Re: Volatility of I-131 NaI

[carol marcus <csmarcus@ucla.edu>]

At 02:23 PM 9/16/99 -0500, you wrote:
>What about people who are allergic to iodine?  Would you be liable if someone
>suffered side effects from some iodide that you "prescribed."
>
>My employer screens employees for this.
>
>The opinions expressed are strictly mine.
>It's not about dose, it's about trust.
>
>Bill Lipton
>liptonw@dteenergy.com
>
>carol marcus wrote:
>
>> At 11:49 AM 9/16/99 -0500, you wrote:
>> >
>> >I read this as meaning "to write as many prescriptions as are necessary"...
>> >for EACH employee susceptible to uptake.
>> >
>> >
>> >carol marcus wrote:
>> >"As it is
>> >> available only by prescription, get one of your docs to write as many
>> >> prescriptions as are necessary, and instruct that anyone using it after an
>> >> accident should report to Nuclear Medicine for a thyroid uptake."
>> >
>> >
>> >at 06:58 AM 9/16/1999 -0500, you wrote:
>> >>This seems to be "pushing the envelope," legally.  Two issues:
>> >>
>> >>(1)  Can a physician write a prescription "to whom it may concern"?
>> >>
>> >>(2)  Can SSKI prescribed for one individual be given to someone else?
>> >>
>> >>The opinions expressed are strictly mine.
>> >>It's not about dose it's about staying out of jail.
>> >>
>> >>Bill Lipton
>> >>liptonw@dteenergy.com
>> >>
>> >>
>> >>carol marcus wrote:
>> >
>> >>>   I also send over a fresh bottle of SSKI from time to time
>> >>> to my RSO, in case I am not around during an accident.  NaI-131 used for
>> >>> radiolabeling is NOT stabilized, and so it could be more of an issue in
>> >>> research laboratories than on Nuclear Medicine services.  If there are
>> >>> laboratories around that use significant quantities of NaI-131 or
NaI-125,
>> >>> it would probably be enough to keep some SSKI around those labs.  As
it is
>> >>> available only by prescription, get one of your docs to write as many
>> >>> prescriptions as are necessary, and instruct that anyone using it
after an
>> >>> accident should report to Nuclear Medicine for a thyroid uptake.  As
>> >thyroid
>> >>> uptake probes are not calibrated for I-131 or I-125 for any clinical
>> >>> purpose, you might invest in some standards to do so in case of a worker
>> >>> contamination situation.  At Harbor-UCLA, the RSO and Nuclear
Medicine have
>> >>> uptake probes, and whenever the RSO calibrates his probe, he sends the
>> >>> sources over to Nuclear Medicine for a calibration as well.
>> >>>
>> >>> <csmarcus@ucla.edu>
>> >Opinions are mine only.
>> >Roger Sawyer
>> >Health Physicist
>> >University of Houston
>> >rsawyer@uh.edu
>> >
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>>
>> Dear Roger:
>>
>> Not at all.  Just stock it, and whomever needs it, takes it.  A prescription
>> like this does not have to be individualized.
>>
>> Ciao, Carol
>>
>> Carol S. Marcus, Ph.D., M.D.
>> <csmarcus@ucla.edu>
>>
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Dear Bill:

Stop trying to practice medicine.  No one is allergic to iodine or iodide.
It is ubiquitous in the body. Large amounts may cause reactions similar to
allergic reactions, but we are talking about only one dose of SSKI before
seeing a physician. People may be allergic to seafood, but it is not the
iodine within it to which they are allergic.  People may have reactions to
iodinated contrast, some very severe and, rarely, fatal, but (1) it is not
an "allergy" and (2) it is the compound that triggers the reaction, not
iodine or iodide.

People with severe renal dysfunction need to control potassium intake, but
one dose won't kill them and people this sick don't work for the fire dept.
and generally not for rad health, either.  People with hyperthyroidism,
untreated, can become more hyperthyroid or hypothyroid with exta iodide, but
maybe that will cause them to seek medical help.  Probably they will not
have a severe hyperthyroid reaction.  In any case, the physician is
basically protected by the "good samaritan" laws of each state, which
protect physicians from volunteering to help in an emergency.

Nothing in medicine is absolutely harmless, but physicians try to do more
good than harm.  To withhold SSKI in a frank emergency because of fear of
very low probability harm with one dose is flawed thinking.  There are other
unusual and severe side effects from SSKI listed in the USP-DI (they are not
listed in the PDR because no manufacturer has paid to advertise them), which
could become a problem if the public had access to huge quantities and
hysterically took huge quantities and gave huge quantities to children.
Most of these side effects are dose-dependent.  This is why I opposed the
stockpiling of SSKI.  I think you may hurt more people than you help.  The
huge releases of I-131 from Hanford years ago did not turn out to be a
problem.  The I-131 that the NRC released from TMI was far too little to be
a problem.  We don't know why young children near Chernobyl developed
thyroid cancer, but we have not seen this in other children who received
NaI-131 for medical reasons. We do know that babies and young children near
Chernobyl received massive doses of SSKI, and it is conceivable that
SSKI-induced thyroiditis led to thyroid cancer.  Thyroiditis is certainly
accociated with thyroid cancer.  While Polish children were given SSKI and
there was no increase in thyroid cancer, I doubt that there was enough
radioactive iodine that far away to give them thyroid cancer in the first
place. The inverse square law is powerful.  It would be interesting to look
at thyroid cancer rates in children in Poland who received SSKI and in those
who did not.  It would also be interesting to compare thyroiditis rates in
the two groups.

In addition to significant adverse reactions from very large doses of SSKI,
there are significant adverse drug interactions as well.  Again, one dose of
SSKI would probably not be sufficient to cause harm, but it is much more
likely with multiple doses.  Again, the PDR doesn't list these, but they are
in the USP-DI.  I have been looking at the 1999 edition, pp2354-2357, Vol 1.
My PDR is also 1999.  It lists SSKI, USP, but you need to go to the USP for
purity standards and the USP-DI (drug information) for adverse effects and
adverse drug interactions.

Ciao, Carol

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