1. DECORPORATION DRUGS TO TREAT INTERNAL RADIONUCLIDE CONTAMINATION* *ADAPTED from Carol S. Marcus, Ph.D., MD PowerPoint Presentation

2. RADIOLOGIC INCIDENTS Accidents in the USA and Canada are unusual –Generally contained; involve few individuals Terrorist incidents would not be contained –Could involve tens of thousands of people Physician involvement –Few have significant experience –Generally limited to KI to decrease thyroid uptake of I-131 from various radiopharmaceuticals

3. DISPERSION DEVICES RADIOLOGICAL DISPERSION DEVICE (RDD) EVENTS –Explosive (“dirty bomb”) –Surreptitious (unnoticed spread) –Destruction of site containing radioactive material, sealed and/or unsealed (e.g. nuclear power plant, hospital) –Detonation of nuclear weapon

4. MEDICAL PERSONNEL MAY BE FACED WITH: –External contamination –Inhaled contamination –Ingested contamination –Wound contamination (e.g. radioactive shrapnel)

5. THERAPY REQUIREMENTS INSTITUTION OF DECORPORATION THERAPY REQUIRES: –Identification of radionuclide(s) –Screening of victims –Quantitation of internal contamination –Therapy thresholds –Stockpiled pharmaceuticals

6. PRINCIPAL CONCERNS MAIN RADIONUCLIDES FROM RDD’S –Strontium (Sr)-90 –Yttrium (Y)-90 –Cesium (Cs)-137 –Iridium (Ir)-192 –Cobalt (Co)-60 –Americium (Am)-241 –Iodine (I)-125 and 131

7. RDD’S CONT’D RADIONUCLIDES FROM RDD’S –Uranium (U)-234, 235, 238 –Plutonium (Pu)-239 –Radium (Ra)-226 –Tritium (H)-3 –Phosphorus (P)-32 –Palladium (Pd)-103 –Mixtures

8. IDENTIFICATION METHODS TO IDENTIFY –Gamma ray spectra –Beta emitters –Alpha emitters –Clues from site explosion –Role of radiation regulators, DOE, and nuclear professionals

9. THRESHOLDS THERAPY THRESHOLDS –May use “allowable levels of intake” for workers (ALI’s) –May use higher contamination thresholds based on deterministic effects –Political pressure for very low thresholds

10. ACCESS DECORPORATION DRUG ACCESS –FDA-approved drugs, approved indications –FDA-approved drugs, unapproved indications –FDA-unapproved drugs, available from a compounding pharmacy –OTC drugs

11. STOCKPILE EXAMPLE LOS ANGELES COUNTY DEPT. OF HEALTH SERVICES- EMERGENCY MEDICAL SERVICES AGENCY STOCKPILE –Prussian blue –Ca/Zn-DTPA –Ca gluconate –Na alginate –D-penicillamine –Ammonium chloride –Na bicarbonate –Dimercaprol (BAL)

12. TREATMENT OVERVIEW RADIOELEMENT AND DECORPORATION TREATMENT OVERVIEW –Americium: parenteral Ca/Zn-DTPA –Cesium: oral Prussian blue –Cobalt: nothing too good, but oral penicillamine worth trying –Iodine: KI within about first 4 hours; consider PTU –Iridium: unknown; try penicillamine

13. TREATMENT OVERVIEW –Palladium: unknown; try oral penicillamine –Phosphorus: oral Na or K phosphate –Plutonium: parenteral Ca/Zn-DTPA –Radium: oral Ca, alginates

14. TREATMENT OVERVIEW –Strontium: i.v. Ca gluconate, oral ammonium chloride, alginates –Tritium: force water to promote diuresis –Uranium: Ca/Zn-DTPA within 4 hrs only; Na bicarbonate –Yttrium: parenteral Ca/Zn-DTPA

15. ALI’S THE ALLOWABLE LEVELS OF INTAKE (ALI’S) FOR RADIATION WORKERS: –Found in 10 CFR Part 20 –By ingestion and inhalation –By halflife of chemical compound (days, weeks, or years)

16. REFERENCES NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides, April 15, 1980. Order on line at www.ncrp.com for $50.00.www.ncrp.com 10 CFR Part 20 REAC/TS website for information on Prussian blue, Ca/Zn-DTPA: www.orau.gov/reacts/ www.orau.gov/reacts/ Medical Management of Radiological Casualties, 2 nd ed., Apr., 2003. AFRRI, Bethesda, MD.

17. KI CANADA LTD For more information, please contact: Tom Gottlieb Senior VP Research KI Canada ltd, 707 Alness Street Toronto Ontario M3J 2H8 416 661 1818 FAX 416 661 1816