Re-Equilibration Flare. The most important assessment for when enough is enough with chelation.

Re-equilibration Flare is a topic I have most often addressed in passing when describing Flare phenomena with chelation with an effective chelator. However its critical importance may be easy to overlook without specifically talking about this subject.

Re-equilibration Flare occurs as a result of the chemical principle that all substances strive to be in equilibrium: le Chatelier's principle. Re-equilibration is perhaps the most effective method to reduce the body's largest reservoir of Gd, which is in the bones. So even though DTPA can remove Gd directly from bone (which other weaker chelators cannot), the most effective way to remove Gd is by relying on le Chatelier's principle (re-equilibration), which involves waiting 1-4 weeks between chelation sessions.

From listening now to a number of patients who describe 'failure' of DTPA chelation, many describe that removal Flare was too strong; many others reflect that either re-equilibration Flare was too strong, and they therefore stopped chelation, thinking something was going wrong, or have found re-equilibration Flare is consistently strong, and therefore chelation is not working.To quickly dismiss removal Flare: if urine Gd is 40 or more times greater post Ca-DTPA chelation than pre-, this largely is a very good thing because it means chelation is removing a lot of Gd. This can then be controlled by giving less chelator or more iv steroids or a combination of both - this is easy to manage. Re-equilibration Flare is a different fish.

Re-equilibration probably starts within 1 day, but becomes somewhat prominent by 1 week, and generally is noticeable in everyone by 3 weeks. This reflects that Gd is leaving bone, some back out through kidneys, but much re-equilibrating to tissues where Gd has been removed from (skin is the largest of these reservoirs). Waiting longer than 4 weeks between chelations, re-equilibration Flare continues to increase and usually peaks in everyone at 3 months, in about 1/3 of each, this re-equilibration Flare may start to decrease, stays stable, or increases. If you are in the category that it starts to decrease, and you have had a number of chelation, > 5, you may continue to not undergo more chelation, because you may have had enough Gd removed that your native immune and other defences are keeping the Gd that is left under control - essentially ignoring it. The other two categories should return to chelation, especially if symptoms are returning. Your native defence mechanisms are telling you that they cannot manage the amount of Gd that is left.

In individuals who received just 1 GBCA injection I now prefer that chelation be repeated every 4 weeks, because I want to get adequate (but not too much) re-equilibration to hasten Gd removal from bone, and hence deplete the total body store of Gd. In individuals who have received multiple GBCA injections however, the amount of Gd removed, and hence the amount of Gd that re-equilibrates can be so substantial that the re-equilibration Flare may be intolerable by 4 weeks. The combination of lesser amount of chelator and shorter intervals between chelation (1 week) may be crucial in this group.

Another important aspect of re-equilibration beyond the critically important role in removal of Gd from bone, is that re-equilibration Flare tells you if you are ready to stop or atleast pause from chelation. If re-equilibration Flare at 4 weeks to 3 months is tolerable and especially if it begins to lessen by 3 months, this may be the most important indicator that pausing/ stopping chelation should be done. Note I also use seeing Gd in the mid yellow range (3-5 mcg/ 24 hr) in 24 hr urine samples. But the perception of manageable re-equilibration is by far the most important. You can always return to chelation, if at a later date, such as 1 year, symptoms begin to worsen again... In my opinion no harm done.

Lastly, re-equilibration Flare may be even more important than removal Flare in confirming that a person has GDD. Even putting in an iv and injection normal saline can result in symptoms, that could be confused with removal Flare in individuals with simple Gadolinium Storage Condition. But symptoms that increase or worsen at 3 months that have the symptom complex of GDD, really can only be seen if you have GDD or another metal deposition disease such as Lead Deposition Disease.

It is crucial to emphasize this point. It is useful to undergo testing periods to see if you have had enough chelation, this involves stopping chelation periods (5 weeks if just 1 GBCA injection, 15 chelation if there has been multiple... and in-between points). If stopping chelation and re-equilibration Flare progressively gets worse (in many) but if at 3 months it seems you are back to where you were at the start of chelation, it is not that chelation has failed you (if chelation done as I write about) it is that the re-equilibration of Gd from bone back to soft tissues still results in too much T cell reaction, and it is crucial not to stop but to get back to chelation. The silver linings: you have less Gd than you started with and now more of the Gd is located in tissues where it is easier to get it out from. One of the many sad truths of GDD is that a number of people who get to that point and the re-equilibration Flare has continued to increase at 3 months, may not have enough money to continue chelation., This is one (of many) shames in our health care system.

Strong early (Removal) Flare and strong Re-equilibration Flare, when chelation is done properly with the correct chelator generally are actually good things, because it means a lot of Gd is being removed, and a lot of Gd is subsequently moving out from bones, respectively. But these Flares should not be intolerable. That is why nuanced chelation with the right amount of chelator, the use of enough immune dampening (right now best done with steroids), and the timing intervals between chelation) are essential.

The sweet spot of chelation.... What I have also called the Goldilocks principle: not too little, not too much, just the right amount.

Richard Semelka, MD