Internal contamination with radioactive cesium and/or radioactive or nonradioactive thallium:
Note: Treatment should begin as soon as possible following exposure (Ref); however, treatment is also effective if therapy is delayed (Ref). Treatment typically continues for ≥30 days (Ref). Consult clinical toxicologist.
Infants and Children <2 years: Very limited data available; expert opinion: Oral: 150 to 250 mg/kg/day in 2 to 4 divided doses (Ref).
Children 2 to 12 years: Oral: 1,000 mg 3 times daily (Ref).
Adolescents:
Cesium exposure: Oral: 1,000 to 3,000 mg 3 times daily and continued for ≥30 days (as needed based on quantitative and radiologic evaluation of cesium elimination) (Ref); in adults, doses up to 10 to 12 g/day have been required in significant contamination events (Ref).
Thallium exposure: Oral: 3,000 mg 3 times daily or 150 to 250 mg/kg/day in 2 to 4 divided doses and continued until total urinary thallium concentrations are <0.5 mg/day, or longer if patient is still symptomatic (Ref).
There are no dosage adjustments provided in the manufacturer's labeling; however, ferric hexacyanoferrate is not systemically absorbed.
There are no dosage adjustments provided in the manufacturer's labeling; however, effectiveness may be decreased due to decreased biliary excretion of cesium and thallium.
(For additional information see "Ferric hexacyanoferrate: Drug information")
Internal contamination with radioactive cesium and/or radioactive or nonradioactive thallium: Note: Treatment should begin as soon as possible following exposure (Ref); however, treatment is also effective if therapy is delayed (Ref). Treatment typically continues for ≥30 days (Ref).
Cesium exposure: Oral: 1 to 3 g 3 times daily and continued for ≥30 days (as needed based on quantitative and radiologic evaluation of cesium elimination); doses up to 10 to 12 g per day have been required in significantly contaminated adults (Ref).
Thallium exposure: Oral: 3 g 3 times daily or 150 to 250 mg/kg/day in 2 to 4 divided doses and continued until total urinary thallium concentrations are <0.5 mg/day (Ref).
Manufacturer's labeling: Dosing in the prescribing information may not reflect current clinical practice. Oral: 3 g 3 times daily.
There are no dosage adjustments provided in the manufacturer's labeling; however, ferric hexacyanoferrate is not systemically absorbed.
There are no dosage adjustments provided in the manufacturer's labeling; however, effectiveness may be decreased due to decreased biliary excretion of cesium and thallium.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
Frequency not always defined.
Gastrointestinal: Constipation (24%), fecal discoloration (blue), gastric distress
Endocrine & metabolic: Hypokalemia (7%)
There are no contraindications in the manufacturer’s labeling.
Concerns related to adverse effects:
• Discoloration: Feces will turn blue; if capsule contents are opened and eaten with food, oral mucosa and detention may also be colored blue.
Disease-related concerns:
• Cardiac arrhythmias: Use with caution in patients with preexisting cardiac arrhythmias; may cause electrolyte imbalances.
• Electrolyte imbalances: May bind to electrolytes in the GI tract. Use with caution in patients with electrolyte imbalances.
• Gastric immotility: Use with caution in patients with decreased gastric motility; constipation should be avoided to prevent increased radiation absorption from the GI tract. Increase dietary fiber or take with fiber laxative to decrease constipation. The cesium- or thallium-bound ferric hexacyanoferrate insoluble complex must move through the GI tract in a timely manner so that the associated radiation is not absorbed.
Other warnings/precautions:
• Radiation exposure: Patients should be instructed to minimize radiation exposure to others or re-exposure to self.
• Radiation toxicity: Appropriate use: Ferric hexacyanoferrate increases the rate of elimination of thallium and cesium; it does not treat complications of radiation exposure. Supportive treatment for radiation toxicity should be given concomitantly. Additional decontamination and/or treatment may be needed if exposure to other radioactive isotopes is known or suspected. Radiation elements that do not undergo enterohepatic recirculation are not removed by ferric hexacyanoferrate.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Capsule, Oral:
Radiogardase: 0.5 g
No
Capsules (Radiogardase Oral)
0.5 g (per each): $3.42
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excretion data for Cesium-137 without ferric hexacyanoferrate: Urine (∼80%); feces (∼20%). Excretion data for thallium without ferric hexacyanoferrate: Fecal-to-urine excretion ratio: 2:1. If ferric hexacyanoferrate is used, detailed treatment information should be reported to the manufacturer; contact the manufacturer or the complete prescribing information for data collection forms. In case of thallium intoxication, elimination of thallium may also be increased by: Induced emesis followed by intubation and lavage; forced diuresis if urinary excretion is <1 mg per 24 hours; charcoal hemoperfusion during the first 48 hours following ingestion; hemodialysis.
Oral: Administer with food to stimulate excretion of cesium or thallium. Capsules may be opened and mixed with bland food or liquid. In critically ill patients who cannot swallow, capsules may be opened and administered by orogastric or nasogastric tube (Ref). Increase dietary fiber or take with fiber laxative to decrease constipation.
Oral: In critically ill patients who cannot swallow, capsules may be opened and administered by orogastric or nasogastric tube. Also, the capsules may be opened and mixed with bland food or liquid. Administer with food to stimulate excretion of cesium or thallium. Increase dietary fiber or take with fiber laxative to decrease constipation (Ref).
Store at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C and 30°C (59°F and 86°F). Brief exposure to temperatures up to 40°C (104°F) may be tolerated provided the mean temperature does not exceed 25°C (77°F); however, minimize such exposure.
Note: Although ferric hexacyanoferrate is comprised of 35% to 40% cyanide, long-term stability studies have demonstrated minimal risk of significant cyanide liberation after at least 10 years of storage in optimal conditions (Mohammad 2015).
Pharmacy supply of emergency antidotes: Guidelines suggest that at least 12.5 to 25 g of ferric hexacyanoferrate be stocked, especially in locations near industrial sites. Suggested amount is stated to be a sufficient quantity to treat 1 patient weighing 100 kg for an initial 8- to 24-hour period (Dart 2018); actual amount to be stocked should take into account site-specific and population-specific needs.
Treatment of known or suspected internal contamination with radioactive cesium and/or radioactive or nonradioactive thallium to increase their rates of elimination (FDA approved in pediatric patients [age not specified] and adults).
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program
There are no known significant interactions.
Food may increase effectiveness by stimulating bile secretion and thereby increasing the amount of cesium or thallium available to bind with ferric hexacyanoferrate. Management: Administer with food to stimulate excretion of cesium or thallium.
Take with food. A high-fiber diet or fiber laxative is recommended to avoid constipation.
Animal reproduction studies have not been conducted. Ferric hexacyanoferrate is not absorbed from the gastrointestinal tract and is not expected to affect the fetus. Cesium-137 crosses the placenta; in one case, reported levels were equal in the mother and the neonate. Thallium also crosses the placenta; fetal death and failure to thrive have been reported. Toxicity from exposure to thallium or radioactive cesium is expected to be greater than the risk of toxicity to ferric hexacyanoferrate. In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey, 2003).
Bowel movements; CBC and electrolytes weekly.
Baseline cesium and/or thallium exposure (whole body counting and/or bioassay, feces or urine sample); urine and fecal cesium and/or thallium weekly during therapy; residual whole body radioactivity after 30 days of treatment.
The ferric hexacyanoferrate lattice preferentially binds cesium and thallium isotopes in the gastrointestinal tract following their ingestion or excretion in the bile (thereby, blocking reabsorption). The resulting complex is eliminated in the feces reducing the absorption of thallium or the radioactive residence time of cesium (Kazzi 2015).
Absorption: Ferric hexacyanoferrate: Oral: None
Half-life elimination:
Cesium-137: Effective: Adults: 80 days, decreased by 69% with ferric hexacyanoferrate; adolescents: 62 days, decreased by 46% with ferric hexacyanoferrate; children: 42 days, decreased by 43% with ferric hexacyanoferrate
Nonradioactive thallium: Biological: 8 days; with ferric hexacyanoferrate: 3 days
Excretion: Ferric hexacyanoferrate: Feces (99%, unchanged) (Radiogardase, 2008)
Hepatic function impairment: May be less effective because of decreased biliary excretion of cesium and thallium.
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