Nuclear Exposure The Role of Potassium Iodide

Evelyn R. Hermes-DeSantis, Pharm.D., BCPS

Ernest Mario School of Pharmacy

Rutgers the State University of New Jersey

ObjectivesObjectives

Discuss the risks associated with a Discuss the risks associated with a nuclear exposure.nuclear exposure.

Select the appropriate management Select the appropriate management for a nuclear exposure.for a nuclear exposure.

Recommend the dosing schedule of Recommend the dosing schedule of potassium iodide.potassium iodide.

Nuclear AccidentsNuclear Accidents Tokaimura, Japan Tokaimura, Japan

September 30, 1999September 30, 1999 Chornobyl Chornobyl

(Chernobyl) Nuclear (Chernobyl) Nuclear Disaster Unit number Disaster Unit number 4 in Ukraine on 4 in Ukraine on Saturday, April 26Saturday, April 26thth 1986 at 1:23 a.m. 1986 at 1:23 a.m.

Three Mile Island Three Mile Island Power Station, Power Station, Pennsylvania, US on Pennsylvania, US on March 28, 1979 March 28, 1979

Cancer riskCancer risk

Three Mile IslandThree Mile Island Very little Very little

radioactivity radioactivity released into the released into the airair

Leukemia rates Leukemia rates increasedincreased

Chernobyl Data Chernobyl Data Belarus and UkraineBelarus and Ukraine

Increase incidence of thyroid cancer Increase incidence of thyroid cancer among children and adolescentsamong children and adolescents

Attributed to ingested or inhaled Attributed to ingested or inhaled radioiodinesradioiodines

Majority of cases received less than Majority of cases received less than 30 cGy to the thyroid30 cGy to the thyroid

Chernobyl Data- PolandChernobyl Data- Poland

KI distributed to 10.5 million KI distributed to 10.5 million children and 7 million adultschildren and 7 million adults

0.37% of newborns demonstrated 0.37% of newborns demonstrated transient increases in TSH and transient increases in TSH and decreases in free T4decreases in free T4

Adverse effects - up to 2% GI, 1% Adverse effects - up to 2% GI, 1% rashrash

Thyroid cancerThyroid cancer

Risk of thyroid cancer – inversely Risk of thyroid cancer – inversely related to agerelated to age

Children exposed to > 5 cGyChildren exposed to > 5 cGy

Radiation exposureRadiation exposure

Immediate effectsImmediate effects Flash and flame burnsFlash and flame burns Blindness – temporary or permanentBlindness – temporary or permanent

Long-term effectsLong-term effects Thyroid cancerThyroid cancer

Effects of radiationEffects of radiation

TimeTime Absorbed dose – directly proportionalAbsorbed dose – directly proportional

DistanceDistance Absorbed dose – decreases rapidlyAbsorbed dose – decreases rapidly Triple the distance – dose is one-ninthTriple the distance – dose is one-ninth

ShieldingShielding LeadLead IndoorsIndoors

Half-livesHalf-lives

Short-livedShort-lived IodinesIodines

Long-livedLong-lived CesiumCesium StrontiumStrontium CobaltCobalt

Decay rate affects managementDecay rate affects management

Clinical effectsClinical effects

Rapidly dividing cells most Rapidly dividing cells most vulnerablevulnerable Dose < 1.0 Gy, damage not severeDose < 1.0 Gy, damage not severe

Cells survive but susceptible to Cells survive but susceptible to subsequent malignant transfusionsubsequent malignant transfusion

Leukemia – 2 yearsLeukemia – 2 years Radiation induced solid tumors – 5-10+ Radiation induced solid tumors – 5-10+

yearsyears

Clinical effects – local Clinical effects – local exposureexposure

3-4 Gy3-4 Gy Epilation in 2-3 weeksEpilation in 2-3 weeks 10-15 Gy10-15 Gy ErythemaErythema 20 Gy20 Gy Moist desquamation, Moist desquamation,

ulcerationulceration 25 Gy25 Gy Ulceration with slow healingUlceration with slow healing 30-50 Gy30-50 Gy Blistering, necrosis at 3 Blistering, necrosis at 3

weeksweeks 100 Gy100 Gy Blistering, necrosis at 1-2 Blistering, necrosis at 1-2

weeksweeks

Effects – whole bodyEffects – whole body < 1 Gy< 1 Gy No symptomsNo symptoms 1 Gy1 Gy Nausea and vomiting (10%) within 48 hoursNausea and vomiting (10%) within 48 hours > 2 Gy> 2 Gy Nausea and vomiting (50%) within 48 Nausea and vomiting (50%) within 48

hourshours 4 Gy4 Gy Nausea and vomiting (90%) within 48 hours; Nausea and vomiting (90%) within 48 hours;

50% mortality without medical 50% mortality without medical attention attention

6 Gy6 Gy 100% mortality within 30 days100% mortality within 30 days 10-30 Gy10-30 Gy

Rapid onset of nausea, vomiting, and diarrheaRapid onset of nausea, vomiting, and diarrhea Latent period x 1 weekLatent period x 1 week Recurrent GI symptoms, sepsis, electrolyte imbalance,Recurrent GI symptoms, sepsis, electrolyte imbalance,

deathdeath

Thyroid exposureThyroid exposure

Largely due to consumption of Largely due to consumption of contaminated fresh cow’s milkcontaminated fresh cow’s milk

Consumption of contaminated Consumption of contaminated vegetablesvegetables

InhalationInhalation

Management exposureManagement exposure

RecognitionRecognition Based on history and clinical findingsBased on history and clinical findings Local injury worse than systemicLocal injury worse than systemic

PreventionPrevention TreatmentTreatment

Symptoms, i.e. burnsSymptoms, i.e. burns Supportive careSupportive care

PreventionPrevention

TimeTime Food control measuresFood control measures

Stored for weeks to months – no riskStored for weeks to months – no risk EvacuationEvacuation ShelterShelter

Therapy for Internal Therapy for Internal ContaminationContamination

TritiumTritium Force fluidsForce fluids

Cesium 134 or Cesium 137Cesium 134 or Cesium 137 Reduce GI absorption, Prussian blueReduce GI absorption, Prussian blue

Strontium 89 or strontium 90Strontium 89 or strontium 90 Reduce absorption (Al POReduce absorption (Al PO44), blockage ), blockage

(strontium lactate), displacement (oral (strontium lactate), displacement (oral phosphate), mobilization (ammonium phosphate), mobilization (ammonium chloride, parathyroid extract)chloride, parathyroid extract)

Therapy for Internal Therapy for Internal ContaminationContamination

Plutonium or other transuranic Plutonium or other transuranic elementselements Chelation with zincChelation with zinc

UnknownUnknown Reduction of absorption (emetics, Reduction of absorption (emetics,

lavage, charcoal, laxatives)lavage, charcoal, laxatives) Iodine 125 or Iodine 131Iodine 125 or Iodine 131

Blockage (KI), mobilization (antithyroid Blockage (KI), mobilization (antithyroid drugs)drugs)

Potassium IodidePotassium Iodide

Short-term administration – safeShort-term administration – safe Adverse effects:Adverse effects:

Gastrointestinal disturbancesGastrointestinal disturbances Allergic reactionsAllergic reactions Minor rashesMinor rashes

Potassium IodidePotassium Iodide

Avoid in patients with:Avoid in patients with: Known iodine sensitivityKnown iodine sensitivity Dermatitis herpetiformisDermatitis herpetiformis Hypocomplementemic vasculitisHypocomplementemic vasculitis

Not necessary to avoid in patients Not necessary to avoid in patients with seafood allergywith seafood allergy

Potassium Iodide – Potassium Iodide – dosingdosing

130 mg KI130 mg KI Adults over 40 years, Predicted Adults over 40 years, Predicted

exposure > 500 cGyexposure > 500 cGy Adults 18-40 years, Predicted exposure Adults 18-40 years, Predicted exposure

> 10 cGy> 10 cGy Pregnant/lactating, Predicted exposure Pregnant/lactating, Predicted exposure

> 5 cGy> 5 cGy

Potassium Iodide – Potassium Iodide – dosingdosing

Children 3-18 years, Predicted Children 3-18 years, Predicted exposure > 5 cGyexposure > 5 cGy 65 mg KI65 mg KI

Children 1 mo-3 years, Predicted Children 1 mo-3 years, Predicted exposure > 5 cGyexposure > 5 cGy 32 mg KI32 mg KI

Birth-1 month, Predicted exposure > 5 Birth-1 month, Predicted exposure > 5 cGycGy 16 mg KI16 mg KI

Potassium IodidePotassium Iodide

Effect last 24 hoursEffect last 24 hours Administer immediately coincident Administer immediately coincident

with cloud, up to 3-4 hours after with cloud, up to 3-4 hours after exposureexposure

Daily dosing until risk of significant Daily dosing until risk of significant exposure by inhalation or ingestion exposure by inhalation or ingestion passespasses

Do NOT repeat dosing in: Do NOT repeat dosing in: Pregnant and lactating womenPregnant and lactating women

Potassium IodidePotassium Iodide

SlaladenitisSlaladenitis Gastrointestinal disturbancesGastrointestinal disturbances Allergic reactionsAllergic reactions Minor rashesMinor rashes

Psychosocial effectsPsychosocial effects

Acute stress reactionAcute stress reaction Post Traumatic Stress DisorderPost Traumatic Stress Disorder Long term risksLong term risks

PreventionPrevention Goal – maintain or restore trustGoal – maintain or restore trust

SummarySummary

Potassium IodidePotassium Iodide SafeSafe Effective for preventing thyroid cancerEffective for preventing thyroid cancer

Evacuation still main protectionEvacuation still main protection