Trace metals include-

Copper, Chromiun, Iodine, Manganese, Molybdenum, Selenium, Zinc

Refer Copper

Trace Metal Symptoms of deficiency

Copper - leukopenia, neutropenia, anemia, decreased ceruloplasmin levels, impaired transferrin formation of secondary iron deficiency skeletal abnormalities, defective tissue formation

Chrominum- impaired glucose tolerance, peripheral neuropathy,,ataxia, confusion

 Iodine -impaired thyroid function, goiter,cretinism

 Manganese- nausea, vomiting, weight loss, dermatitis, changes in growth and hair color

Molybdenum-  tachycardia, tachyapnea, headache, night blindeness, nausea, vomiting, central scotomas, edema, lethargy, disoreintation, coma, hypermethioninemia, hypouricewmia, hypouricuria, low urinary excretion of inorganic sulfate and elevated urinary excretion of thiosulfate

Selenium - muscle pain and tenderness, cardiomyopathy, Kwashiorkor, Keshan disease

 Zinc-  diarrhea, apathy, depression, parakeratosis, hypogeusia, anorexia, dysomia, geophagia, hypogonadism, slendomegaly, impaired wound healing

Supplement to IV solution given for TPN

Trace metals include-

Copper, Chromiun, Iodine, Manganese, Molybdenum, Selenium, Zinc

Refer Copper

Symptoms of toxicity are unlikely to occur at recommended doses.

Hypersentivity to iodides may result in angioneurotic edema,

cutaneous and mucosal hemorrhages ,fever, arthalgia lymph node enlargement and eosinophillia

Do not give undiluted by direct injection into a peripheral vein because of the potential for infusion, phlebitis, tissue irritation and potential to increase renal loss of minerals from a bolus injection.

Molybdenum without copper supplement- copper -deficient patients

Precautions-

Replacement trace metals therapy- beyond maintenance requirements may be necessary in protracted vomiting or diarrhea, in patients with fistula drainage or nasogastric suction or in acute catabolic states.

Diabetes mellitus- in assessing the contribution of chromium suipplements to maintenance of glucose homeostasis consider that the patient may be diabetic

 Iodine- is readily absorbed throufg skin ,lungs, and mucous membranes. Give consideration to the environment, topical skin disinfection and wound treatment practices with surgical swabs and solutions containing iodine and povodone iodine.

Air in the coastal areas is known to contain more iodone than inland areas.

Benzyl alcohol- some of these products contain benzyl alcohol which has been associated with a fatal -gasping syndrome - in premature infants

Warnings-

Renal failure or biliary tract obstruction- metals may accumulate. Serial determinations of serum trace metal concentrations may be a valuable guideline .

Consider the possibility of copper and manganes retention in patients with biliary tract obstruction. Adjust, reduce or omit use in renaldysfuntion for GI malfunction.

Consider contributions from blood transfusions . Frequently determine plasma levels. Wilsons disease- avoid administrating copper suplements tompatients with genetic disorder of copper metabolism.

Decreased serum levels- administration of copper in the absence of zinc in the absence of copper may cause decreases in plasma levels.

Perform periodic detreminations of plasma zinc and copper for subsequent determinations

 Copper deficiency- Molybdenium promotes tissue copper mobilization and increases urinary copper excretion, excessive amount produce a copper dificiency.

Frequently check the metabolism of copper in patients receiving molybdenium.

Multiple trace element solutions- present a risk of overdosage when the need for one trace element is appreciably higher than that for other trace elements in the formulation

 Administration of trace elements as separate entities may be required.

Hypersensitivity- sensitizationto iodides and deaths due to aanaphylactic shock after use have occured .

Evaluate patient for hypersentivity before initiating TPN. If patient develops a reaction withdraw TPN immediately and institute appropiate measures.

Pregnancy- It is not known whether trace elements can cause fetal harm or can affect reproducive capacity. Give to a prergnant woen only if claerly required.

Molybdenium crosses the placenta palcenta.

Presence of selenium in placenta and umbilcal cord blood has been reported.

Indication-

Supplement to IV solution given for TPN

Dosage:

Adults- 0.15 to 0.8mg/day

Children- 2 to 10mcg/kg/day

Overdosage Symptoms

Chromiun- nausea, vomiting, GI ulcers, renal/hepatic damage,convussions

Copper- prostratn, behaviour change,diarrhea, progressive marasmus, hyptonia, photophobia, hepatic damage and peripheal edema

Iodine- sore mouth, increased salivation,coryza, sneezing, swelling of the eyelids, severe headache, pulomonary edema.tenderness of salivary glands, acneiform skin lesions, skin eruptions. Abundant fluid and salt intake helps in eliminatin of iodides.

Manganese- manganes madness, irritabilitry, speech disturbances, abnormal gait, headache, anorexia, apathgy, and impotence

Molybedenum- gout-like syndrome wth increasedblood levels of molybdenum, uric acid and xanthine oxidase.

Selenium- hair loss, weak nails, dermatitis, dental defects, GI dosorders, nervousness, mental depression, metallic taste, vomting and gaslic odor of breath, and sweat. Death was preceded by coma. No effective antidote is known.

Zinc- Acute toxicity was reported in an adult when 10mg zinc was infused ovr 1 hour on each consecutive days. Profused sweating, decreased consciouisness, blurred vision, tachycardia, marked hypothermia.

Copper Supplements-

1. Allergies- Tell your doctor if you have ever had any unusual or allergic reactions to copper supplements or other related medicines. Also tell your doctor if you are allergic to any other substances such as foods, preservatives or dyes.

2. Pregnancy- large amounts of dietary supplements in pregnancy may be harmful to the mother and or / fetus and should be avoided

3. Breast feeding- large amounts of dietary supplements while breast feeding may be harmful to the mother and should be avoided

4. Children- problems in children have not been reported with normal daily intake.

5. Elderly- problems in elderly have not been reported

6. Other medicines- tell your doctor if you are any other medicines- Penicillamine or Trientine or Zinc supplements - use with copper supplements may decrease the amount of copper that gets into the body.

Copper supplements should be taken 2 hrs after penicillamine, trientine or zinc supplements

7. Other medical problems- tell your doctor if you have any other medical problems- Biliary disease or Liver disease -taking copper suplements may cause high blood levels of copper, anddosage for copper may have to be changed Wilsons disease (too much copper in the body) - copper supplements may make this condition worse.

8. Missed dose- If you miss a dose of this medicine take it as soon as possible. However if it is almost time for your next dose go back to your regular dosing schedule. Do not double doses.

Pharmacology-

Chromium-

Trivalent chromium is a part of glucose tolerance factor an essential activator of insulin-medicated reactions. Chromiun helps maintain normal glucose metabolism and peripheral nerve function.

Administration of chromium supplements to chromium deficient patients can result in normalization of the glucose tolerance curve from the diabetic-like curve typical of chromium deficiency.

Copper-

Serves as co-factor for serum ceruloplasmin. an oxidase necessary for proper formation of iron carrier protein, transferrin. Copper also helps maintain normal rates of red and white bolld cell formation.

Iodine-

Absorption from GI tract is rapid and complete. Skin and lungs can also absorb iodine. On administration iodine equilibrates in extracellular fluids and although all body cells contain iodide, it is specifically concentrated by the thyroid gland, which is estimated to contain 7 to 8 mg total iodine.

Manganese-

serves as an activator for several enzymes. Managanese is bound to a specific transport protein, transmanganin, and is widely distrubuted, but it concentrates in mitochrodria-rich-tissues such as brain, kidney, pancreas and liver.

Molybdenium-

Iis a constituent of the enzymes xanthine oxidase, sulfite oxiodase and aldehyde oxidase. Tissue storage of molybedenium varies with the intake levels and is affected by the amount of copper and sulfate in the diet. Consistent levels are observedc in liver,kidney, and adrenal cortex.

Selenium-

Is a part of glutathione peroxidase which protects cell components from oxidative damage due to peroxide produced in cellular metabolism. Pediatric condition.Keshan disease and Kwashiokor have been associated with low dietary intake of selenium.

Dietary supplementation with selenium salts reduces the incidence of the conditions among affected children.

Zinc-

Serves a cofactor for > 70 different enzymes. Zinc facilitates woundhealing , helps maintain normal growth rates, normal skin hydration and the senses of taste and smell. Zinc resides in the muscle ,bone, skin, kidney, liver, pancreas retina,prostrate, andpaticularlybin red and white cells.

Pregnancy-

It is not known whether trace elements can cause fetal harm or can affect reproducive capacity. Give to a prergnant women only if claerly required. Molybdenium crosses the placenta palcenta. Presence of selenium in placenta and umbilcal cord blood has been reported.