Dimercaprol

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# Overview
Dimercaprol is a heavy metal chelator that is FDA approved for the treatment of arsenic, gold and mercury poisoning. It is indicated in acute lead poisoning when used concomitantly with Edetate Calcium Disodium Injection USP.   Common adverse reactions include Blepharospasm, conjunctivitis, lacrimation, nasal discharge,
tightness sensation in chest, limbs, jaw and abdomen, injection site pain, nausea, vomiting, headache, paresthesia, tremor.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

### Mild Arsenic or Gold Poisoning
- 2.5 mg/kg of body weight four times daily for two days.
- Two times on the third day.
- Only once daily thereafter for ten days.

### Severe Arsenic or Gold Poisoning
- 3 mg/kg every four hours for two-days
- Four times on the third day
- Twice daily thereafter for ten days.

### Mercury poisoning
- 5 mg/kg initially, followed by 2.5 mg/kg one or two times daily for ten days.

### Acute Lead Encephalopathy
- 4 mg/kg body weight is given alone in the first dose
- Thereafter at four-hour intervals in combination with Edetate Calcium Disodium Injection USP administered at a separate site.
- For less severe poisoning the dose can be reduced to 3 mg/kg after the first dose.
- Treatment is maintained for two to seven days depending on clinical response. *Successful treatment depends on beginning injections at the earliest possible moment and on the use of adequate amounts at frequent intervals

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Dimercaprol in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Dimercaprol in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)

### Mild Arsenic or Gold Poisoning
- 2.5 mg/kg of body weight four times daily for two days.
- Two times on the third day.
- Only once daily thereafter for ten days.

### Severe Arsenic or Gold Poisoning
- 3 mg/kg every four hours for two-days
- Four times on the third day
- Twice daily thereafter for ten days.

### Mercury poisoning
- 5 mg/kg initially, followed by 2.5 mg/kg one or two times daily for ten days.

### Acute Lead Encephalopathy
- 4 mg/kg body weight is given alone in the first dose
- Thereafter at four-hour intervals in combination with Edetate Calcium Disodium Injection USP administered at a separate site.
- For less severe poisoning the dose can be reduced to 3 mg/kg after the first dose.
- Treatment is maintained for two to seven days depending on clinical response. *Successful treatment depends on beginning injections at the earliest possible moment and on the use of adequate amounts at frequent intervals

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Dimercaprol in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Dimercaprol in pediatric patients.

# Contraindications
- Dimercaprol (Dimercaprol Injection USP) is contraindicated in most instances of hepatic insufficiency with the exception of postarsenical jaundice.
- The drug should be discontinued or used only with extreme caution if acute renal insufficiency develops during therapy.

# Warnings
- There may be local pain at the site of the injection.
- A reaction apparently peculiar to children is fever which may persist during therapy.
- It occurs in approximately 30% of children.
- A transient reduction of the percentage of polymorphonuclear leukocytes may also be observed.

# Adverse Reactions

## Clinical Trials Experience

### Cardiovascular
- Rise in blood pressure accompanied by tachycardia.
- This rise is roughly proportional to the dose administered.
Doses larger than those recommended may cause other transitory signs and symptoms in approximate order of frequency as follows:

### Gastrointestinal
- Nausea
- abdominal pain
- in some instance, vomiting

### Nervous System
- Headache
- Tingling of the hands
- Burning sensation in the penis

### Ophtalmology
- Conjunctivitis
- Lacrimation
- Blepharal spasm

### Other
- Rhinorrhea
- Salivation
- Sweating of the forehead, hands and other area
- Occasional appearance of painful sterile abscesses.
- Burning sensation in the lips, mouth and throat
- A feeling of constriction, even pain, in the throat, chest, or hands
Many of the above symptoms are accompanied by a feeling of anxiety, weakness, and unrest and often are relieved by administration of antihistamine.

## Postmarketing Experience
There is limited information regarding Dimercaprol Postmarketing Experience in the drug label.

# Drug Interactions
There is limited information regarding Dimercaprol Drug Interactions in the drug label.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): C
Animal reproduction studies have not been conducted with dimercaprol. It is also not known whether dimercaprol can cause fetal harm when administered to a pregnant woman, or can affect reproduction capacity. dimercaprol should be given to a pregnant woman only if clearly needed.
It is not known whether this drug is excreted in human milk. However, because many drugs are excreted in human milk, caution should be exercised when dimercaprol is administered to a nursing woman.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Dimercaprol in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Dimercaprol during labor and delivery.

### Nursing Mothers
There is no FDA guidance on the use of Dimercaprol in women who are nursing.

### Pediatric Use
There is no FDA guidance on the use of Dimercaprol in pediatric settings.

### Geriatic Use
There is no FDA guidance on the use of Dimercaprol in geriatric settings.

### Gender
There is no FDA guidance on the use of Dimercaprol with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Dimercaprol with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Dimercaprol in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Dimercaprol in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Dimercaprol in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Dimercaprol in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Intramuscular

### Monitoring
There is limited information regarding Dimercaprol Monitoring in the drug label.

# IV Compatibility
There is limited information regarding the compatibility of Dimercaprol and IV administrations.

# Overdosage
- Dosage exceeding 5 mg/kg will usually be followed by vomiting, convulsions and stupor, beginning within 30 minutes and subsiding within 6 hours following injection.

# Pharmacology

## Mechanism of Action
- The sulfhydryl groups of dimercaprol form complexes with certain heavy metals thus preventing or reversing the metallic binding of sulfhydryl-containing enzymes.
- The complex is excreted.
- The sustained presence of dimercaprol promotes continued excretion of the metallic poisons - arsenic, gold and mercury.
- It is also used in combination with Edetate Calcium Disodium Injection USP to promote the excretion of lead.

## Structure

## Pharmacodynamics
There is limited information regarding Dimercaprol Pharmacodynamics in the drug label.

## Pharmacokinetics
There is limited information regarding Dimercaprol Pharmacokinetics in the drug label.

## Nonclinical Toxicology
There is limited information regarding Dimercaprol Nonclinical Toxicology in the drug label.

# Clinical Studies
There is limited information regarding Dimercaprol Clinical Studies in the drug label.

# How Supplied
- 3 mL (100 mg/mL) ampules, box of 10 (NDC 17478-526-03).

## Storage
- Store at 20 to 25C (68 to 77F)

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
There is limited information regarding Dimercaprol Patient Counseling Information in the drug label.

# Precautions with Alcohol
Alcohol-Dimercaprol interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- Bal In Oil

# Look-Alike Drug Names
There is limited information regarding Dimercaprol Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price