Question and Answer with a Practitioner
Questions and answers are often time helpful for the broader community as generally a number of people have the same questions.
Here I think is an informative recent exchange:
It seems she had just an MR arthrogram with little GBCA given. So will be critical to control Flare, but oral steroids may be sufficient, because there will be not much Gd to remobilize.
1. Is IV steroids a must during the procedure (I gather from your email it is) or have you been able to control the flare response with oral methylprednisone alone? If so then I think it would be best for my patient to see you in person since I am unable to prescribe IV steroids. If people seem to have very severe symptoms
it is largely a must. She only had little GBCA. You could try the first chelation to do 4 doses Methylp oral where I have written 3.. see how she does with Flare then. 2. How many cycles of treatment do you typically perform on a patient?
If she had just the one small dose - then as few as 3 may be sufficient. Generally with 1 dose they need 5 sessions. Sometimes up to 10.
3. What is the rationale behind using CA and then ZN DTPA? The reason I ask is that my pharmacist may only be able to obtain Ca-DTPA. Therefore would it be sufficient to do two days of Ca-DTPA in a row?
Zn replaces Zn removed with Ca-DTPA.. You could give her mineral replacement (Mg especially important) 3 days after chelation including Zn (if you only have Ca-DTPA- as it will remove Zn). First chelation you probably anyways should only do 1/2 dose Ca-DTPA (also split in 2). I would only do 1 day chelation with Ca-DTPA.. Doing just 1 day you could increase the frequency, rather than every 3 weeks, you could try 2, and if she tolerates that then go to weekly.
4. What methodology are you using to test Gadolinium levels? This might be related to question #2 as you may tailor the number of treatments towards the levels of Gadolinium on testing.
24 hr urine with DOCTORS Data (doctors.data.com) they can send Fedex boxes. Can miss the first urine if that is not set up yet.
5. If a patient is unable to undergo treatment with DTPA have you found any efficacy using EDTA?
There is no reason that they can't do DTPA- I would not use EDTA- I have written numerous blogs on it. Stability 300,000 times less Gd-EDTA compared to Gd-DTPA.
6. Is the flare response an allergy to the DTPA or is it inflammation due to mobilization of the DTPA?
It is primarily a T-cell reaction to the remobilization of Gd. The more Gd mobilized the more Flare - hence the greater the importance of steroids. She may not have that much Gd in her, so Flares may be mild - but steroids still important to train the immune system to ignore Gd