red-Grey/Mottled/SST/sometimes a gold top • Contains polymer with a specific gravity between serum and RBCs • Uses o LV enzymes o Hormones o Blood chemistry o Many other tests Pink tube • Contains potassium EDTA • Uses o Blood bank studies o Blood typing o Any other whole blood hematology Order of Draw Guidelines STop Red Light Green Light Ready Go 1) STerile - yellow 2) Red tube 3) Light blue 4) Green tube 5) Light purple (lavender) 6) READY – red/grey/ mottled tube 7) GO – grey Factors That Can Affect Blood Samples Basal state of patient • Whether or not a patient has eaten or fasted before blood work will alter some levels • If patient does not fast, the following tests will be altered: o Glucose will be higher o Triglycerides will be higher o Cholesterol (HDL,LDL, VLDL) will be higher o Protein will be higher o Electrolytes will be higher

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Ask patients how long they have fasted, and what they ate before beginning to fast. If patients have fasted for longer than 14 hours, results may be dropped even lower and may alter diagnosis.

Physical activity prior to test: • Exercise immediately prior to blood collection will alter results in the direction indicated: o Cortisol will be elevated o Creatinine will be elevated o Electrolytes will be decreased o Lactic acid will be increased o Proteins and amino acids will be elevated o Enzymes may be elevated including CPK, AST and LD o Platelet and coagulation factors will be elevated Stress: • Stress can impact blood collection by the following o WBC are elevated o Albumin is elevated o Fibrinogen is elevated o Glucose and insulin are both elevated o Iron may be decreased o Hormones such as cortisol, Aldosterone, rennin, TSH and PRL may be elevated or decreased depending on the individual o Crying in the newborn elevates WBC by up to 140% and remains elevated for up to 2 hours. o Hyperventilation changes electrolytes, decreases pH, and elevates fatty acids. Age: •

Certain blood values will change with aging due changes in diet or lifestyle such as decreased activity. o Cholesterol and triglycerides will generally increase with age o DHEA decreases with age o Androgens decrease with age

Hormones: • Hormones will change depending on phases of the menstrual cycle, or where a patient is with respect to puberty and menopause/andropause o Testosterone is very low in boys before puberty then increases in men until age 40, where levels begin to decline o Estrogen decreases after menopause. o Testosterone may increase in women after menopause

o DHEA increases until age 30 where it begins to decrease. DHEA may decrease prematurely or dramatically by a decade prior to diseases such as breast cancer or HIV Sex •

The following laboratory values will differ depending on the sex of the patient. o Creatinine is higher in males due to increased muscle mass o Hemoglobin and Hematocrit are lower in females due to menstruation.

Diurnal rhythms: • Several lab values change throughout the course of the day and may need to be monitored over a 24 hour period to obtain accurate results. o The following are all decreased in the afternoon:  Cortisol  ACTH  TSH  T4  Plasma rennin  Aldosterone  Insulin o Eosinophils are increased in the afternoon. Posture: • Standing can influence the following laboratory values: o Elevate cholesterol by 10% o Elevate triglycerides by 12% o Elevate HDL by 7% • Position of patient may also impact values for enzymes, calcium, Fe, proteins, lipids. • The standard position for drawing blood is seated. Pregnancy: • Pregnancy influences the following values: o RBCs decrease due to an increase in blood volume. o HCG increases o Glucose should only increase slightly o Albumin will decrease Altitude • Altitude increases red blood cells after a period of 2-3 weeks • EPO will be elevated at higher altitudes but this is rarely tested. Humidity • Electrolytes will be affected by changes in humidity

Drugs • The following drugs will influence laboratory values: o Vitamin C will affect glucose if 10g or more are used per day o Diuretics lower potassium unless they are specifically potassium sparing. o H MG-CoA reductase inhibitors (Lipitor) will lower triglycerides and elevate HDL. They will also elevate AST and ALT and possible creatinine (due to rhabdomyolysis) in some patients o Methotrexate (chemotherapy drug) will lower WBC, folate, and elevate liver enzymes o Oral contraceptives will alter hormone levels and deplete certain vitamins. Using a Tourniquet • Using a tourniquet can increase the following levels o Cholesterol o Iron o Protein o Potassium o Calcium o Lactate can be increased if a tourniquet is used as well as fist pumping throughout collection • Liver enzymes may decrease with tourniquet use. Possible reasons for Specimen Rejection: • Hemolysis • Patient did not fast • Clots in a tube with anticoagulant • Wrong tube for test • Insufficient sample size • Discrepancy between requisition form and information on the tube such as name, date, time and test requested. • Unlabelled tubes • Expired tubes

Types of Intravenous Solutions Hypertonic • Above 375 mmol/L • Causes RBC shrinkage, which increases the amount of nutrients in the bloodstream. • Examples include: o Meyer’s cocktail

o D5W (mixed with saline or lactated ringer) Hypotonic o Below 250 mmol/L o Causes RBC swelling and lysis. o Examples include: o ½ normal saline (.45% NaCl) o Sterile water o Patients with sickle cell anemia, iron deficiency, macrocytic anemia or glucose-6phosphate dehydrogenase (G6PD) deficiency are most at risk for lysis from hypotonic solutions. Isotonic o 290 mmol/L (250-375) o No cellular changes occur. o Examples include o Saline (.9% NaCl) o Lactated ringer solution

Intravenous Vitamin and Mineral Therapy Vitamin A o Forms Injected o A mixes well with saline, water and D5W o exposure to sunlight and heat will destroy the vitamin o Typical Dosing o adults can receive as much as 1000 IU per day for several days o Usages: o Cautions and Toxicity Symptoms o Potential for irritation at IV site o Toxicity can cause anemia, alopecia and liver enlargement. Vitamin D o Forms Injected: o Mixes well with D5W, saline or sterile water o Typical Dosing o 200 IU/ml o As much as 50000 IU/week in research o RDA 400 IU/ml although leading experts believe it may be closer to 4000 IU (oral) o Usages: o Deficiency Symptoms: rickets, osteomalacia, osteoporosis, SAD

o Cautions and Toxicity Symptoms: o Monitor calcium, RBC mg, BUN and LV enzymes when giving high doses o May falsely elevate serum cholesterol, AST and ALT Vitamin E o Forms Injected: o in oil or water base o Damaged by light, 64% adheres to bag wall therefore needs to be done in glass if using an oil base o Alpha tocopherol only. Not mixed unless compounded. o Typical Dosing o 100 IU/ml o RDA 100 IU o Usages: o Deficiency Symptoms: reduce RBC half life, neuromuscular proprioception, vision sense, gate o Deficiency symptoms: sickle cell and thalassemia o Cautions and Toxicity Symptoms: o Monitor liver enzymes o May falsely elevate AST and ALT Vitamin K o Forms Injected: o D5W, saline, ringers o 3 types K1, K2, K3 o K1 enhances coagulation o K2 is associated with bone health o K1 is IV in emergency only aqua based o Typically given IM for acute hypoprothrombinemia o Given TPN in to prevent hypoprothrombinemia o Given slowly o Typical Dosing o 5-10 mg/week adult, 2-5 mg/week child, (infants at birth 1-2 mg) o Usages: o Deficiency Symptoms: hypoprothrombinemia and increased bleeding. o Clotting factors 2,7,9,10 require vitamin K o Cautions and Toxicity Symptoms: o Monitor prothrombin time o Risk of death from anaphylaxis Biotin o Forms Injected: o Typical Dosing

o 1 or 1.2 mg/ml o No RDA o Usages: o Deficiency Symptoms: decreased carbohydrate metabolism, dry grey skin, pale tongue, alopecia and anemia o Manganese is a cofactor o Involved in synthesis and release of insulin o Low in livers of children who die of SIDS o Cautions and Toxicity Symptoms: B1- Thiamine o Forms Injected: o Unstable in light o Typical Dosing o 100 mg/ml o RDA 1-2 mg o 50-100 mg/day adult, 10-25 mg/day children o Usages: o Deficiency symptoms: beriberi, confusion, decreased coordination, memory loss and numbness of the hands and feet. o Used in alcohol detoxification to prevent Wernike-korshicoff - 100 mg/day and 50-100 mg/day thereafter o Cautions and Toxicity Symptoms: o risk of allergic reaction when given IM B2- Riboflavin o Forms Injected: o Typical Dosing o 25-50 mg/ml o Usages: o Involved in the formation of FADH o Deficiency symptoms: fatigue, muscle weakness, blurred vision, dermatitis, vertigo, mild anemia, alopecia, chelosis and a magenta coloured tongue. o Rapidly excreted with large amounts of alcohol excretion and rapidly degraded by light o Cautions and Toxicity Symptoms: B3- Niacin o Forms Injected: o Mixes well with saline or sterile water. o Niacinimide is B3 form used. o Typical Dosing o 100 mg/ml

o Usages: o Deficiency symptoms: dementia, death, dermatitis, muscular weakness or loss of coordination o Cautions and Toxicity Symptoms: o Give niacinamide to prevent flush o Safe in pregnancy and lactation o Monitor AST and ALT B5- Pantathenic Acid o Forms Injected: o D5W, sterile water and ringers o Typical Dosing o 250 mg/ml, up to 1000 mg o Usages: o Deficiency symptoms: adrenal fatigue, constipation or abdominal pain, tachycardia, insomnia, and increased number of infections o Stabilizes the other B vitamins in solution o Can be used after abdominal surgery to treat or prevent paralytic ileus by promoting peristalsis o Important for the conversion of choline to acetyl choline o Important for cortisol production o Cautions and Toxicity Symptoms: o Do not give pantathenic acid within one hour of administering succinal choline or within 12 hours of administering neostigmine or similar sympathomimetic agents. B6- peridoxine o Forms Injected: o o Typical Dosing o 100 mg/ml o Usages: o Deficiency symptoms: glossitis, anemia, anorexia, cheilosis, joint pains, seizures, profound weakness, stomatitis, PMS. o Used to treat isoniazide overdose o Deficiency can be induced by drugs such as: oral contraceptive, antibiotics including sulpha drugs, isoniazide, hydralzine and penicilamine. o Magnesium is a cofactor o Enhances B12 absorption o Increases HCl production o Cautions and Toxicity Symptoms: o Safe in pregnancy o High doses may falsely elevate urobilogin

Folic Acid o Forms Injected: o Mixed in saline, H2O and dextrose o Incompatible with calcium gluconate, minerals, and ascorbic acid o Not routinely given with TPN or IV drips because it clogs the administration set. o Typical Dosing o max dose 10 mg/ml o Usages: o Deficiency symptoms: numbness, weakness in extremities, restless leg syndrome, megaloblastic anemia and paranoia. o Depleted in patients using oral contraceptives. o Sulfasalizine for IBS blocks the absorption of folic acid. o Methotrexate, used for rheumatoid arthritis and cancer decreases the absorption of folic acid. o Cautions and Toxicity Symptoms: o Side effects: Yellow urine B-12- Cobalamine o Forms Injected: o Cyanocobalimine is typically used by medical doctors. It is excreted in the urine quickly o Hydrxocobalamine is safer, has a longer shelf life, and is more absorbable o Cyanocobalamine is contraindicated in Lebers disease. This disease typically in males who smoke. If given cyanocobalamine these patients can go blind in 24 hours. o Methlycobalamine is the best choice for neurological diseases such as MS, Parkinson’s, ALS, and some circadian disorders. o Typical Dosing o 1 mg-5 mg/mL o Usages: o Deficiency symptoms: numbness in feet, tremor, dementia and glossitis, pernicious anemia. o IM for shingles or fibromyalgia o Cautions and Toxicity Symptoms: o Vitamin C o Forms Injected: o Easily oxidized in heat or light o Sources include: corn, beet and tapioca o Typical Dosing o 500 mg/ml or 222 mg/mL with EDTA as a preservative

o scurvy: up to 1000 mg (7-10g) = conventional treatment o children = 3000 mg/d o adults = 6g/d o RDA = 60 mg/d o Severe burns = 2g/d for collagen production o Usages: o Deficiency symptoms: scurvy, (bleeding gums, wounds reopen, scar tissue fails), osseous lesions, faulty bone and teeth formation o Deficiency can also cause defects in hydroxylase enzymes. o Patients require more vitamin C with stress, decreased immunity, inflammation, increased oxidant load, pregnancy, burns or trauma. o Drugs that can decrease: oral contraceptives and corticosteroids. o Vitamin C crosses the placenta and enters breast milk. o Vitamin C therapy for Cancer:  Tumor cells have increased demand for glucose due to increased metabolic rates. Vitamin C has a similar structure to glucose and can enter tumor cells at high concentrations. High intracellular vitamin C increases hydrogen peroxide production which may kill tumor cells. o Cautions and Toxicity Symptoms: o Controversial claims that greater than 1g/d of vitamin C increases the risk of kidney stones. o May falsely elevate glucose in the urine of diabetics o May alter serum coumadin levels o May cause false positive occult stool test. o Patients require G6PD test before IV therapy to prevent hemolysis Calcium o Forms Injected o 10% calcium gluconate o Calcium glycerol phosphate or acetate are used less commonly o Store at room temperature, in the dark. Crystallizes if refrigerated. o Typical Dosing o Emergency hypocalcemia requires 7-14mEq (1.5-3ml of 10% solution) o Children: 1-7mEq o Neonate: up to 1 mEq o Hypokalemia: up to 14 mEq in adults o Magnesium intoxication can require as much as 7 mEq o Uses o Deficiency symptoms: hypertension, musculoskeletal problems, rickets, periodontal disease, tooth decay, stunted growth, depression, agitation, brittle nails, delusions, or osteoporosis. o Important for blood coagulation, muscle contraction and bone formation

o Metabolism of calcium affected by phosphorus, magnesium and vitamin D status. o Increase need for calcium in osteoporosis, hyperparathyroidism, celiac or Crohn’s disease, chronic diarrhea and pancreatitis o Hypocalcemia is associated with Chebosvec’s sign/Trousseau’s sign o Crosses placenta and is excreted in breast milk o Cautions and Toxicity Symptoms o Can irritate veins if pushed quickly o Caution with patients on cardiac glycosides. IV calcium can cause arrhythmia o Caution with sarcoidosis and renal calculi o Contraindicated in patients with ventricular fibrillation o Overdose of calcium can cause: constipation, nausea, vomiting, hypercalcemia, tingling sensations and weakness o May lower serum Fe values and transiently elevate plasma hydrocortocosteroids Iron o Forms Injected o Iron dextran or Infufer o Half life of iron is 5-20 hours o IM is only used if oral is not effective or with severe hemorrhage o Liquid supplements will not constipate o Typical Dosing o 50-200 mg IM o Uses o Deficiency symptoms: microcytic anemia, hypochromic anemia, palpitations, pale conjunctiva, decreased capillary refill, fatigue, confusion, irritability, dysphagia, glossitis, angular stomatitis, brittle nails, depression, vertigo, spoon nails, tachycardia or exertional palpitations. o Absorption of iron is affected by calcium, copper, zinc and manganese. o Iron crosses the placenta and enters breast milk o Cautions and Toxicity Symptoms o Can cause teratogenisis, significant inflammation in rheumatoid arthritis and ankylosing spondylitis o Use with caution in patients who are alcoholics, or have hepatitis or liver impairment. o Contraindicated in non-iron deficient anemias, hemochromotosis, thalasemia and sickle cell anemia o Side effects may include: chest pain, tachycardia, arrhythmia, oxidative stress, or anaphylaxis. Magnesium o Forms Injected

o Magnesium chloride, magnesium sulphate. o Typical Dosing o 200 mg/mL to 500 mg/mL o Uses o Deficiency symptoms: muscle cramps, sinus arrhythmia, tachycardia, constipation, hypothermia, insomnia, or dysmenorrheal. o Involved in the conversion of T4 to T3 o Magnesium has anticonvulsant properties. o Can be used to stop an MI o Crosses the placenta and is excreted in breast milk o B6 is a cofactor o Cautions and Toxicity Symptoms o Contraindicated during hypermagnesia, heart blocks or during active labour o IV adverse reactions include: flushing, hypoglycemia, bradycardia, decreased heart rate Zinc o Forms Injected o 5-10 mg/ml sulphate or 1 mg/ml chloride o Typical Dosing o o Uses o Deficiency symptoms: night blindness, poor wound healing, male reproductive problems, acne, anorexia nervosa, alopecia, white spots on nails, poor memory and impaired insulin activity. o Concentrated in the testes and adrenals. o Can be depleted by oral contraceptive pills. o Involved in metalloenzyme pathways. o Competes with iron and copper for absorption. o Sublingual supplements can be used for viral infections. o Affects the absorption and activity of certain B vitamins. o Cautions and Toxicity Symptoms o Zinc induced anemia Copper o Forms Injected o Copper sulphate or chloride o Typical Dosing o o Uses o Deficiency symptoms include: kinky hair, fragile bones (mimics rickets), hypochromic macrocytic anemia, and alopecia. o Cautions and Toxicity Symptoms

o Wilson’s disease is a copper storage disease with symptoms including mental status changes that mimics schizophrenia also may have a brown ring around the iris. IV copper would be contraindicated in this case. o IV zinc or copper may compete with each other. Chromium o Forms Injected o Carrier: sterile water or saline o Typical Dosing o RDA: 200 mcg/d o 600 – 1000 mcg/d typically used for diabetes o Uses o Enhances insulin sensitivity and increases insulin half life. o Stored in the pancreas, brain, muscles (especially the heart muscle), kidneys, spleen, testes and lungs. o The ability to absorb chromium appears to decrease with age o Cautions and Toxicity Symptoms Selenium o Forms Injected o Carrier: sterile water or saline o Selenium chloride is the most common injected form. o Typical Dosing o RDA: 200 mcg/d o Treatment dose can be up to 1000mcg/d o Uses o Deficiency signs and symptoms include: viral infections, cataracts, male reproductive issues and asthma. o Decreases side effects of platinum cancer drugs. o May prevent skin cancer. o Cautions and Toxicity Symptoms Molybdenum o Forms Injected o Carrier: sterile water or saline. o Ammonium molybdenum is the most common injected form. o Typical Dosing o RDA = 200 mcg o Uses o Deficiency symptoms include: sulphite sensitivity (Mb is cofactor for sulphate oxidase enzyme), asthma like symptoms, tachycardia, headache, disorientation. o May be a link between Mb deficiency and esophageal cancer o May encourage excretion of copper, zinc and iron.

o Excreted by the kidney o Important cofactor in alcohol metabolism o May reduce incidence of dental carries o Cautions and Toxicity Symptoms o Caution in pregnancy. Mb crosses the placenta. Strontium o Forms Injected o Typical Dosing o No RDA has been established o Uses o Deficiency symptoms include: decreased bone density. o May also play a role in glucose metabolism and the development of teeth. o Cautions and Toxicity Symptoms o Excess strontium can lead to brittle bones. o Radioactive strontium (ST90) is carcinogenic. This, or radioactive iodine can be treated with non-radioactive strontium or iodine respectively. Manganese o Forms Injected o Carrier: sterile water or saline o Manganese chloride or sulphate most common injected forms. o Typical Dosing o RDA=15-20 mg o Uses o Important in the development and maintenance of ligaments, bones, vertebral discs, tendons, nerve transmission and glucose tolerance. o Useful in the treatment of tinnitus and poor memory. o Excreted into bile o Cautions and Toxicity Symptoms o Toxicity symptoms mimic Parkinson’s disease with tremors, mask-like face, disco-ordination, pill-rolling or intention tremors. o Manganese and zinc may lower iron absorption if dosed too high. Boron o Forms Injected o Carrier: sterile water or saline o Typical Dosing o RDA= 2-3 mg o Uses o Important in bone mineralization, joint stability and CNS function. o Cautions and Toxicity Symptoms o Dosages above 300 mg cause nausea, vomiting, diarrhea, dermatitis and lethargy.

o Controversial treatment in patient with a history of breast cancer due to boron’s estrogenic effects. Vanadium o Forms Injected o Carrier: sterile water or saline o Typical Dosing o o Uses o Deficiency symptoms include: impaired insulin sensitivity, impaired thyroid hormone metabolism, hypercholesterolemia. o Stored in the liver, kidneys, spleen, bones, and testes o Excreted in urine o Deficiency in animals decreases milk production and causes abortion o Cautions and Toxicity Symptoms o Animal studies show that 20 mg/day can increase blood pressure. Potassium o Forms Injected o Available as potassium chloride, phosphate or acetate for injection. o Typical Dosing o o Uses o Deficiency symptoms include: muscle cramping, fatigue, increased perspiration, anorexia, insomnia, impaired cognition, constipation, and weakness o May experience polyurea, polydipsia in deficiency state due to impaired glucose tolerance. o ECG changes:  U wave  Decreased ST segment  Flat T wave o Cautions and Toxicity Symptoms o Hyperkalemia symptoms include: fatigue, weakness, confusion, dyspnea and potentially cardiac arrest and heart block. o ECG changes:  Peaked T wave  Depressed ST segment  Prolonged QT interval  Widened QRS  Loss of P wave o When given IV in hospital, patient is monitored with ECG to avoid overdosing.

o Potassium should NEVER be pushed. A drip is slower and more manageable. Sodium o Forms Injected o Available in saline or lactated ringer’s solution o Typical Dosing o o Uses o Deficiency symptoms include: dizziness, apprehension, anorexia, loss of taste, weakness, sense of ‘doom’. o Can be caused by excessive vomiting, diarrhea, diuretics, blood loss or adrenal insufficiency. o Cautions and Toxicity Symptoms o Iodine o Forms Injected o Carrier: saline or sterile water o Sodium iodine is the most common injected form. o Typical Dosing o RDA= 200mcg o Uses o Both deficiency and excess can cause goiter. o Deficiency symptoms include: hypothyroidism, infertility, and delayed sexual development. o Also important for oxygen utilization and protein metabolism. o Cautions and Toxicity Symptoms o Toxicity symptoms include: diarrhea, heat intolerance, weight loss and tachycardia. o Potential risk of anaphylaxis with IV use. o Iodine supplementation may cause acne. Sodium Bicarbonate NaHCO3 o Forms Injected o o Typical Dosing o o Uses o Metabolic acidosis. o Aspirin overdose. o Cautions and Toxicity Symptoms o Contraindicated in metabolic or respiratory alkalosis. o Contraindicated in cases with excessive chloride loss.

o Do not use to adjust pH with vitamin C therapy. Introduction to Ozone Therapy Physiological Responses to Ozone o Produces reactive oxygen species (ROS) that can kill bacteria. o Increase in ROS decreases body’s stores of antioxidants such as vitamin C and depletes stores of glutathione. Consider supplementing with antioxidants, selenium, glycine, and N-acetylcysteine to replenish stores. o Increases cytokines such as gamma interferon, TNF, IL-2, IL-6, IL-8, GM-CSF, and NF-kappa-B. o Decreases serum uric acid levels. o Reduces lactic acid build up which may be beneficial for fatigue. o Immunostimulatory effects by increasing phagocytosis by neutrophils. Potential Clinical Uses o Herpes zoster o Burn victims o Rectal insufflation for proctitis, Crohn’s, and GI tumors. o Vaginally for cervical dysplasia or infections o Catheterized into bladder for infections or bladder carcinoma. o Used locally for skin infections (gangrene) or dental cavities. Methods for Clinical Use o Uses large gauge needles (18 or 19 gage). o Blood is drained from patient into a glass bottle. o Heparin is added to prevent clotting. o Ozone is added. o On IV pole you hang up glass bottle and run a line to patient’s arm. A micropore filter is inserted to stop clots and allow air to enter the bottle. o Glass bottles are used with special teflon tubing to prevent ozone from breaking down plastics. Cautions and Toxicity Symptoms o Needs to be injected IV very carefully, it can kill the patient. o Mixed data on ozone’s effect on platelets. If patent has increased or decreased platelets, ozone therapy is contraindicated. o Tissue damage can occur if concentration is too high. o Contraindicated for inhalation. Destroys lung tissue on contact. o Also contraindicated in porphyrias, excess T4, SLE, acute bleeding and in patients with photosensitivity. o Contraindicated in subacute appendicitis or cholecystitis. Ozone may enhance the disease process, increase fluid and pus and lead to rupture.

Introduction to Hydrogen Peroxide Therapy Physiological Responses to Hydrogen Peroxide o Involved in metabolic pathways that use oxidases, peroxidases, cyclooxygenases, lipoxygenase, myeloperoxidase, catalyses, and superoxide dismutase. o Molecule at a 120 degree angle and is therefore unstable and susceptible to spontaneous mutation. o Half life is only 7/10ths of a second. o Dilates blood vessels in the periphery, coronary arteries, pulmonary arteries and blood vessels of the brain o In vitro hydrogen peroxide appears to cause lipid peroxidation, induce chromosomal damage, degrade cytochrome C, cause DNA breakage as well as RBC hemolysis, protein degradation and platelet aggregation. o Increases TNF and IL-2 which is beneficial to the immune system. Potential Clinical Uses o Circulatory stimulant which may reduce small clots and plaques. o Anti-infective against bacteria, viruses and fungi. o Cancer treatment via immune system impact. o Topically for improving circulation (Raynauds) or for fungal infections. Methods for Clinical Use Intravenous Uses o Carried in D5W using glass containers. o 1 ml of 3% H2O2 per 100 ml of D5W o Sodium bicarbonate may be added to neutralize the pH of the solution o Heparin may be added to prevent clotting. o Infusion rate is 150-170 ml per hour. o Patients should not have any antioxidant therapy on the same days as hydrogen peroxide treatments. External Uses o Can be used topically for fungal infections or to improve circulation in the extremities. o Foot soak includes: o 20 parts water o 1 part of 3% of H202 o 1 tsp Epsom or sea salts o Patient can do the soak at least once a day 4-5 times per week. Soak should last 20-30 minutes. Cautions and Toxicity Symptoms o May be pain at injection site due to solution pH. o If drip rate is too rapid, patient may experience chest pain or shortness of breath. Control by slowing drip rate.

o Patients may experience a reaction to microbial die off: Hexheimer reaction. Symptoms may include fever, sweating, headaches, fatigue, nausea or diarrhea. o Uncommonly, vasculitis may occur with rapid drip rates. o Contraindicated in pregnancy, granulomatous diseases or conditions with weak cell membranes such as sickle cell anemia or Thalasemia. Ultraviolet Therapy Physiological Responses to Ultraviolet Light o Different types of UVC light cause different physiological reactions. UVA is used to produce vitamin D. UVB and UVC cause sunburn as well as increase risk of skin cancer. o When blood is irradiated with UV light, cellular changes include: increased numbers of RBC and WBC and decreased thrombocytes. o Fibrin is lowered and platelet aggregation is decreased, contributing to lower blood viscosity. o Increases glucose tolerance o Improves cholesterol levels. Potential Clinical Uses o Light therapy is used in hospital to promote the breakdown of bilirubin in babies with jaundice. o Lupus vulgaris. o Detoxification o Asthma o Polio o Paralytic ileus o Viral and bacterial infections o Possible uses in cancer o Thrombophlebitis Methods for Clinical Use o 18 gage needles is inserted into vein. o Blood is drawn into the UVC machine (Knott machine) and is exposed to UV radiation for approximately 10 seconds. o The blood is then returned to the patient. Cautions and Toxicity Symptoms o UVC and Sulpha drugs increased mortality and poor outcome versus either treatment alone. o Contraindicated in autoimmune diseases, pregnancy, blood dyscrazias and contained infections. o Overexposure to UVC can damage RBCs and cause a severe reaction or even death.

Introduction to Colchicine Therapy Physiological Responses to Colchicine o Effective in the treatment of gout due to the binding of colchicine to tubulin which blocks mitosis and miosis. Also interferes with the transcellular movement of collagen which may reduce scaring and adhesions. o Appears to inhibit certain functions of PMNs and inhibits WBC chemotaxis. o Anti-inflammatory properties including preventing inflammation at nerve roots in degenerative disk disease. o May reduce pain by increasing endorphin release. o Reduces atopic reactions associated with degenerative disc disease including inflammation and dryness of the skin at affected spinal level. o May shrink vertebral disc bulges and inhibiting amyloid protein deposition within the disc. Potential Clinical Uses o Acute treatment for gout attack. Allopurinol is used preventatively for chronic gout. o Bechet’s disease is a multi system chronic vasculitis that responds to cholchicine therapy. Conventional treatments include corticosteroids. o Pyrone’s disease causes inflammation of the penis due to scar tissue that prevents adequate blood flow. This condition can be brought on by beta blockers and is relieved with cholchicine therapy by degrading plaques and preventing scar formation. o Familiar Mediterranian Fever presents most commonly in the Jewish, Arabic, Armenian and Turkish communities as severe febrile attacks with joint and chest pain. It can also cause skin eruptions and in some patients, amyloidosis. Colchicine therapy reduces amyloid deposits and can thus be used with this condition. o Schnitzer syndrome is a chronic urticarial skin condition associated with monoclonal IgM gammopathy. Clinically presents as an intermittent fever and joint and bone pain that develops into osteosclerosis at the site of pain. This autoimmune condition also presents with lymphadenopathy, elevated ESR, leukocytosis and enlarged liver and spleen. o Autoimmune hemolytic anemia var. warm antibody o Idiopathic thrombocytopenia purpura o Psoriatic arthritis has improvements in joint pain, but not associated psoriasis. o Scleroderma Methods for Clinical Use o 2 syringe technique o Syringe 1 contains colchicine and sterile water o Syringe 2 contains hydroxycobalamin (or methycobalamin), magnesium chloride and sterile water.

o Using a butterfly, push half of contents of syringe 2. This confirms entry into the vein and the magnesium causes relaxation of the vessel. o Then inject the total contents of syringe 1. o Use the remainder of syringe 2 to flush. o Solutions of colchicine should not be turbid when injected. Compatible with sterile water or sodium chloride solutions. Incompatible with D5W and solutions that contain a bacteriostatic agent. o Monitor 24-hour creatinine clearance to ensure adequate elimination. Cautions and Toxicity Symptoms o Side effects include nausea and vomiting. o Monitor liver enzymes, platelets and alkaline phospahate during this type of treatment. o Contraindicated in pregnancy due to anti-mitotic effects. o Alkaloid content may be cumulative over time. o Extravasation may occur causing destruction and necrosis of surrounding tissues. Treatment includes topical corticosteroids. o Interferes with B12 absorption irreversibly when used orally. o Contraindicated in conditions with a compromised blood brain barrier (acute brain injury) or seizures. o Toxicity symptoms include: thrombocytopenia, leucopenia, pancytopenia, agranulocytosis, aplastic anemia, renal failure, bone marrow suppression and disseminated intravascular coagulation. Introduction to Chelation Therapy EDTA (Disodium ethylene diamine tetracene) Minerals with affinity for EDTA o Calcium EDTA will chelate lead (Pb) and zinc (Zn) o Magnesium EDTA will chelate calcium o Other minerals with affinity include: iron (Fe), manganese (Mn) Clinical Uses o Atherosclerosis is associated with calcium deposition in arteries and arterioles. EDTA has been used to successfully reduce need for surgeries (including angioplasty) and reduce coronary plaques. o Intermittent claudication has been improved with EDTA in an RCT. o Used to treat lead toxicity which includes symptoms such as abdominal pain, vomiting, constipation, headaches, irritability, myalgia, arthralgia, learning or behavioral disorders. Severe lead toxicity may include convulsions. Iron deficiency may be seen on lab results. Methods for Clinical Use

o Kidney function must be assessed before beginning treatment to ensure adequate excretion will take place. o Sterile water, D5W or NaCl are carriers. Dosage varies based on the weight of the patient. An average dose is usually 3g. o Treatment cannot be repeated twice in 24 hours and no more than two times per week. o Half life of 30-60 minutes. o EDTA itself is not significantly metabolized Cautions and Toxicity Symptoms o May leach essential minerals or induce hypocalcemia. o Can cause cardiac arrhythmias, nausea, vomiting, diarrhea, fever, headache, urinary urgency, renal damage. o May cause allergic reaction in patients. o Magnesium EDTA can cause hypoglycemia or hypotension due to the large dose of magnesium. o Supplement with zinc during EDTA treatment to prevent deficiency. DPTA Minerals with affinity for DPTA o Americanum (Am), plutonium (Pu), iron, zinc, copper Clinical Uses o Used for accidental poisoning in chemical plants or laboratories. o Excreted in the urine without being significantly metabolized. Methods for Clinical use o Similar to EDTA but slightly lower doses. Cautions and Toxicity Symptoms o Need to supplement patients with zinc during DPTA treatment to prevent deficiency. o May leach other essential minerals such as manganese, and copper. LIHOPO Minerals with affinity for LIHOPO o Chelation of plutonium and americanum. Clinical Uses o Differs in structure to EDTA and DPTA Methods for Clinical Use

Cautions and Toxicity Symptoms BAL (British Anti-Leuocyte) Minerals with Affinity for BAL o Affinity for arsenic (As), lead (Pb), mercury (Hg), antimony (Sb) and gold (As) o Primarily used for arsenic Clinical Uses o Used for arsenic poisoning which presents with delusions, restlessness, irritability, sleep disturbances and burning pains (Think of arsenicum album homeopathic picture). Methods for Clinical Use o Half-life is approximately 1 hour. o Excreted in both urine and feces. o Monitor patient’s excretion with kidney function tests to ensure adequate elimination. Cautions and Toxicity Symptoms o Use with caution in patients with glucose-6-phosphate dehydrogenase deficiency (G6PD). BAL may cause hemolysis of fragile RBCs o BAL should be given slowly to avoid systemic toxic symptoms. o Adverse effects are common and may include: hypertension, tachycardia, pain at site, vomiting, burning sensation in mouth and throat, lacrimation, hypersalivation, and headaches. o The sulfur like odor of BAL can cause nausea in sensitive patients. DMSA (Succimer) Minerals with Affinity for DMSA o Excellent mercury (Hg) chelator o Also has an affinity for lead, arsenic, antimony, bisthmuth (Bi) and gold. Clinical Uses o Used for mercury toxicity. Methods for Clinical Use o Not available in Ontario for Naturopathic doctors. o Average dose is 500 mg TID orally for adults. o Patients take DMSA for 2-3 days then remain off for the balance of two weeks, then repeat. Taken between meals and before bed. o Half-life of approximately 2 hours; is excreted in the urine.

Cautions and Toxicity Symptoms o Caution with G6PD deficiency o Stool and urine smelling of rotten eggs (Sulfur content) o Adverse events are less common than other chelators. Symptoms include: nausea, vomiting, diarrhea, gastroenteritis, skin rash. o May cause allergy due to sulfur content. DMPS (Dimaval) Minerals with affinity for DMPS o Affinity for mercury, lead, arsenic, bisthmuth, antimony and gold. o Highest affinity for mercury Clinical Uses o Mercury poisoning o Heavy metal testing Methods for Clinical Use o Used as a urine challenge to test for the presence of heavy metals. Patient urinates, then a DMPS push is given. Urine is collected for 24 hours and measured for heavy metals. o Does not cross the blood brain barrier and therefore only accounts for mercury or other metals in body stores. Cautions and Toxicity Symptoms o Considered to be more toxic than DMSA o Adverse reactions are similar to DMSA including skin rashes and odorous stool. Deferoxamine Minerals with Affinity for Deferoxamine o The most common iron chelator. o Has an affinity for aluminum (Al) and gallium (Ga) Clinical Uses o Hemachromatosis or acute iron toxicity. Methods for Clinical Use o Excreted in the urine and bile. Cautions and Toxicity Symptoms o Adverse reactions include: allergic reactions, abdominal discomfort, leg cramps and tachycardia. o Long term use may cause occular toxicity and blurred vision.

o Causes hearing loss in up to 25% of children given deferoxamine for transfusional iron overload. Deferiprone Minerals with an Afiinity for Deferiprone o Used for iron chelation. o Also has an affinity for aluminum and gallium Clinical Uses o Developed as an alternative to deferoxamine. Patients may require alternation between these two chelators to avoid side effects. o Not as effective for liver iron overload as deferoxamine. o Requires a higher dose than deferoxamine due to a smaller number of available binding sites. Methods for Clinical Use Cautions and Toxicity Symptoms o Adverse reactions: nausea, skin rashes, elevated liver enzymes, agrnaulocytosis. o May cause elevation of ANA in up to 25% of patients and is therefore contraindicated in lupus (SLE), scleroderma (SS) and rheumatoid arthritis (RA) to avoid exacerbation. D-Penicillamine Minerals with an Affinity for D-Penicillamine o Chelates copper. o Weaker affinity for lead. Clinical Uses o Used in Wilson’s disease by removing copper from the liver, brain, testes and other areas it is stored. o Wilson’s disease can present with schizophrenia like symptoms as well as a hallmark brown ring around the iris of the eye. Methods for Clinical Use o Orally at 500 mg TID or intravenously if the oral dose is not tolerated. o B6 antagonist therefore patients may need to be supplemented with B6 during treatment. o Will also chelate zinc which should be supplemented. Cautions and Toxicity Symptoms o May cause symptoms including: cutaneous lesions, gastrointestinal symptoms, hypoguesia (loss of taste). o Risk of allergic sensitivity to D-Penicillamine.

Trientine (Trien-2HCl) Minerals with and Affinity for Trientine o Chelates copper. Clinical Uses o Wilson’s disease for patients who cannot tolerate D-Penecillamine. Methods for Clinical Use o Monitor iron and zinc levels. o Administered orally, excreted in the urine. Cautions and Toxicity Symptoms o Can cause sensitivity reactions and impair iron absorption.

Ditiocarb Sodium Minerals with an Affinity for Ditocarb Sodium o Affinity for cadmium (Cd) Clinical Uses o Cadmium has estrogen-like effects in the body and toxicity with cadmium has been implicated in bladder, breast, prostate and endometrial cancers. o Industrial accidents with cadmium. Methods for Clinical Use o Given IV and excreted in the urine and bile. o Half life is 5 minutes. Cautions and Toxicity Symptoms o May cause mylosuppression and gastric ulcers. o Long term use has been associated with peripheral neuropathy. Summary of Toxic and Essential Minerals Chelated by Each Agent Chlelating agent Deferoxamine D-penicillamine Succimer (DMSA) Dimaval (DMPS) Deferiprone Na2CaEDTA

Toxic ions excreted Al, Ga Pb Pb, As, Hg, Au Pb, As, Hg, Au Al, Ga Pb

Essential ions excreted Fe3, Zn2, Cu2+ Cu2+, Zn2+ Cu2+ Cu2+ Fe3+, Zn2+, Cu2+ Fe, Zn, Cu, Mn

Na3DTPA BAL Trientine Ditiocarb sodium

Pu, Am Pb, As, Hg, Au Cd

Fe, Zn, Cu, Mn Cu Cu, Zn, Mn Cu, Zn, Mn