Succimer (Dimercaptosuccinic ACID, DMSA)

SUCCIMER (DIMERCAPTOSUCCINIC ACID, DMSA)

Succimer is a water-soluble analog of dimercaprol, and like that agent it has been shown in animal studies to prevent and reverse metal-induced inhibition of sulfhydryl-containing enzymes and to protect against the acute lethal effects of arsenic. In humans, treat-ment with succimer is associated with an increase in urinary lead excretion and a decrease in blood lead concentration. It may also decrease the mercury content of the kidney, a key target organ of inorganic mercury salts. In the USA, succimer is formulated exclu-sively for oral use, but intravenous formulations have been used successfully elsewhere. It is absorbed rapidly but somewhat vari-ably after oral administration. Peak blood levels of succimer occur at approximately 3 hours. The drug binds in vivo to the amino acid cysteine to form 1:1 and 1:2 mixed disulfides, possibly in the kidney, and it may be these complexes that are the active chelating moieties. Experimental data suggest that multidrug-resistance protein 2 (Mrp2), one of a group of transporter proteins involved in the cellular excretion of xenobiotics, facilitates the renal excre-tion of mercury compounds that are bound to the transformed succimer and to unithiol. The elimination half-time of trans-formed succimer is approximately 2–4 hours.

Indications & Toxicity

Succimer is currently FDA-approved for the treatment of children with blood lead concentrations greater than 45 mcg/dL, but it is also commonly used in adults. The typical dosage is 10 mg/kg orally three times a day. Oral administration of succimer is compa-rable to parenteral EDTA in reducing blood lead concentration and has supplanted EDTA in outpatient treatment of patients who are capable of absorbing the oral drug. However, despite the dem-onstrated capacity of both succimer and EDTA to enhance lead elimination, their value in reversing established lead toxicity or in otherwise improving therapeutic outcome has yet to be established by a placebo-controlled clinical trial. In a recent study in lead-ex-posed juvenile rats, high-dose succimer did reduce lead-induced neurocognitive impairment when administered to animals with moderate- and high-dose lead exposure. Conversely, when admin-istered to the control group that was not lead exposed, succimer was associated with a decrement in neurocognitive performance. Based on its protective effects against arsenic in animals and its ability to mobilize mercury from the kidney, succimer has also been used in the treatment of arsenic and mercury poisoning.

In limited clinical trials, succimer has been well tolerated. It has a negligible impact on body stores of calcium, iron, and magne-sium. It induces a mild increase in urinary excretion of zinc and, less consistently, copper. This effect on trace metal balance has not been associated with overt adverse effects, but its long-term impact on neurodevelopment is uncertain. Gastrointestinal dis-turbances, including anorexia, nausea, vomiting, and diarrhea, are the most common side effects, occurring in less than 10% of patients. Rashes, sometimes requiring discontinuation of the medication, have been reported in less than 5% of patients. Mild, reversible increases in liver aminotransferases have been noted in 6–10% of patients, and isolated cases of mild to moderate neutro-penia have been reported.