Management of lead poisoning or elevated blood lead level ≥50 mcg/dL in non-pregnant adults

BAL: dimercaprol; BLL: blood lead level; BUN: blood urea nitrogen; CaNaEDTA: calcium disodium ethylenediaminetetraacetic acid; CBC: complete blood count; CNS: central nervous system; DMPS: 2,3 dimercaptopropane-1-sulfonate; DMSA: 2,3-dimercaptosuccinic acid, succimer; EDTA: ethylenediaminetetraacetic acid; FEP: free erythrocyte protoporphyrin; OG: orograstric; NG: nasogastric.

* Blood lead levels reflect both ongoing sources of lead exposure that may be occurring as well as the constant outflow of lead from any internal stores that have accumulated over time. The primary internal storage site is bone, where lead stores have a residence time ranging from years to decades. Sources of ongoing lead exposure include workplace (eg, plumbers, smelters, miners, painters, construction workers), hobbies (eg, target shooting at firing ranges), retained bullets, and others (eg, folk remedies). Refer to UpToDate content and table on sources of lead exposure for expanded list and discussion on obtaining an exposure history.

¶ Maternal lead exposure may increase the risk of spontaneous abortion, preterm birth, small for gestational age, and increased blood pressure (pre-eclampsia). Refer to UpToDate content on occupational and environmental risks to reproduction in females.

Δ Health related effects are dose-dependent and vary based on duration of exposure.

• Short term exposure, mild to moderate increase in BLL: difficulty concentrating, headache, fatigue, myalgias, irritability.
• Higher BLLs, particularly with prolonged exposure: abdominal pain, constipation, ileus, arthralgias, weakness, motor neuropathy (extensor weakness), anemia, semen abnormalities, memory impairment, lead line.
• Extremely high BLLs: delirium, seizures.
• Long-term exposure, even with mild increase in BLL: increased blood pressure, cardiovascular problems, tremor, decreased kidney function, increased cognitive aging.

Refer to UpToDate content and table on effects associated with lead exposure in adults.

◊ After removal from all lead exposure, we start chelation if BLL 50 to 79 mcg/dL and symptoms/signs are most likely due to lead poisoning. If asymptomatic or symptoms not consistent with lead poisoning, evidence is lacking supporting benefit of chelation compared with solely removal from the lead exposure.

§ If source of exposure has been identified and control measures have been instituted, when elevated BLL is reduced to <15 mcg/dL, BLL may be monitored every 3 months. Refer to UpToDate content for further recommendations on BLL monitoring.

¥ Choice of chelator depends on availability and should be made in consultation with occupational/environmental medicine specialist or toxicologist with experience with chelation therapy.

‡ Ensure using calcium EDTA instead of EDTA to prevent hypocalcemia. A potential adverse effect of chelation therapy is redistribution of lead into the CNS. Traditionally, BAL was administered 4 hours prior to CaNaEDTA, but BAL is no longer available. We therefore administer DMSA orally if possible (or via NG/OG) in place of BAL. Refer to UpToDate content on management of lead toxicity in adults.