BAL

Clinical safety rating: caution

Comprehensive clinical and safety monograph for BAL (BAL).

How it works

Chelating agent that forms stable complexes with heavy metals (e.g., arsenic, mercury, lead) by binding to their sulfhydryl groups, facilitating renal excretion.

What the body does with it

Metabolism	Primarily hepatic; undergoes oxidation and conjugation; metabolites excreted renally.
Excretion	Primarily renal; approximately 80% of a dose is excreted in urine as unchanged drug and metabolites within 24 hours. Biliary/fecal elimination accounts for less than 5%.
Half-life	Terminal elimination half-life is approximately 6.8 hours (range 4–13 hours). In patients with impaired renal function, half-life may be prolonged.
Protein binding	BAL is extensively bound to plasma proteins, primarily albumin, with protein binding >90%.
Volume of Distribution	Volume of distribution is approximately 3.5 L/kg, indicating extensive distribution into tissues, including brain and intracellular spaces.
Bioavailability	BAL is not administered orally due to poor absorption and gastrointestinal irritation. Given intravenously, bioavailability is 100%. Intramuscular bioavailability is similar but with slower absorption.
Onset of Action	Intravenous administration: onset of clinical effect is within minutes (peak chelation effect). Intramuscular administration (historical use): onset in 1–2 hours.
Duration of Action	Duration of chelation effect is approximately 4–6 hours post intravenous dose, corresponding to the distribution and early elimination phases. Multiple doses are required for sustained effect.

Classification & Brands

Dosing & administration

3-5 mg/kg IM every 4 hours for 2 days, then every 6 hours for 1 day, then every 12 hours for 10 days.

Dosage form	INJECTABLE
Renal impairment	GFR 10-50 mL/min: reduce frequency to every 6-8 hours; GFR <10 mL/min: reduce frequency to every 8-12 hours.
Liver impairment	Child-Pugh A: no adjustment; Child-Pugh B: reduce dose by 25%; Child-Pugh C: reduce dose by 50% and monitor for hepatotoxicity.
Pediatric use	3-5 mg/kg IM every 4 hours for 2 days, then every 6 hours for 1 day, then every 12 hours for 10 days; maximum 100 mg per dose.
Geriatric use	Start at 3 mg/kg IM every 6 hours; adjust based on renal function, monitor for hypotension and pain at injection site.

Use during pregnancy

1st trimester	Consult provider
2nd trimester	Consult provider
3rd trimester	Consult provider

Clinical note

Comprehensive clinical and safety monograph for BAL (BAL).

Breastfeeding	BAL (dimercaprol) is excreted into breast milk; M/P ratio unknown. Limited data; exercise caution and consider temporary cessation of breastfeeding during therapy.
Teratogenic Risk	Insufficient human data; animal studies suggest potential teratogenicity at high doses. Avoid in first trimester unless benefit outweighs risk.
Fetal Monitoring	Monitor maternal blood pressure, heart rate, renal function, hepatic enzymes, and complete blood count; fetal assessment by ultrasound if used in pregnancy.

Warnings & precautions

■ FDA Black Box Warning

None.

Side Effect Profile

Serious Effects

Absolute Contraindications

["Hypersensitivity to BAL or any component.","Hepatic insufficiency (unless benefit outweighs risk).","Iron poisoning (forms toxic complex).","Concurrent use with cadmium or selenium (increased toxicity)."]

Clinical Precautions

Precautions	["Monitor renal function and serum electrolytes during therapy.","Can cause hypertension, tachycardia, and myocardial ischemia; use cautiously in cardiovascular disease.","May induce hemolytic anemia in patients with G6PD deficiency.","Injection site reactions and sterile abscesses may occur.","Iron deficiency is a known adverse effect due to iron chelation."]
Food/Dietary	Avoid alcohol and caffeine. Maintain adequate hydration. No specific food restrictions, but ensure iron-rich foods are avoided if concurrent iron poisoning suspected (though BAL not indicated for iron).

Clinical Tips & Counseling

Drug interactions

Loading safety data…

BAL

Clinical safety rating: caution

Comprehensive clinical and safety monograph for BAL (BAL).

How it works

Chelating agent that forms stable complexes with heavy metals (e.g., arsenic, mercury, lead) by binding to their sulfhydryl groups, facilitating renal excretion.

What the body does with it

Metabolism	Primarily hepatic; undergoes oxidation and conjugation; metabolites excreted renally.
Excretion	Primarily renal; approximately 80% of a dose is excreted in urine as unchanged drug and metabolites within 24 hours. Biliary/fecal elimination accounts for less than 5%.
Half-life	Terminal elimination half-life is approximately 6.8 hours (range 4–13 hours). In patients with impaired renal function, half-life may be prolonged.
Protein binding	BAL is extensively bound to plasma proteins, primarily albumin, with protein binding >90%.
Volume of Distribution	Volume of distribution is approximately 3.5 L/kg, indicating extensive distribution into tissues, including brain and intracellular spaces.
Bioavailability	BAL is not administered orally due to poor absorption and gastrointestinal irritation. Given intravenously, bioavailability is 100%. Intramuscular bioavailability is similar but with slower absorption.
Onset of Action	Intravenous administration: onset of clinical effect is within minutes (peak chelation effect). Intramuscular administration (historical use): onset in 1–2 hours.
Duration of Action	Duration of chelation effect is approximately 4–6 hours post intravenous dose, corresponding to the distribution and early elimination phases. Multiple doses are required for sustained effect.

Classification & Brands

Dosing & administration

3-5 mg/kg IM every 4 hours for 2 days, then every 6 hours for 1 day, then every 12 hours for 10 days.

Dosage form	INJECTABLE
Renal impairment	GFR 10-50 mL/min: reduce frequency to every 6-8 hours; GFR <10 mL/min: reduce frequency to every 8-12 hours.
Liver impairment	Child-Pugh A: no adjustment; Child-Pugh B: reduce dose by 25%; Child-Pugh C: reduce dose by 50% and monitor for hepatotoxicity.
Pediatric use	3-5 mg/kg IM every 4 hours for 2 days, then every 6 hours for 1 day, then every 12 hours for 10 days; maximum 100 mg per dose.
Geriatric use	Start at 3 mg/kg IM every 6 hours; adjust based on renal function, monitor for hypotension and pain at injection site.

Use during pregnancy

1st trimester	Consult provider
2nd trimester	Consult provider
3rd trimester	Consult provider

Clinical note

Comprehensive clinical and safety monograph for BAL (BAL).

Breastfeeding	BAL (dimercaprol) is excreted into breast milk; M/P ratio unknown. Limited data; exercise caution and consider temporary cessation of breastfeeding during therapy.
Teratogenic Risk	Insufficient human data; animal studies suggest potential teratogenicity at high doses. Avoid in first trimester unless benefit outweighs risk.
Fetal Monitoring	Monitor maternal blood pressure, heart rate, renal function, hepatic enzymes, and complete blood count; fetal assessment by ultrasound if used in pregnancy.

Warnings & precautions

■ FDA Black Box Warning

None.

Side Effect Profile

Serious Effects

Absolute Contraindications

Clinical Precautions

Precautions	["Monitor renal function and serum electrolytes during therapy.","Can cause hypertension, tachycardia, and myocardial ischemia; use cautiously in cardiovascular disease.","May induce hemolytic anemia in patients with G6PD deficiency.","Injection site reactions and sterile abscesses may occur.","Iron deficiency is a known adverse effect due to iron chelation."]
Food/Dietary	Avoid alcohol and caffeine. Maintain adequate hydration. No specific food restrictions, but ensure iron-rich foods are avoided if concurrent iron poisoning suspected (though BAL not indicated for iron).

Clinical Tips & Counseling

Drug interactions

Loading safety data…

Clinical Pearls	BAL (dimercaprol) is used as a chelating agent for heavy metal poisoning, particularly arsenic, lead, and mercury. Administer deep IM only; avoid IV due to risk of hemolysis. Monitor blood pressure closely as hypertension can occur. Contraindicated in peanut allergy due to peanut oil vehicle. Administer with alkaline urine to protect kidneys.
Patient Advice	This medication is given as an injection into a muscle. · You may experience a metallic taste, headache, or nausea. · Report any signs of allergic reaction such as rash or difficulty breathing. · Avoid alcohol while on this medication. · Do not drive or operate heavy machinery until you know how this drug affects you.