Development of a therapeutic procedure for bismuth intoxication with chelating agents

Although bismuth poisoning is still a rare phenomenon, the increasing use of bismuth-containing drugs warrants a systematic approach to the treatment of bismuth overdose. An effective method of enhancing the elimination of toxic amounts of bismuth from the body has not been reported. Therefore we performed a study to select the best chelator to treat bismuth poisoning. Dimercaprol (BAL), meso-2,3-dimercaptosuccinic acid (DMSA), D,L-2,3-dimercapto-propane-I-sulfonic acid (DMPS), D-penicillamine (D-PEN), N-acetyl-D,L-penicillamine (Ac-PEN), thiopronine (TP), sodium-calcium edetate (EDTA) and deferoxamine (DFO) were tested with an in vitro model of equilibrium dialysis and an in vivo model of rats poisoned with bismuth. The rats (n = 6 per substance tested) were treated with the chelators in intraperitoneal doses of 250 mumol/kg.day for 3 consecutive days. Afterward, tissue and blood samples were collected. Bismuth concentrations were determined with electrothermal atomic absorption spectrometry in serum, buffer, urine, blood, brain, kidney, liver, spleen, and bone. Using in vitro results, we constructed a ranking of chelating agents; it appeared not to predict the in vivo results. The dithiol compounds (DMPS, DMSA and BAL) were effective in most organs (especially in kidney and liver) resulting in a higher elimination of bismuth in urine by DMPS and BAL. BAL was the only chelator effective in lowering brain bismuth concentrations, whereas treatment with EDTA resulted in increased brain bismuth levels. For D-PEN and DFO, no effects could be demonstrated. For clinical practice, DMSA and DMPS may well be the chelators of choice; the application of BAL should be reserved for very severe cases of poisoning because of its own toxicity.