What is the treatment for boric acid poisoning?

Treatment of Boric Acid Poisoning

Immediately initiate aggressive fluid resuscitation with forced diuresis using intravenous fluids and furosemide, and strongly consider early hemodialysis for any patient with significant boric acid ingestion, particularly if serum boric acid levels exceed 70 μg/mL or if signs of systemic toxicity are present.

Initial Management and Decontamination

• Perform gastric lavage if the patient presents within 1-2 hours of ingestion 1
• Administer activated charcoal followed by a laxative (magnesium sulfate) to limit further absorption 1
• Begin aggressive intravenous fluid resuscitation immediately, even before laboratory confirmation of serum boric acid levels 2, 3

Forced Diuresis Protocol

Forced diuresis is the cornerstone of treatment and should be initiated early to prevent severe renal damage and its complications. 2, 3

• Administer 3-4 liters of intravenous fluid over 4 hours combined with furosemide 100 mg to maintain high urine output 3
• This approach achieves elimination rates comparable to hemodialysis when started early 3
• Continue forced diuresis until serum boric acid levels fall below 30 μg/mL and clinical symptoms resolve 2

Hemodialysis Indications

Hemodialysis is highly effective and should be performed early in severe poisoning, even before renal dysfunction becomes apparent. 2, 1

• Initiate hemodialysis for serum boric acid levels ≥70 μg/mL, regardless of symptoms 4
• Consider hemodialysis for any symptomatic patient with confirmed elevated levels 1, 5
• Hemodialysis achieves boric acid clearance of approximately 235 mL/min with a 70% extraction ratio 2
• The half-life of boric acid decreases from 13.5 hours with conventional treatment to 3.8 hours during hemodialysis 1
• Multiple hemodialysis sessions may be required; perform twice within the first 39 hours for severe poisoning 1

Monitoring Parameters

• Measure serum boric acid concentrations at admission, 12 hours after admission, then every 24 hours for 5 days 2
• Monitor urinary boric acid concentrations to assess elimination 2, 1
• Check renal function tests, electrolytes, and acid-base status regularly to detect metabolic acidosis and acute renal failure 2, 5
• Assess for signs of shock and cardiovascular collapse, which are potentially fatal complications 3, 5

Clinical Manifestations to Monitor

• Most patients (88.3%) remain asymptomatic even after ingestion 4
• Common symptoms include vomiting, abdominal pain, and diarrhea 4
• Serious manifestations include altered consciousness, fever, skin erythema, hypotension, metabolic acidosis, and oliguria 2, 1, 3
• Cardiac insufficiency is a potential cause of death in severe cases 5

Treatment Duration and Endpoints

• Continue treatment until serum boric acid levels decrease to approximately 30 μg/mL 2
• Clinical improvement typically occurs within 64-84 hours after admission with appropriate treatment 2, 3
• Inadequate diuresis dosing may result in persistent fever, nausea, vomiting, and headache 3

Critical Pitfalls to Avoid

• Do not delay hemodialysis waiting for signs of renal dysfunction—early intervention prevents severe renal damage 2
• Do not underestimate the severity based on initial presentation—patients may appear minimally symptomatic initially but deteriorate without aggressive treatment 4
• Do not use insufficient doses of furosemide—inadequate diuresis prolongs symptoms and recovery time 3
• Recognize that death can occur from circulatory collapse and shock despite treatment, particularly in elderly patients or those with massive ingestions (>30 g) 5