What is the treatment for arsenic poisoning?

Treatment of Arsenic Poisoning

Immediately remove the patient from the source of arsenic exposure and consider hemodialysis for severe cases with significant toxicity, as this is the preferred extracorporeal treatment modality. 1

Immediate Management Steps

Source Removal and Decontamination

• Remove the patient from the source of exposure as the first critical step 1
• If arsenic is in powder form on the skin, brush it off using a gloved hand or cloth and remove all contaminated clothing 1
• For skin or eye exposure, immediately irrigate the affected area with copious amounts of water 1
• Activate emergency medical services (EMS) immediately if the patient shows life-threatening symptoms such as sleepiness, seizures, difficulty breathing, or vomiting 1

Poison Control Consultation

• Contact the Poison Help hotline for guidance on treatment approach 1
• Do not administer anything by mouth unless specifically advised by poison control or emergency medical personnel 1
• Do not give activated charcoal or syrup of ipecac unless specifically directed by poison control 1

Extracorporeal Treatment for Severe Toxicity

Hemodialysis as First-Line

• Intermittent hemodialysis is the preferred extracorporeal treatment modality for severe arsenic poisoning with significant toxicity 1
• This recommendation comes from the Society of Critical Care Medicine and should be implemented when available 1

Alternative Dialysis Options

• If hemodialysis is not available, continuous kidney replacement therapy (CKRT) should be used 1
• Peritoneal dialysis may be used in resource-limited settings but is significantly less effective than hemodialysis or CKRT 1

Chelation Therapy Considerations

While the most recent guidelines 1 do not specifically detail chelation protocols, research evidence suggests chelation agents may have a role:

• Chelating agents such as dimercaptopropanol (BAL), dimercaptosuccinic acid (DMSA), and dimercaptopropanesulfonic acid (DMPS) have been used historically for arsenic poisoning 2, 3
• In acute cases, initial treatment with BAL combined with DMPS should be considered based on research evidence 2
• These agents work by binding to arsenic's high affinity for vicinal dithiol groups 2

Important caveat: The 2025 guidelines prioritize removal from exposure and extracorporeal treatment over chelation therapy, suggesting a shift in treatment paradigm toward dialysis-based approaches for severe cases 1

Supportive Measures

Nutritional Support

• Maintain good folate status, as this is important for arsenic elimination from the body 1

Long-Term Monitoring

• Chronic exposure requires long-term monitoring for development of arsenic-related cancers, particularly skin, lung, and bladder cancers 1
• This monitoring recommendation comes from the American Cancer Society 1

Special Population Considerations

Pregnancy

• Arsenic trioxide is highly embryotoxic and should be avoided during pregnancy 1
• This is a critical consideration from the American College of Obstetricians and Gynecologists 1

Diagnostic Pitfall to Avoid

• Do not dismiss elevated urinary arsenic levels in patients with high seafood consumption, as organic arsenic from seafood can mask concurrent inorganic arsenic exposure 1
• Seafood consumption elevates urinary arsenic without clinical toxicity, but this can confound diagnosis of true inorganic arsenic poisoning 1, 4
• It is essential to distinguish between inorganic arsenic (highly toxic and carcinogenic) and organic arsenic (relatively non-toxic) 1, 4