1. 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

2. Objectives Discuss the risks associated with a nuclear exposure. Discuss the risks associated with a nuclear exposure. Select the appropriate management for a nuclear exposure. Select the appropriate management for a nuclear exposure. Recommend the dosing schedule of potassium iodide. Recommend the dosing schedule of potassium iodide.

3. Nuclear Accidents Tokaimura, Japan September 30, 1999 Tokaimura, Japan September 30, 1999 Chornobyl (Chernobyl) Nuclear Disaster Unit number 4 in Ukraine on Saturday, April 26 th 1986 at 1:23 a.m. Chornobyl (Chernobyl) Nuclear Disaster Unit number 4 in Ukraine on Saturday, April 26 th 1986 at 1:23 a.m. Three Mile Island Power Station, Pennsylvania, US on March 28, 1979 Three Mile Island Power Station, Pennsylvania, US on March 28, 1979

4. Cancer risk Three Mile Island Three Mile Island Very little radioactivity released into the air Very little radioactivity released into the air Leukemia rates increased Leukemia rates increased

5. Chernobyl Data Belarus and Ukraine Increase incidence of thyroid cancer among children and adolescents Increase incidence of thyroid cancer among children and adolescents Attributed to ingested or inhaled radioiodines Attributed to ingested or inhaled radioiodines Majority of cases received less than 30 cGy to the thyroid Majority of cases received less than 30 cGy to the thyroid

6. Chernobyl Data- Poland KI distributed to 10.5 million children and 7 million adults KI distributed to 10.5 million children and 7 million adults 0.37% of newborns demonstrated transient increases in TSH and decreases in free T4 0.37% of newborns demonstrated transient increases in TSH and decreases in free T4 Adverse effects - up to 2% GI, 1% rash Adverse effects - up to 2% GI, 1% rash

7. Thyroid cancer Risk of thyroid cancer – inversely related to age Risk of thyroid cancer – inversely related to age Children exposed to > 5 cGy Children exposed to > 5 cGy

8. Radiation exposure Immediate effects Immediate effects Flash and flame burns Flash and flame burns Blindness – temporary or permanent Blindness – temporary or permanent Long-term effects Long-term effects Thyroid cancer Thyroid cancer

9. Effects of radiation Time Time Absorbed dose – directly proportional Absorbed dose – directly proportional Distance Distance Absorbed dose – decreases rapidly Absorbed dose – decreases rapidly Triple the distance – dose is one-ninth Triple the distance – dose is one-ninth Shielding Shielding Lead Lead Indoors Indoors

10. Half-lives Short-lived Short-lived Iodines Iodines Long-lived Long-lived Cesium Cesium Strontium Strontium Cobalt Cobalt Decay rate affects management Decay rate affects management

11. Clinical effects Rapidly dividing cells most vulnerable Rapidly dividing cells most vulnerable Dose < 1.0 Gy, damage not severe Dose < 1.0 Gy, damage not severe Cells survive but susceptible to subsequent malignant transfusion Cells survive but susceptible to subsequent malignant transfusion Leukemia – 2 years Leukemia – 2 years Radiation induced solid tumors – 5-10+ years Radiation induced solid tumors – 5-10+ years

12. Clinical effects – local exposure 3-4 GyEpilation in 2-3 weeks 3-4 GyEpilation in 2-3 weeks 10-15 GyErythema 10-15 GyErythema 20 GyMoist desquamation, ulceration 20 GyMoist desquamation, ulceration 25 GyUlceration with slow healing 25 GyUlceration with slow healing 30-50 GyBlistering, necrosis at 3 weeks 30-50 GyBlistering, necrosis at 3 weeks 100 GyBlistering, necrosis at 1-2 weeks 100 GyBlistering, necrosis at 1-2 weeks

13. Effects – whole body < 1 GyNo symptoms < 1 GyNo symptoms 1 GyNausea and vomiting (10%) within 48 hours 1 GyNausea and vomiting (10%) within 48 hours > 2 GyNausea and vomiting (50%) within 48 hours > 2 GyNausea and vomiting (50%) within 48 hours 4 GyNausea and vomiting (90%) within 48 hours; 50% mortality without medical attention 4 GyNausea and vomiting (90%) within 48 hours; 50% mortality without medical attention 6 Gy100% mortality within 30 days 6 Gy100% mortality within 30 days 10-30 Gy 10-30 Gy Rapid onset of nausea, vomiting, and diarrhea Rapid onset of nausea, vomiting, and diarrhea Latent period x 1 week Latent period x 1 week Recurrent GI symptoms, sepsis, electrolyte imbalance, death Recurrent GI symptoms, sepsis, electrolyte imbalance, death

14. Thyroid exposure Largely due to consumption of contaminated fresh cow’s milk Largely due to consumption of contaminated fresh cow’s milk Consumption of contaminated vegetables Consumption of contaminated vegetables Inhalation Inhalation

15. Management exposure Recognition Recognition Based on history and clinical findings Based on history and clinical findings Local injury worse than systemic Local injury worse than systemic Prevention Prevention Treatment Treatment Symptoms, i.e. burns Symptoms, i.e. burns Supportive care Supportive care

16. Prevention Time Time Food control measures Food control measures Stored for weeks to months – no risk Stored for weeks to months – no risk Evacuation Evacuation Shelter Shelter

17. Therapy for Internal Contamination Tritium Tritium Force fluids Force fluids Cesium 134 or Cesium 137 Cesium 134 or Cesium 137 Reduce GI absorption, Prussian blue Reduce GI absorption, Prussian blue Strontium 89 or strontium 90 Strontium 89 or strontium 90 Reduce absorption (Al PO 4 ), blockage (strontium lactate), displacement (oral phosphate), mobilization (ammonium chloride, parathyroid extract) Reduce absorption (Al PO 4 ), blockage (strontium lactate), displacement (oral phosphate), mobilization (ammonium chloride, parathyroid extract)

18. Therapy for Internal Contamination Plutonium or other transuranic elements Plutonium or other transuranic elements Chelation with zinc Chelation with zinc Unknown Unknown Reduction of absorption (emetics, lavage, charcoal, laxatives) Reduction of absorption (emetics, lavage, charcoal, laxatives) Iodine 125 or Iodine 131 Iodine 125 or Iodine 131 Blockage (KI), mobilization (antithyroid drugs) Blockage (KI), mobilization (antithyroid drugs)

19. Potassium Iodide Short-term administration – safe Short-term administration – safe Adverse effects: Adverse effects: Gastrointestinal disturbances Gastrointestinal disturbances Allergic reactions Allergic reactions Minor rashes Minor rashes

20. Potassium Iodide Avoid in patients with: Avoid in patients with: Known iodine sensitivity Known iodine sensitivity Dermatitis herpetiformis Dermatitis herpetiformis Hypocomplementemic vasculitis Hypocomplementemic vasculitis Not necessary to avoid in patients with seafood allergy Not necessary to avoid in patients with seafood allergy

21. Potassium Iodide – dosing 130 mg KI 130 mg KI Adults over 40 years, Predicted exposure > 500 cGy Adults over 40 years, Predicted exposure > 500 cGy Adults 18-40 years, Predicted exposure > 10 cGy Adults 18-40 years, Predicted exposure > 10 cGy Pregnant/lactating, Predicted exposure > 5 cGy Pregnant/lactating, Predicted exposure > 5 cGy

22. Potassium Iodide – dosing Children 3-18 years, Predicted exposure > 5 cGy Children 3-18 years, Predicted exposure > 5 cGy 65 mg KI 65 mg KI Children 1 mo-3 years, Predicted exposure > 5 cGy Children 1 mo-3 years, Predicted exposure > 5 cGy 32 mg KI 32 mg KI Birth-1 month, Predicted exposure > 5 cGy Birth-1 month, Predicted exposure > 5 cGy 16 mg KI 16 mg KI

23. Potassium Iodide Effect last 24 hours Effect last 24 hours Administer immediately coincident with cloud, up to 3-4 hours after exposure Administer immediately coincident with cloud, up to 3-4 hours after exposure Daily dosing until risk of significant exposure by inhalation or ingestion passes Daily dosing until risk of significant exposure by inhalation or ingestion passes Do NOT repeat dosing in: Do NOT repeat dosing in: Pregnant and lactating women Pregnant and lactating women

24. Potassium Iodide Slaladenitis Slaladenitis Gastrointestinal disturbances Gastrointestinal disturbances Allergic reactions Allergic reactions Minor rashes Minor rashes

25. Psychosocial effects Acute stress reaction Acute stress reaction Post Traumatic Stress Disorder Post Traumatic Stress Disorder Long term risks Long term risks Prevention Prevention Goal – maintain or restore trust Goal – maintain or restore trust

26. Summary Potassium Iodide Potassium Iodide Safe Safe Effective for preventing thyroid cancer Effective for preventing thyroid cancer Evacuation still main protection Evacuation still main protection