Chelation Protocol
By William Shaw PhD.

For Mercury and other toxic metals
If you have a patient or child with a positive test result for heavy metal toxicity, you will want to seriously consider chelation using Dimercaptosuccinic acid (DMSA), which is approved for use by the USFDA (as succimer, Chemet ) as a treatment of lead poisoning in children. This chelating agent binds to the heavy metals (including lead, mercury, arsenic, cadmium, antimony, and nickel) and eliminates them through the urine. DMSA will not chelate aluminum and Malic Acid (500 mg/day) has been shown in studies to chelate this toxic metal. Since many symptoms of autism are similar to the symptoms of mercury poisoning, (i.e.; immune dysfunction, visual disturbances, motor/coordination defects), many children who undergo chelation treatment have seen significant and sometimes dramatic improvement (especially with children age 5 and under). Benefits of chelation therapy that have been reported to include improved receptive and expressive language, improved eye contact, decrease in self-stimulatory behaviors ("stimming"), improved social interactions, and improvement in muscle strength and coordination.

IT IS STRONGLY RECOMMENDED THAT ANY CHELATION THERAPY BE SUPERVISED BY A MEDICAL DOCTOR.

Pre-Chelation Preparation:
1. Treat Yeast and Bacteria
Because many children with autism struggle with yeast and bacteria overgrowth, it is important to treat these overgrowths before administering DMSA and ALA. DMSA and ALA will feed and exacerbate existing overgrowths and they will experience a worsening of autistic symptoms.

2. Supplement with Minerals:
It is important to supplement with zinc, selenium, magnesium, molybdenum, manganese, vanadium and chromium. Because most autistic children have an excess of copper, any supplement give should not contain copper. Because DMSA will bind with zinc during the chelation process, supplementation of 1-2 mg/kg/day is recommended during chelation ("ON" days) and during the "OFF" days as well.

3. Supplements with Vitamins:
Because of poor diets, poor absorptions, and environmental toxins, many vitamins are depleted in autistic children. During the process of removing heavy metals, it is especially important to support the body with antioxidants (Vitamin C, E, and Beta Carotene) and B Vitamins (B6, B12, Folate and Niacin). It is recommended that the following supplements be added to the diet for at least a one-week period prior to the start of chelation. Always introduce new supplements one at a time every three days in order to assess a possible allergic reaction. Recommended dosages are

Vitamin C: 50 mg/kg/day given in divided doses throughout the day.
Vitamin E: 2-4 mg/kg/day (3-6 IU/kg/day)
Vitamin B6: Up to 15 mg/kg/day of B6
Beta-Carotene/
Vitamin A: Minimum of 2,500 IU/day

4. Other Important Supplements
Taurine - This supplement aids in the production of bile salts and it thought to aid in the elimination of toxins as well as fighting yeast. Many autistic children are deficient in Taurine and benefit when supplementing with 250 - 500 mg/day.

L-Glutathione - Often deficient in children with autism, glutathione is important in the detoxification process and is a powerful antioxidant. Recommended dosage is 100 - 200 mg/day may be helpful. Many physicians have recommended the transdermal form of glutathione to their patients.

Milk Thistle - An important herb, which is important for supporting and protecting the liver during chelation. Recommended dosage is 100 - 200 mg twice daily during "ON" and "OFF" days.of chelation.

Melatonin - This pineal hormone helps to regulate the sleep/wake cycle, which is malfunctioning in many children with autism. Also a powerful antioxidant, melatonin may play an important part in protecting neurons from mercury damage. (Reference). In addition, this hormone is concentrated in the mitochondria and therefore has a protectant effect against oxidative damage (Reference). Dosages of up to 0.1 mg/kg at bedtime can help with sleep problems. Studies have established its safety for children in long-term use. (Reference)

Alpha-Lipoic Acid - Also known as Lipoic Acid or ALA, this powerful antioxidant, is also very a potent chelating agent. ALA should be given in conjunction with DMSA only, and is usually added after a chelation period of at least four months with DMSA only. ALA is considered more effective at removing brain mercury than DMSA because it is fat soluble and capable of bypassing the blood/brain barrier.

Other Important Information:
1. Abstain from fish and seafood
2. There must not be any amalgam (metal) fillings in the teeth. Use white composite material instead. Have all existing metal fillings removed BEFORE starting chelation. These fillings are sometime under crowns as well.
3. No more thimerosal-containing vaccines. Check package inserts of every vaccine before allowing them to be administered. Thimerosal is used as a preservative agent and contains close to 50% mercury.
4. Evaluate and eliminate any other sources of heavy metal contamination. It is recommended to drink only water that is purified by reverse osmosis or distillation. While undergoing chelation, lots of water should be consumed to facilitate excretion of metals through the urine.
5. Appropriate tests should be run to monitor blood counts, kidney and liver function, and mineral levels. Urine Metals tests can be run to evaluate the levels of metals being excreted.

Laboratory Testing
The following information regarding testing was taken from the Defeat Autism Now! (DAN!) "Mercury Detoxification Consensus Group Position Paper."

"Since DMSA has been reported to cause elevations in hepatic transaminases, serum ALT and AST should be monitored during therapy. Likewise, white cell and platelet counts should be followed. Both elevation of liver enzymes and bone marrow suppression are dose-related and have been, to date, completely reversible. Also, review of the literature indicates that, while some patients are more sensitive, sensitivity appears to remain constant. This would suggest that patients who tolerate DMSA initially will rarely, if ever, develop sensitivity later in therapy.

Complete blood count (CBC) with platelet count and liver enzymes should be checked after the first or second cycle and, assuming no abnormalities are found, rechecked periodically while therapy continues. If elevated liver enzymes or depressed cell counts are found, the DMSA should be stopped and the laboratory tests followed until the values return to baseline. If the abnormalities were not too severe and they return to baseline promptly, the DMSA can be resumed at a lower dose with careful monitoring.

Urine metal analysis for mercury and other toxic metals may help direct the duration of therapy. The optimum time for collecting the urine specimen is after the second dose of the cycle and within six hours of the last dose of the cycle. Timed specimens are best, but may not be practical in children who are not toilet-trained. When a 24-hour specimen is not possible, 12 or 6-hour specimens are completely acceptable. In children who are continent at night, the first morning urine represents an 8-hour collection, on average.

Random or spot urine specimens are problematic, as they may miss the time of peak excretion especially when DMSA is given every 8 hours. One way to overcome this problem is to obtain two or more random specimens and combine them. This will "average" the mercury excretion over several samples. The best time to get a spot urine sample is two to four hours after a dose.

Some practitioners have found stool mercury analysis to be helpful, as much of the mercury excreted with alpha lipoic acid will be found in the bile. The major limitation to stool mercury is that the stool contains both mercury excreted in the bile as well as any mercury ingested in the diet and not absorbed. Without knowing the amount of mercury in the diet, it is impossible to accurately interpret stool mercury levels. The best way to use stool mercury levels is to obtain a level before treatment. Assuming that the dietary mercury remains relatively constant, this will provide a baseline for subsequent measurements."

Dosages for DMSA and ALA:

*The four-hour protocol is often the easiest on young children (regarding side effects) but the hardest on the parents (regarding sleep). It is recommended to start with the lower dosage and work up once a child seems to have tolerated the dosage. Once ALA is added, it is desirable to follow a four-hour protocol because of ALA's pharmacokinetics. Giving this every four hours will ensure the metals are removed instead of being redistributed in the body.

**The eight-hour protocol is more likely to be tolerated by older children and adults. It is suggested that you start with the lower amount to start, and increase dosage slowly as tolerated. If significant side effects exist, lower the dosage until the side effects are tolerable.

***Do not add ALA until chelation with DMSA alone has continued for a minimum of 4 months. It is advisable to run a urine metals test to make sure that most of the body burden of metals has been eliminated.

Dosage Schedules and Directions
Whether choosing a 4 or 8-hour dosing schedule, it is very important to be strict in order to keep the blood levels of DMSA consistent. No dosages should be skipped and given EVEN AT NIGHT. If more than one half hour passes past the time for the scheduled dose, it is strongly advised to stop chelation treatment for at least a few days before restarting. Many parents have found success in having watches with alarms that remind them for each dose. For children who do not swallow capsules, the capsules can be opened up and mixed in a tart liquid such as orange or lemon juice. Using a syringe is an effective way to make sure the full dose is received. Many children will receive a dose from a syringe at night without even waking up. DMSA can be pre-mixed in a tart liquid for up to 8 hours without losing potency.

When following an every 4-hour schedule, a possible dosage schedule would be 8:00 am, 12:00 pm, 4:00 pm, 8:00 pm, 12:00 am, and 4:00 am. This schedule would be followed for 3 days with the last dose being at 4:00 am on the third day. This weekend of treatment would be considered a round.

When following an every 8-hour schedule, a possible dosage schedule would be 8:00 am, 4:00 pm, and 12:00 am. This schedule would be followed for 3 days with the last dose being given at 12:00 am on the third day. It is important to follow each round of chelation with a rest period of at least 4 days.

Many parents chelate with an eleven-day resting period and as a result, chelate every other weekend. It is easier to chelate during the weekends when the children are not in school. If more aggressive chelation treatment is desired, every weekend can be used for chelation, but this may be very hard on the child and should not continue if physical symptoms (fatigue, lethargy, regression, etc.) and other side effects do not abate before chelation is resumed. It is not advisable to chelate when a child is sick.

Common negative side effects of DMSA are nausea, diarrhea, loss of appetite, flatulence, and fatigue. Some parents have reported nasal congestion and mild cold symptoms during the first few treatment periods. Some regression may also occur in language and behavior during treatment but should resolve soon after ceasing treatment. Symptoms will be worse at the start of chelation therapy and will improve with each subsequent cycle of treatment. Oftentimes, reducing the dosage make these symptoms less severe.

Rare side effects of DMSA are rare and include allergic reaction, toxic epidermal necrolysis (TEN) and erythema multiforme (Stevens-Johnson syndrome. Neutropenia and thrombocytopenia may also occur in very rare situations. If these side effects occur, chelation treatment should be suspended and other options should be evaluated.

When to stop chelation treatment
The decision to stop chelating should be based on clinical and laboratory evidence. Because Mercury can be tightly bound, chelation can last as long as one year for very young children, and longer for older children and adults. Some people stop chelating soon after improvement is no longer being seen and has reached a "plateau." Another reason to stop chelation therapy is if the child shows no significant progress or experience regression that does not cease after a round is completed. Some temporary regression can occur during initial rounds treatment, but should be followed soon by significant gains. Sometimes gains can be hidden by the side effects of yeast and bacteria overgrowth, which sometimes worsens during chelation therapy. It may be helpful to follow each round of chelation therapy with a 3-4 day course of natural antifungal and antibacterial products such as Oregano Oil, Grapefruit Seed Extract, MCT Oil, or Olive Leaf Extract. It is a good idea to rotate these products so the organisms do not have time to develop a resistance. Also, it is important to give a lot of good bacteria such as

Lactobacillus to help keep the intestinal tract healthy. Some good products that many parents have had success with include Culturelle, Primal Defense, and Aqua Flora.

Many physicians and parents like to use the Urine and Fecal Metal tests to see what metals are being eliminated, when to add ALA, or when to stop chelation. Another helpful tool is to repeat the Metals Hair test 3-4 months after chelation.