THE AUTISM RESEARCH INSTITUTE "Research That Makes a Difference"
The Autism Research Institute (ARI) has been in the forefront of research on the causes and treatment of autism since its founding in 1967. In that era, autism was considered to be a psychological disorder caused by the mother's emotional rejection of the child. Bernard Rimland, Ph.D., the founder of the ARI (as well as the founder of the Autism Society of America), is credited with destroying the "blame the mother" theory and setting autism research on its present course of seeking answers in the biomedical domain.
The ARI's Defeat Autism Now! (DAN!) project, initiated in 1995, is ARI's response to the abysmally slow rate of progress in autism research. ARI has enlisted a consortium of cutting-edge scientists and physicians from around the world to seek answers at an accelerated pace. The Mercury Detoxification Position Paper is one of many ARI/DAN! initiatives directed toward defeating autism as quickly as possible.
ARI depends upon the generosity of concerned individuals and organizations. Your help will speed the day when the horror of autism fades into history.
All donations are tax-deductible and are acknowledged.
ARI is a 501(c)(3) organization. Federal ID No. 95-2548452.
Autism Research Institute - 4182 Adams Ave., San Diego, CA 92116 - www. autismresearchinstitute.com Fax: 619-563-6840
TI& project was supported in part by a grant from: Kirkman Laboratories 1-888-KIRKMAN www.ldrkmaniabs.com "A Full Line of Products for the Autistic Child"
7....... Position Paper on Mercury Detoxification
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TABLE OF CONTENTS
3....... Backgromd and Introduction
18 ...... Appendix A: Detoxification Regirnen
20 ...... Appendix B: Treating Gut Dysbiosis
22 ...... References
25 ...... Follow-Up Research: Treatment Evaluation Form
THE AUTISM RESEARCH INSTITUTE "Research That Makes a Difference"
The Autism Research Institute (ARI) has been in the forefront of research on the causes and treatment of autism since its founding in 1967. In that era, autism was considered to be a psychological disorder caused by the mother's emotional rejection of the child. Bernard Rimland, Ph.D., the founder of the ARI (as well as the founder of the Autism Society of America), is credited with destroying the "blame the mother" theory and setting autism research on its present course of seeking answers in the biomedical domain.
The ARI's Defeat Autism Now! (DAN!) project, initiated in 1995, is ARI's response to the abysmally slow rate of progress in autism research. ARI has enlisted a consortium of cutting-edge scientists and physicians from around the world to seek answers at an accelerated pace. The Mercury Detoxification Position Paper is one of many ARI/DAN! initiatives directed toward defeating autism as quickly as possible.
ARI depends upon the generosity of concerned individuals and organizations. Your help will speed the day when the horror of autism fades into history.
All donations are tax-deductible and are acknowledged.
ARI is a 501(c)(3) organization. Federal ID No. 95-2548452.
Autism Research Institute - 4182 Adams Ave., San Diego, CA 92116 - www. autismresearchinstitute.COM Fax: 619-563-6840
General Disclaimer
This monograph is not intended as medical advice. Its intention is solely informational and educational. Please consult a qualified medical or health professional if you wish to pursue the ideas presented.
Every effort has been made to ensure that the information contained in this monograph is a complete and accurate representation of a consensus opinion of the listed contributors. However, neither the authors, contributors not the sponsoring organization, The Autism Research Institute, is engaged in rendering professional advice or services to the individual reader. The ideas, procedures and suggestions contained in this monograph are not intended as a substitute for consulting with your physician and obtaining medical supervision as to any activity, procedure or suggestion that might affect your health. Neither the authors, nor contributors, nor the sponsoring organization shall be liable or responsible for any loss, injury or damage allegedly arising from any information or suggestion in this monograph.
-The Consensus Position Paper-
This consensus position paper represents the current views of the undersigned physicians and research scientists. The consensus process was initiated at a conference convened for this purpose by the Autism Research Institute on February 9-11, 2001 in Dallas, Texas. The participants continued their discussions by telephone, fax, e-rnail and, in some cases, in-person discussions. The final version was approved on April 20, 2001. James R. Laidler, M.D. guided the consensus through nine vigorously debated drafts with exemplary patience, skill and tact.
No one is more aware than the undersigned that this document represents merely a beginning step in our long-term efforts to solve an exceedingly difficult problem. We have much to learn.
Sidney M. Baker, M.D. Weston, Connecticut
Teresa C. Binstock Estes Park, Colorado
Kenneth Bock, M.D. Rhinebeck, New York
Marvin Boris, M.D. (a) Woodbury, New York
Jeff Bradstreet, M.D. Palm Bearh, Florida
Stephanie Cave, M.D. Baton Rouge, Louisiana
Stephen M. Edelson, Ph.D. Salem, Oregon
Jane El-Dahr, M.D. New Orleans, Louisiana
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Carol Englender, M.D. Newton Highlands, Massachusetts
Frank George, M.D. Sun City, Arizona
John Green, M.D. Canby, Oregon
Boyd E. Haley, Ph.D. Lexington, Kentucky
Stephanie Hoener, N.D. (a) Palm Bay, Florida
Amy Holmes, M.D. Baton Rouge, Louisiana
John Kucera, M.D. Colorado Springs, Colorado
James R. Laidler, M.D. Portland, Oregon
Michael Lyon, M.D. (a) Vancouver Island, Canada
Maureen H. McDonnell, R.N. (b) Pennington, New Jersey
a: Not present at Dallas conference
b: Conference coordinator
Background and Introduction to the Position Paper of the Consensus Conference On The Mercury Detoxification of Autistic Children
Bernard Riniland, Ph.D., Director Autism Research Institute
An enormous, alarming, and unexplained increase in the prevalence of autism is being reported, on an almost daily basis, in the U.S., the U.K., and elsewhere. California maintains what is probably the world's best and most systematic database on autism and other developmental disabilities. In California the reported increase in the prevalence of autism over a 20-year period is over one thousand percent. Similar enormous increases have been reported from studies in New Jersey and elsewhere in the U.S., in the U.K., in the Middle East, and in Asia.
While the reality of the increase is beyond doubt, there is great controversy over the cause. Many experts believe the primary cause is the increase in the number of vaccines given to children from birth to age two, which has risen from 8 in 1980 to 22 in the year 2001.
The increased number of vaccines has brought with it an increased exposure of young infants to mercury intoxication. The preservative thimerosal, which is used in many vaccines, consists of approximately 50% mercury. In 1998 the Food and Drug Administration requested the vaccine manufacturers to begin the process of removing thimerosal from the vaccines. Thimerosal- containing vaccines are still being used in 2001.
Mercury is highly toxic in even very small doses, and some individuals are exquisitely sensitive to mercury. Some infants have been given, in one day, as much as 100 times the maximum dosage of mercury permitted by the Environmental Protection Agency's standards, based on the weight of an adult. An infant's system is much less capable of dealing with toxins than an adult's.
During the late 1960s, my then graduate,-student assistant, Dale Meyer, became interested in the fact that mercury poisoning mimicked many of the symptoms of autism. She wrote a research paper on the subject which is no doubt still somewhere in my files. She wrote that acrodynia and pink disease were puzzling ailments which caused numerous symptoms, including those of autism, that had baffled medical investigators for many decades, until the cause, mercury in teething lotions and diaper powders, was discovered. "Interesting," I remember thinking. "Another mystery solved. But only of historical interest." How wrong I was!
I had assumed, very naively as it turned out, that the FDA and the drug manufacturers would thenceforth scrupulously avoid using mercury. I was aware that minute amounts of mercury, along with other toxins, such as aluminum and formaldehyde, were used as preservatives in vaccines, but, after all, I assumed, since everyone now knew that these substances are extremely toxic, those highly sophisticated vaccine-makers would not possibly use amounts which even approach dangerous levels. Bad guess!
In early 2000, parent Sallie Bernard and several other concerned and inquisitive parents began looking into the mercury issue. They learned that thimerosal was used in most vaccines at levels that greatly exceeded the upper limits decreed safe by the US Environmental Protection Agency
In her testimony before the US House of Representatives in July, 2000, Sallie, the primary author of the report, testified: "The symptoms which are diagnostic of or strongly associated with autism itself are found to arise from mercury exposure, as described in available literature on past cases of mercury poisoning."
"These similarities," she testified, "include the defining characteristics of autism - and they include traits strongly associated with autism and found in nearly all cases of the disorder - sensory disturbances such as numbness in the extremities and mouth, aversion to touch, and unusual response to noise; movement disorders like toe-walking, hand flapping, clumsiness, and choreiform movements; and cognitive impairments in specific domains like short-term, verbal and auditory memory and in understanding abstract ideas." In addition, she noted, mercury poisoning can cause many of the same biological abnormalities as are seen in autism, including immune system dysfunction and anomalies in the cerebellum, amygdala, and hippocampus.
Bernard noted that the growing prevalence rate of autism closely matches the introduction and spread of thimerosal-containing vaccines and that autistic symptoms generally emerge at the time the child is given these vaccines. She added "Our group has also documented a number of cases of autistic children with toxic levels of mercury in hair, urine and blood." In addition, she noted, mercury is more toxic to males than to females, and the male-to-female ratio in autism is 4 to 1.
Noting that low doses of mercury tend to harm genetically susceptible individuals, Bernard pointed out that "autism has been recognized as one of the most heritable of all neurological disorders and is strongly associated with familial autoimmune disorders."
Bernard and her colleagues called for an immediate ban on thimerosal-containing childhood vaccines.
In October 2000 1 attended a meeting called by the National Institute of Environmental Health Sciences, on the possible role of mercury in the causation of autism. The meeting was attended by a number of physicians and scientists. One of the physicians, Dr. Stephanie Cave of Baton Rouge, Louisiana, told the group that in her experience over a number of years in treating over 400 autistic children with various modalities, she had found no modality which was more effective in a great many autistic children than mercury detoxification. Other physicians who also had experience with mercury detoxification in autistic children, including several who were themselves parents of autistic children, strongly supported Dr. Cave's remarks.
I was very much aware that there was a great deal of disagreement among physicians as to the most appropriate procedures for mercury detoxification and decided that it would be highly desirable to call a consensus conference - a think tank - of experienced physicians and scientists to review the available evidence and come up with a position paper presenting the safest and most effective methods of treating autistic children for mercury intoxication.
A few weeks later, while attending an autism conference in Portland, Oregon, I had the pleasure of meeting Dr. Jim Laidler, the father of two autistic boys, both of whom he had treated for mercury toxicity, with excellent results. I learned that Jim had maintained a strong interest in metal toxicity ever since his college-student days, and had continued to study the subject during his medical training. I also learned that he was writing a paper on mercury detoxification, and already had read over 700 articles!
I asked if he would be willing to help coordinate the writing of our position paper for the Consensus Conference on the Detoxification of Autistic Children, and he agreed. In the following pages you will see the fruits of his highly competent and diligent efforts.
The Autism Research Institute convened a weekend Consensus Conference on the Detoxification of Autistic Children in Dallas, Texas in February, 2001. The attendees were 25 carefully selected physicians and scientists knowledgeable about mercury and mercury detoxification. The 15 physicians present included 7 who were parents of autistic children and who had detoxified their own children with good results. The physician attendees present had treated well over 3,000 patients for heavy metal poisoning, about 1,500 of them being autistic children. The chemists, toxicologists and other scientists present had a combined total of almost 90 years of experience in research on the toxicology of mercury.
The purpose of the meeting was to arrive at a consensus document that would delineate the safest and most effective methods of detoxifying autistic children. Nine candidate detoxification protocols, including five submitted by non-attendees, were considered in detail by the conferees.
The meeting was an outstanding success. Despite my initial concern that the various areas of disagreement would prove divisive, the participants discussed the controversial issues harmoniously and agreed that it would be feasible to arrive at the consensus position that was hoped for.
During the next six weeks Jim Laidler and the other participants were deluged with e-mails, faxes and phone calls as the conferees discussed, rediscussed, thrashed out, modified, reviewed and revised each and every aspect of the proposed position paper. Finally, the last details were agreed upon - with the clear understanding on everyone's part that there is much more to be learned.
Jim Laidler has done a marvelous job of coordinating and organizing the disparate ideas and points of information provided by the various contributors.
It is a tribute to Jim Laidler's skill, as well as to the reasonable open-mindedness of the other conferees, that only two of the attendees demurred from signing the report. One of those who demurred was a chemist, a world-authority on mercury poisoning, who did not sign the Consensus Report because he felt that as a chemist he should not be commenting on the most appropriate ways of dealing with patients. However, he wrote, "I was very impressed with the people I met at the Dallas meeting. I learned a great deal. If I had an autistic child, I would rush him or her to the physicians I met in Dallas."
The other attendee who demurred was also a chemist, but his reason was quite different. He sees the problem in a different light than everyone else, and is working on a new and innovative approach toward solving it. I have a great deal of respect for this scientist, and am looking forward, with great anticipation, to learning more about his new ideas and procedures, when he is ready to share them with us. Albert Szent-Gyorgy once said, "Genius is the ability to look at what others have looked at, and see what they have not seen." When our chemist friend is ready to make his ideas public, we will present them in the Autism Research Review International. He just may be right. I hope so!
I should mention several topics, discussed at the Dallas conference and in subsequent communications, that did not reach consensus status but nevertheless commanded a significant
degree of attention and support. These topics, which will be raised again at future consensus meetings, include:
the use of intravenous vitamin C as a detoxicant
improving pancreatic function through the use of secretin and by normalizing body acidity with weak acids such as lemon juice or vinegar finding ways of using DMPS more safely
causing transdermat excretion of toxins by saunas or epson salt baths
Any clinician with data or experience to share on these or related topics is encouraged to communicate with us.
In the meantime, however, I am confident that the document on the following pages, even though it is best described as still a "working paper," provides the best information available at the present time.
As the parent of an autistic adult son, and as a worker in the field of autism research for over 40 years, I feel privileged to have been a part of the Consensus Committee that produced the following "Position Paper on the Detoxification of Autistic Children."
MERCURY DETOXIFICATION OF AUTISTIC CHILDREN: CONSENSUS POSITION PAPER
James R. Laidler, M.D.
Purpose
A few years ago, several people began to explore the possibility that at least some of the children with autism are manifesting a type of mercury poisoning. A landmark monograph written by Sallie Bernard, Albert Enayati, B.S, Ch.E, M.S.M.E., Heidi Roger, Theresa Binstock, Lyn Redwood, R.N, M.S.N, C.R.N.P., and Woody McGinnis, M.D. served as a call to action. Acting on this theory, several practitioners began treating autistic patients with'a variety of detoxifying regimens to remove the mercury and try to reverse the damage. Although no outcome studies have yet been published, the clinical experience of a number of practitioners has been extremely encouraging.
Unfortunately, there are more autistic children who might benefit from this therapy than any of the practitioners currently engaged in mercury detoxification therapy could treat in their lifetimes. In addition, there is such divergence in the details of therapy among practitioners that comparison of their outcomes is impractical. Finally, a number of practitioners have expressed an interest in initiating detoxification therapy but need guidance in how best to begin. For all of these reasons, the DAN! mercury detoxification consensus group met in Dallas, Texas on February 9 - 11, 2001 to gather some of the top scientists and practitioners in the field to develop a protocol for mercury detoxification in the autistic child.
Rationale
Many of the features of autism bear striking similarity to certain features of mercury poisoning, especially the immune dysfunctions', 2, visual disturbanCeS3,4 , and motor/coordination defeCtS5 seen in a growing number of autistic children. Treating autistic children with agents to remove mercury and/or other heavy metals has brought about significant improvement in many of them, sometimes dramatic improvement. This improvement is coincident with increased excretion of mercury and/or other metals in most but not all patients. Some have theorized that those who im- prove without increased mercury excretion are suffering from some other metal toxicity.
Another possibility, which also explains those patients who improve without significant heavy metal excretion, is that the chelating agents are working in some other fashion and that the heavy metal excretion is coincidental to this other effect. For example, there are clinical studies showing that autistic children with significant allergy problems have elevated eysteine/sulfate ratios in their blood, and there are other indications of disordered sulfur amino-acid chemistry. Sulfhydryl- bearing agents, such as DMSA and others, remove cysteine6 and thereby improve some sulfur amino acid imbalances.
Yet another possibility under investigation is the anti-oxidant effect of the drugs and supplements used and their ability to compensate for deficiencies in the native anti-oxidant systems. Quite a few autistic children have laboratory evidence of anti-oxidant deficiency; low intracellular glutathione7is commonly found in these children. What may be happening in these children is that the DMSA and other agents "put out the fire" of intracellular oxidation and help restore the
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normal anti-oxidant functions. Whatever the action may be, DMSA therapy has been shown to help a large number of autistic children.
It is important to remember that autism is a syndrome, not a disease. The "diagnosis" of autism covers a wide spectrum of children, many as different from each other as they are different from "typical" children. No one causative factor has been identified for autism and the possibility exists that autism is not a single disease but several individual diseases that share a similar presentation. With that in mind, it is not surprising that no single treatment has been found that works for all children with autism.
Preparatory treatment
Many, if not most, autistic children suffer from some degree of intestinal dysbiosis, abnormal intestinal permeability and nutritional derangements which must all be corrected as much as pos- sible prior to any attempt at detoxification. Without this preparatory treatment, the adverse side effects of therapy may be magnified. Without the correction of their intestinal dysfunctions, any improvement from the treatment may be hard to detect.
Many of the drugs and supplements used for mercury detoxification are rich sources of nutrition for bacteria and fungi. If treatment is started while the child is suffering from overgrowth of abnormal or pathogenic organisms, they will experience explosive growth of these organisms with subsequent worsening of their symptoms.
This monograph is but a part of the DAN! treatment protocol for autistic children, so this is not the place for a detailed discussion of how to correct their intestinal problems. However, a brief outline of the process is included (Appendix B) to help practitioners who are not familiar with the process.
Inclusion testing
Urine, blood and hair mercury are typically normal or negative unless the mercury exposure has been fairly recent. On occasion, urinary mercury will be elevated if the child is in a catabolic state due to growth or malnutrition. In these situations, the mercury stored in tissues may be released as those cells are broken down.
Provoked excretion of mercury and heavy metals is the only accurate way to estimate the total body burden of heavy metals. This is performed by administering a chelating agent prior to collection of urine for heavy metal analysis. The usual provoking agents are 2,3-dimercapto- succinic acid (DMSA) and 2,3-dimercapto-propane-sulfonate (DMPS). Of these two, DMSA is safer, but DMPS is somewhat more effectives,9. The usual way to gather a provoked urine specimen is to administer the chelating agent and then to collect the next six to twelve hours of urine produced. The usual DMSA dose for a single-dose provocation is 10 mg/kg.
No reference ranges exist for provoked urinary heavy metal excretion, so the interpretation of the results is problematic. Given that the problem in autistic children may be excessive sensitivity to mercury or other heavy metals, any level over the reference range for unprovoked urine heavy metals may be sufficient indication for a trial of therapy. In addition to mercury, lead, cadmium, arsenic, antimony and many other metals are extracted by DMSA'O, so the urine metal analysis may show a number of toxic metals.
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Other than looking for the heavy metals directly, one can look for evidence of their effects. Mercury and other heavy metals suppress the effect of a number of enzymes, some of which can be easily tested. The most commonly available of these is glucose-6 phosphodiesterase (G-6PD); a quantitative G-6PD activity may reveal levels intermediate between normal and deficient in heavy metal poisoning". Of note, there has been one report of hemolysis in a patient with abso- lute G-6PD-deficiency'2, but DMSA has been used extensively in populations with a high incidence of G-6PD deficiency and sickle cell disease without problems. Less commonly available is glutathione reductase, which is also reduced in heavy metal poisoning 13. Low glutathione levels in the red cells are not specific for heavy metal toxicity, but may be supporting evidence.
Another commonly available test is blood or urine pyruvic acid. Pyruvic acid can be elevated for a number of reasons, but mercury is notorious for interfering with the mitochondrial pyruvate dehydrogenase complex, where it binds to and deactivates the lipoic acid coenzyme, resulting in elevated pyruvic acid.
Mercury and other heavy metals interfere with heme synthesis, leading to urinary excretion of uroporphyrin and coproporphyrin. Mercury also causes production of pre-coproporphyrin, which may be considered a specific marker for mercury poisoning 14,15. Analysis of uroporphyrin and coproporphyrin can be done at most clinical laboratories; pre-coproporphyrin analysis can also be done, but most laboratories do not routinely have that test available.
Mercury and other heavy metals (such as lead) can cause progressive myelin degeneration with the development of antibodies to myelin basic protein (MBP) and glial fibrillary acidic protein
16,11
(GFAP) . While these changes are not diagnostic of mercury intoxication, they point to ongoing degeneration in the central nervous system.
Depletion or deficiency of the cellular antioxidant systems is seen in a number of autistic children. A common finding in autistic children is an abnormally low erythrocyte glutathione level. The potential causes for this deficiency in cellular antioxidant substances are myriad, ranging from congenital deficiency to toxins; heavy metals are well-documented causes of intracellular antioxidant depletion. Whether the cause is too little production, rapid consumption or a combination of the two, many of these children can benefit from exogenous antioxidant support. Since DMSA and many of the other supplements used to treat mercury and heavy metal intoxication are powerful antioxidants, this may be mechanism of action in some children who improve, especially those who show little excretion of toxic metals.
Since it is possible that neither removal of metals nor supplementing cellular antioxidants are the mechanism of action, an empiric trial of DMSA therapy may be warranted. This trial should be done for a limited time and without changing any other therapy, including physical therapy, occupational therapy, speech therapy, etc. If no definitive results are seen in four to six weeks, discontinue therapy and look again for any changes.
Pre-treatment testing
DMSA can cause bone marrow suppression and is potentially hepatotoxic's. There have been no reports yet of permanent bone marrow suppression or liver damage, but the literature has many case reports of significant neutropenia and thrombocytopenia during therapy with DMSA. Prior to starting therapy, it is important that a complete blood count (CBC) with platelet count be
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checked, both to provide a baseline as well as to detect any pre-existing abnormalities. Blood levels of liver transaminases (ALT and AST) are also important for the same reasons.
DMSA is primarily excreted in the urine'9, so kidney dysfunction will cause it to accumulate in the blood. To prevent serious toxicity, it is important to detect any decreased renal function prior to starting therapy. In the absence of any signs or symptoms of renal insufficiency, blood urea nitrogen (BUN) and creatinine levels should be adequate to document normal renal function. If there are any reasons to suspect renal insufficiency, creatinine clearance should be measured. Periodic checks of blood urea nitrogen and creatinine should also be performed when other blood studies are done.
Several investigators have found that autistic children are typically low in blood zinc and high in blood copper. Many other minerals, such as selenium and magnesium, are often low as well. The body stores of these minerals can be estimated by measuring the red blood cell mineral content. Serum copper and plasma zinc levels are considered to be the most accurate reflections of total body content of these two minerals, but not many laboratories can perform this assay consistently. Other options are platelet and erythrocyte copper and zinc levels. Practitioners who decide to use copper and zinc levels routinely are advised to closely monitor their analytical laboratory and to perform periodic quality-control checks with known samples.
Detoxification
Of the chelating agents available at present, DMSA (succimer, Chemet@) provides the optimal combination of safety and efficacy. DMSA has been used extensively for nearly fifty years and is
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approved by the USFDA to treat lead poisoning in children; its safety record is exemplary . There is far less experience using DMPS, especially in children, and the adult experience with it has shown that it is significantly more toxic than DMSA. DMPS is currently not approved for any use by the USFDA.
Several animal studies have shown that DMSA is capable of removing a portion of the mercury bound in the brain2l'22. Some of these studies have also shown that, months after exposure, mercury still moves between the blood and brain in both directionS23 . It should be noted that, to date, no studies have definitively shown any chelating agent capable of removing mercury from the human brain, no doubt due to the reluctance of human subjects to have their brains removed for analysis. One autopsy study has demonstrated that, despite urine and blood mercury levels in the normal range, mercury will persist in the brain and other organs for many years without adequate chelation therapy24.
DMSA should be given in doses of no more than 10 mg/kg/dose and no more than 30 mg/kg/day with a maximum dose of 500 mg (1500 mg/day maximum). Exceeding these limits has been associated with a significantly higher incidence of side effects and toxicity. The dosing interval can be any convenient period, as long as the dose limits are not exceeded. There is no convincing evidence to suggest that dosing intervals shorter than eight hours provide any inherent benefit, although a lower dose given more frequently may help to reduce troublesome side effects. In addition, the subset of children who experience improvement only while receiving DMSA may benefit from more frequent dosing. Clinical experience supporting 3- or 4-hour dosing intervals is matched by equally good results with 8-hour dosing. As always, the dosing interval should be based on the clinical response of the individual patient.
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DMSA is usually given orally but it can, if necessary, be given intravenously. There is also some experience with rectal administration via suppository. Despite the sulfurous smell, most children will take it if it is mixed with a suitable masking liquid, such as orange juice or other sweet beverage. One study has shown that mercury-intoxicated rats prefer water containing DMSA to pure water, while the control animals would shun the water with DMSA 25; this phenomenon has been seen in some children as well. Acidic or neutral liquids are best to maintain the activity of the DMSA while in solution. DMSA will retain approximately 80% of its activity after 24 hours in solution, but prolonged storage in solution may result in significant degradation and loss of effectiveneSS26. If the child will swallow capsules, the whole issue of taste and smell can be neatly bypassed.
The treatment period can last from three to five days with a "rest period" of at least as long as the treatment period. A treatment of three days followed by a rest period of eleven days provides adequate time for bone marrow suppression to resolve and yet is short enough for rapid removal of tissue mercury. A three-day treatment period allows the drug to be administered over the weekend (Friday evening through Monday morning), which can be a tremendous convenience.