Heavy Metal Testing: Chelation-Provoked Samples & Irrelevant Reference Ranges

Don’t be fooled by chelation “experts” or misleading lab tests.

A number of laboratories offer testing for toxic metals through blood, urine, and hair samples. The metals of most concern are lead, mercury, arsenic, and cadmium. We know a lot about the health effects of heavy metals because they have been around forever. These toxicities are real, and we all ought to avoid new exposures. Some people need therapy aimed at pulling these metals out of us. The trick is figuring out who that is.

Enter chelation. There’s little if any doubt that chelating agents (DMSA, EDTA, DMPS, etc.) bind to and increase the urinary excretion of various metals. However, with only two recent exceptions (discussed below), the labs performing this testing have used some underhanded hokus-pokus that make the patient results look far worse than they really are.

How did they do this? Many alternative labs report chelation-provoked results on an unprovoked reference range. That may not sound bad, but it's a BIG “no-no" in medicine. Comparing chelation-provoked toxic metal testing to the unprovoked ranges leads to the appearance of shockingly high levels of the metals. Not just occasionally, but most of the time.

Some might argue that an experienced clinical eye may not need separate reference ranges for provoked samples. Perhaps true, but one could just as easily suggest that this misreporting of results is the rails on which many alarmed patients are rolled into expensive, long-term and risky chelation therapy programs that they don’t need—while neglecting other more likely causes of their ailments.

Let me back up a bit for perspective. As alternative functional practitioners, we strive to use the best science available to diagnose to treat marginalized patients who aren’t getting the care they need from conventional medicine. Our practices serve as the testing grounds for new ideas and ideally as safe harbors for today’s “medical refugees.” Together, our practices subdivide the “syndromes” through investigating hidden causes and probing for responses to alternative treatments. We’re frequently decades ahead of convention, and though always improving, sometimes we end up lost in the sticks. There is often a degree of doubt in what we do, and a wise course to take is one of the open-minded skeptic.

My concern is that the apples-to-oranges comparison of chelation challenged vs. unprovoked samples is being paired with a VERY generous list of health problems attributed to metal toxicity. The result is that patients may get shuttled into months or years of chelation treatments on extremely doubtful diagnostic grounds. It’s not unheard of for chelation educators to suggest that even patients’ with provoked results that don’t go up be kept on the protocols because their tissues are “holding onto the metals”. Be that as it may, the financial incentives for both for the providers and labs are also apparent—and concerning.

To be clinically useful, results for chelated heavy metal testing need to be reported on a reference range that is specific to a chelating agent and the dosage of that agent. Until chelator and dose specific reference ranges exist, chelation-provoked testing should not be done.

To be clear, I’m not suggesting that chelation treatment has not helped patients with true heavy metal toxicity. In fact, I’m reasonably confident that it has. I use for testing is whole blood sampling and reference ranges established by the CDC. Before I order this testing, I need to see a route by which the patient may have been exposed. Exposure routes include ingestion, skin absorption, air pollution, dental work, surgical implants, occupation or travel.

Lets look at what’s out there in terms of metal testing:

Doctors Data has a long history in alternative testing for metals. Whether the sample was obtained from a provoked or unprovoked patient they still use a single reference range. The bottom of the report offers this small font explanation: “Reference intervals and corresponding graphs are representative of a healthy population under non-provoked conditions. Chelation (provocation) agents can increase urinary excretion of metals/elements.”

Genova Diagnostics also does urinary metal testing. They also use a reference range based on a healthy population under non-provoked conditions. In the commentary of their report they white: “Provocation with challenge substances is expected to raise the urine level of some elements to varying degrees, often into the cautionary or TMPL range. The degree of elevation is dependent upon the element level present in the individual and the binding affinities of the challenge substance.”

Metametrix (recently purchased by Genova) offering a single “catch-all” chelation-provoked reference range in addition to the unprovoked normal range. This is a step in the right direction, but its notable that their chelation ranges were created by pooling samples received from patients that were provoked with undisclosed (and presumably widely variable) amounts of “DMSA, EDTA, or other chelating agents.” Also notable is that there is no indication whether the samples came from healthy or sick patients.

Quest Diagnostics offers blood and urine testing of toxic metals. Quest only published reference ranges for the 24 hour urine test. Some may applaud their conservative reference ranges while others might deride them for dismissing as “normal” what may be clinically significant levels. No chelator specific levels reference ranges were offered. Here’s what they listed:
· Arsenic: 24-Hour Urine ≤80 µg/L
· Cadmium: 24-Hour Urine ≤5.0 µg/L
· Lead: 24-Hour Urine <80 µg/L
· Mercury: 24-Hour Urine ≤20 µg/L (Toxic ≥150 µg/L)

LabCorp offered the following reference ranges for urinary toxic metals (random and 24 hour) including separate reference ranges for Lead with specific doses of IV EDTA and PO DMSA chelation challenges:
· Arsenic: 0-50 μg/L, 0-50 μg/24 hours; inorganic arsenic: <20 μg/L
· Cadmium: <2.0 μg/g creatinine, <3.0 μg/24 hours
· Lead: <50 μg/L, <80 μg/24 hours; 150 μg/g creatinine
· Lead with chelation therapy: <600 μg/24 hours (after 1g IV EDTA or 2g DMSA PO)
· Mercury: <5.0 μg/g creatinine, <20.0 μg/L

Of the five labs I looked into, there was not a lot of agreement on reference ranges. Only LabCorp dared offer a chelator-specific reference range for one metal. (Bravo!) The only problem was that LabCorp appears to have brazenly strayed into treatment recommendations by suggesting specific doses of IV EDTA and PO DMSA without regard to the patients weight! (WHOOPS!) Every other chelation challenge protocol I have seen, suggested dosing in mg/kg—close, but yet so far. Metametrix stuck a nonspecific toe into chelation challenged reference-arranging, but I fear that they failed to shed distinguishing light on the murky situation.

So it’s fair to say that metal toxicity testing is a developing science. It will be a lot of work for the labs to standardize reference ranges for various doses of the different chelating agents for each toxic metal. Until this work is done, chelation provoked testing is utterly unreliable. Without chelator-specific reference ranges, chelation “experts” may be pressuring patients into long, expensive, and potentially dangerous chelation programs that may or may not actually be addressing the underlying problem.

If you have an history of exposure to toxic metals should you get tested? Absolutely. Use unprovoked blood and urine samples to determine if toxic metals are really problem for you. The Toxin Exposure Questionnaire (TEQ-20) that I developed for IFM is a good place to start. Download it here and share your results with Dr. Morris https://app.box.com/s/5r325ni0zbi47f00nxv81pnrodcr6eih