Why won’t the medical toxicologist chelate the metals out of my body?!

Spoiler: We will. If you need it. And most people don’t.

A common reason to see a medical toxicologist in an outpatient clinic is because a test for metals in the body returned ‘abnormal’. These tests are often ordered by ‘non-traditional’ practitioners or well-intended physicians doing a wide battery of tests to find a cause for mysterious symptoms. In many cases the test was done incorrectly, and when repeated using the appropriate body fluid and processed the appropriate way, the result is normal. In most cases the test was not necessary.

Medical toxicologists see only a tiny fraction of patients in the United States who are inappropriately diagnosed and treated for metal ‘poisoning’. There are a lot of grifters out there who profit by taking advantage of people concerned about toxic exposures or who are looking for an explanation for physical complaints like fatigue or pain. A popular (and in my opinion, useless) term right now is ‘brain fog’. Look up any toxin and someone will tell you it causes brain fog. (Seriously – google “Does [toxin of choice] cause brain fog?”) This is not a medical term. It can be used to describe a feeling without any measurable findings. And then it can be attributed to just about any toxin.

Many practitioners order metal tests frequently, specifically using inappropriate testing methods that are destined to support a diagnosis of poisoning. They then go on to provide expensive chelation treatments. Sometimes though, the practitioner ordering the test was acting in good faith and when presented with a result that seems abnormal, they refer the patient to a medical toxicologist for possible chelation treatment.

Diagnosing metal poisoning

We are all exposed to metals in our environment. Through air, water, and food we absorb arsenic, lead, mercury, cadmium, copper…the list goes on. We may also be exposed to some metals, like gadolinium or aluminum, through medical procedures or treatments. As a result of living life, we all have some low level of various metals in our bodies.

The concern is when the route of exposure, dose, and form of the metal work together to create toxicity. For example, you could swallow elemental mercury in its silvery liquid form and never get sick. But take that same mercury, heat it up and inhale it, and it could kill you.

So when the medical toxicologist assesses a patient for metal toxicity they are considering all these things. The details of the exposure, the specific symptoms and findings someone has, and the test result. If there is no known history of exposure (above that which is a normal part of being a human on earth) and/or the symptoms and exam findings are not what we would expect from the metal, we don’t typically send the test. When we do test, we target the metals we are concerned about. What we never do is have the patient take a chelating drug before testing, otherwise known as a provoked urine challenge.

Provoked urine challenge tests

A commonly misused test for diagnosing metal poisoning is the provoked urine challenge test, where prior to providing a urine sample for testing, the patient is given a chelator (the provoking drug) that binds to metals in the body and pulls them from tissues where they are stored and into the urine. This is guaranteed to raise the concentration of metals in your urine whether or not you are poisoned and often results in many different metals falling outside of the ‘normal reference range.’ The results are then used as justification for alternative practitioners to declare there is a high body burden of metal and that the patient is poisoned. Patients then spend tens of thousands of dollars on prolonged courses of chelation treatments for a condition that doesn’t exist.

There are a bunch of reasons why these tests should not be used. If interested in more detail here is a publication that explores the topic further.

Recommendations for Provoked Challenge Urine Testing

To keep it simple, everyone exhibits an increase in their urine metal concentrations after taking a chelator, and the amount of the increase is variable, with no relation to whether someone has poisoning or not. Other alterations in the timing of the sample collection and correction for urine creatinine lead to falsely elevated values. Comparing the final manipulated result to normal reference ranges for a population that did not first take a chelator is misleading, to say the least.

When does a medical toxicologist use chelation?

There are certainly situations where we diagnose metal toxicity and prescribe chelation. Lead poisoning is a frequent indicator for treatment with a chelating drug, and there is an established blood concentration of lead that determines when chelation is recommended. Specific levels are not as useful with other metals. Just because they are elevated above the normal reference range does not necessarily indicate poisoning. For example, if you eat a ton of high mercury containing fish you may push your levels up. It is extremely unlikely in the United States that you would have enough of an exposure to develop mercury poisoning though. Typically, in these cases we advise a shift in diet to lower mercury containing fish and the levels decline. No chelation needed. (Interestingly there seem to be quite a few celebrity testimonials of almost dying from mercury poisoning due to fish. This phenomenon in the entertainment industry is not reflected in the medical literature.)

The number one treatment for any metal poisoning is removal from the exposure.

The first thing we do when someone has an elevated lead level is identify the source and remove the patient from the exposure. The same holds for all other metal exposures. That is usually the only treatment needed.

In conclusion, medical toxicologists are not trying to be difficult when they decline to provide chelation for a diagnosis of poisoning that they don’t agree with. We, like most physicians who value evidence – based practice, administer medications after weighing the potential benefits against the potential harms. Chelators are medications with risks. They bind to essential minerals and calcium, they can have unpleasant side effects, and they can produce allergic reactions. And, of course, they can be expensive. We don’t want to disappoint you, but above all we want to provide you with safe and effect medical care.