There is an art and a science to chelation therapy, but without the science it can be quackery.

It is true of everything in medicine, and in fact many have reflected how practicing good medicine is an art based on science.

Chelation is a subject which is, better to say, should be, based on science, but to do at the highest levels becomes an art. But without science it is, can be, quackery. I will distill the bullet points of the science. A few events have stimulated the writing of this blog now, one is the recent release of findings from the TACT II in JAMA, which was studying the impact of using a chelator disodium Ca-EDTA to remove Calcium from arterial plaques in the body. I do not intend to be dismissive, but on its surface, yes this form of EDTA does remove calcium, but why would it remove tightly bound calcium in coronary artery plaques, and not more loosely bound calcium in blood and soft tissues? To the authors credit, their study which looked at coronary artery based heart attack, found no advantage for heart attack reduction with this agent, compared to without it, but did show increased lead removal in the majority of individuals. Another launching point for this blog is that some experts in gadolinium toxicity in animals are doubtful that chelation works.

So these are the commandments of chelation:

1. There has to be existing science, or the high likelihood of science, that the metal or cation in question causes disease. So in obvious examples: if Gd makes you sick, getting it out (chelation the most effective method) makes sense. At the present time the science that heavy metals, notably lead, cause autism, is not present with sufficient evidence, that chelating for heavy metals makes sense. In time this may change. So right now chelating patients with autism could be interpreted as quackery. This would be especially true if the practitioner has no peer-reviewed literature to support it.

2. If you are chelating a particular metal, the chelator with the highest stability constant should be used. Otherwise an unacceptable amount of redistribution of that metal will occur. So for Gd and for Lead that chelator is DTPA.

3. If you are performing chelation you have to understand the concepts of Metal Removal and Metal Removal Flare, Metal Redistribution and Metal Redistribution Flare, and Metal Re-equilibration and Metal Re-equilibration Flare. These occur for all metals which are causing toxicity in the individual based on the immunogenicity/ toxicity paradigm for heavy metals. This paradigm differs for different metals with varying effects on immunogenicity and toxicity.

4. In performing chelation for a specific heavy metal you should be aware of the various repositories of it in the body. The two major durable repositories are bone and fat, and these two repository dominance varies for different metals (and different drugs). They tend to be dominant for fat, with fat-soluble drugs, and dominant for bone with water-soluble drugs.

5. If there is an immunogenic component to the heavy metal toxicity you must manage the immunogenic effect. The standard approach is with steroids and antihistamines.

6. It is possible to be allergic to essentially anything, especially any chemical. But documentation of a significant allergy relates to point 3 above. You can also be allergic to your own cells, this is the basis of auto-immune disease.

7. Even if a chelator has high stability with the metal in question, it must have documented that it actually removes Gd in vivo. This can be readily shown with 24 hr urine for heavy metals pre- and post-chelation. With some agents stool testing may also be necessary - this depends on the amount of biliary elimination of the complexed heavy metal is likely to occur.

The only treatment method for persistent Gd toxicity (GDD) that has been validated in the peer-review literature is iv DTPA chelation, and strongly advised immune management with steroids and antihistamines. It is not unreasonable for it to be considered that other chelating agents, if they have lower stability constant for Gd than DTPA, is some form of quackery. If I was to be asked in any setting whether I thought using EDTA or DMSA or a combination of both met the standard of care for treating GDD, I would say no. If I was asked if using HOPO to chelate for sufferers with GDD met the standard of care, I would say yes.

If all of the above points are met, then Heavy Metal chelation is established as science, as much, or more, than most other medical treatments for anything else. Basically we are showing the following: you got the heavy metal and are sick from it, we are using something that can remove the metal, we are documenting that we are removing it with chelation through urine testing, you are experiencing the various Flares that are intrinsic to treatment, and ultimately you are getting better, provided you have sufficient number and sufficient appropriate-style chelations. Sufficient appropriate-style chelations refers to the practitioner knowing the various nuances of chelation, understanding the 3D chess game, and this is where the art comes in.... A few things I have to keep a little proprietary.

If someone was to say that chelating with iv DTPA and steroids and antihistamines for GDD was not effective, I would have 4 things to say:

1. you have no experience with this, and therefore are speaking on the basis of Opinion unconfounded by knowledge.

2. you may have a financial interest in saying it does not work

3. you may have a self-serving psychological reason.

4. you do not understand you are causing great harm to patients by steering them away form the only effective treatment.

Probably this is some combination of the 4 points, like the 4 horsemen of medical misinformation.

Richard Semelka,MD