Excellent questions. Brief response. Fine points about DTPA chelation.

Given the math of gadolinium retention - if a 72kg patient receives 14.4ml GBCA containing 7.7g MultiHance, and assuming 95% is removed naturally after 3 months, that leaves approximately 385mg retained. With chelation reportedly removing around 50mcg per day, and levels dropping after initial chelations, how do we achieve "near-cure" status? Even at 50mcg daily, removing 385,000mcg would take years. Is most of the retained gadolinium stored inertly in bone, making only a smaller portion clinically significant for symptoms? This question seems to come up frequently among patients trying to understand the treatment mechanism.

About Gd removal with chelation. . I post about 99% removed by 1 year, on its own, from 3 months to 1 year there is also the background native removal that DTPA magnifies. The chelation has the immediate removal for 1 day, but stimulates persistent removal by re-equilibration (albeit tiny amounts). Ultimately some Gd is always left behind. It is not a question of removing all the Gd, but enough of the Gd that a person's immune system can largely ignore it.

1. Is CaDTPA Day1 and ZnDTPA Day 2 necessary now that it's just a 45 minute drive away? Is spacing them out, or doing just CaDTPA/ZnDTPA more sensible

2. How important are the little details in the chelation itself, like the bolus injection, splitting the dose to 2 halves, the duration of the IV, sitting for 40 min, supine for 40, etc...

3. What are some good ways to manage the flare without steroids?

4. Thanks to the distance I can play around with the rate of chelation. With that in mind, is once per 2 weeks or 3 weeks more sensible now that the overhead of chelation is much lower?

Some elements of the regimen are important, others less so

1. Ca-DTPA before ZnDTPA makes sense. Zn-DTPA continues the process of removing Gd, including Gd loosened but not removed by Ca-DTPA day 1. Zn-DTPA also restores Zn removed by Ca-DTPA day 1. Doing them back-to-back day 1/ day2 probably important, not essential. Doing them both on one day is too much removal and will stimulate too much Flare reaction.

2. Bolus injection of DTPA is important. Split dose probably helps, by giving two DTPA flushes through the extracellular matrix, the second picking up Gd loosened but not removed.. Bolus injection reproduces how Gd was delivered in the first place, and captures/ pulls Gd out of the extracellular matrix. Drip injection of DTPA really only removes Gd along the vessel walls. At some time after multiple chelations, much of the Gd in soft tissues may be re-equilibrated Gd and no longer primary deposition Gd. Re-equilibration Gd likely stays along and in the vessel walls. Perhaps after 10 bolus chelations, iv drip DTPA may be then reasonable, but not before.

3. Lower steroid dose is the first step to less steroids. After 5 chelations, Flare generally is much reduced so at that time one can take minimal steroids/ no steroids I use steroids all the time because I am concerned about Flare. Concerned because too much Flare is not a good experience for a patient in general, and also secondarily that the strong Flare does not cause individuals to panic and stop chelation. Most often the impetus for strong Flare is a significant amount of Gd removal. So individuals who stop because of severe Flare are exactly the ones who are probably benefitting the most from chelation..

   Turmeric/ ibuprofen/ loratadine may be sufficient in place of steroids,.

4.   Chelation once every 3-4 weeks is generally ideal to maximize the benefit of re-equilibration. This means getting Gd out of bone.

   . If a person has received multiple GBCA injections then re-equilibration can be massive (and re-equilibration Flare massive). In that case chelation every 1-2 weeks makes sense, and it also makes sense to use less chelator and maybe only 1 of them (such as 1/2 dose Ca-DTPA) to minimize removal Flare and re-equilibration Flare.

Richard Semelka, MD