GDD after Multiple GBCA Injections: What to do, Nuances of Treatment
What about the person who has had > 10 GBCA injections and now suddenly has GDD?
The first thing I have to question, did the symptoms develop after the 10th or 20th or 30th GBCA injection, or were subtle symptoms present with much earlier GBCA injections and just then became intolerable after the 10th, 20th, 30th chelation. I think though that it can suddenly develop after multiple GBCA injections, and some serious perturbation of the immune system happened just before the current GBCA injection, that knocked the immune system down, that set in motion the wheels for a serious reaction. Excess exercise, serious illness, serious infection, serious reaction to another drug or vaccine, high potency iv antibiotics.
The problem is, now you have developed the sensitivity to react to Gd, but superimposed on a large body store of Gd. The best analogy I can think of: the body has carefully stored the Gadolinium in various tissues, all tissues, but especially bone and skin, like an explosives expert carefully storing test tubes of nitroglycerine in a van, so there is no movement that can set off an explosion. So there are a number of unexploded vials of nitroglycerine sitting there, lined up in the van. Then the 30th vials is brought in... and it explodes... Now all the vials are in play. Or like the final scene in the blockbuster Godzilla movie maybe 25 years ago, where the final scene is of the basement in some huge building in New York, maybe it is Madison Square Gardens, thousands of Godzilla eggs, and now they start hatching.
The tendency is to think, I have so much Gd in me, that why bother trying to get it out. I never have a pessimistic outlook to start with. But treatment is much more careful, much longer, and much more nuanced than with disease following 1 or few GBCA injections. Unlike 1 GBCA- GDD, where the amount of Gd in the body in play is quite small, so removal-related Flare and Re-equilibration Flare result in relatively little bulk Gd movement, so the impetus for severe Flare is relatively speaking, much less; multiGBCA has much greater impetus because much more Gd is moving.
It seems that the initial removal-related Flare (0-2 days post chelation) may be manageable with iv and oral steroids, the re-equilibration Flare (10 days +) can be massive. That is because the amount of Gd that re-equilibrates (moves from bone back to soft tissues) can be enormous: in the order of a full GBCA injection or more.
So it becomes absolutely crucial to adhere to when the individual experiences re-equilibration Flare to try to repeat chelation in a time frame not to exceed when the Flare becomes intolerable, which if Flare is intense already at day 10, then chelation may need to be repeated with weekly chelations.
Gd removal Flare should be offset by starting with lower dose chelation, such as 1/2 dose Zn-DTPA and more intense steroid coverage. oral and iv steroids. Then escalate amount of chelation and decrease the amount of steroid.
Particular attention needs to be paid to re-equilibration Flare, that it does not become intolerable.
But, some re-equilibration is always important though, because this is an important method to deplete bone reservoir of Gd, so I do not endorse shorter than weekly chelations.
The other major issue, my standard recommendation is that for all comers they need to understand that 5 chelations are generally the minimal recommended, to allow for several cycles of re-equilibration to remove Gd from bone. Some individuals with 1 GBCA who experience severe Flare after 1-2 chelations and decide the sky is falling and terminate (against my advice) chelation, many of them the Flare generally diminishes, because the 1 chelation has removed a fair amount of the body store of Gd, so there simply is very little left to react to. Individuals with 10+ GBCA injections do not have the luxury to stop chelation early because they have a large body store of Gd, that is now all in play. Multi-dose GBCA sufferers do not have the luxury of wiggle room.
In my experience, tragically for multiGBCA sufferers, failure of therapy generally is due to the fact they cannot afford to pay for a sufficient number of chelations, that when they stop they have not removed sufficient Gd such that the eventual re-equilibration remains intolerable.
So for multi-GBCA injection GDD sufferers, the optimistic bare minimum will be 15 chelations, and with almost no wiggle room in the time intervals between chelations. iv steroids will be nearly essential for atleast the first 5, and probably 10 chelations. They will likely also need to take for a prolonged period afterwards effective oral chelation: oral HOPO or oral DTPA.
Richard Semelka, MD