Safety recommendations for I-131 vary among health care providers

New data highlight disparities in safety recommendations provided to patients after administration of radioactive iodine therapy for thyroid disease, leading the American Thyroid Association to push for more guideline standardization.

National safety recommendations for treatment after radioactive iodine (I-131) do not exist. Carol Greenlee, MD, and colleagues assessed the consistency of guidelines given to patients undergoing this treatment. Using a 27-question online survey, the researchers polled major medical society members and other health care providers who utilize I-131 for treatment of thyroid disease about their safety practices. There were 311 endocrinologists, surgeons, nuclear medicine radiologists and allied health professionals who responded to the survey.

“The good news is that safety precautions were routinely provided to patients receiving I-131 therapy, and these were ample to provide the protection required by the Nuclear Regulatory Commission guidelines, even after liberalizing the release criteria in 1997,” Greenlee, of Western Slope Endocrinology in Grand Junction, Colo., told Endocrine Today.

Diverse recommendations

Despite routine safety instructions, however, respondents reported that patients often received recommendations from more than one treating specialist. Greenlee said the instructions on safety practices were not usually discussed or standardized among providers, therefore leaving respondents unsure of whether their recommendations were comparable or conflicting or which provider should ensure that patients understand the instructions.

According to the results, starting at doses between 259 megabecquerel (MBq) and 1,073 MBq, more than 60% of respondents suggested patients refrain from contact with children, sexual activity and breast-feeding for more than 48 hours after treatment, although recommendations for personal hygiene, laundry and meal preparation varied. Hospitalization for treatment and duration of stay were dependent on social situation and the dose of I-131, the researchers said. Twenty percent of respondents also reported that insurance coverage influenced the decision to recommend outpatient vs. inpatient therapy.

Weak points

Results also highlighted areas that warrant closer attention.

“Some areas need to be addressed more routinely, particularly screening for pregnancy and providing advice on pregnancy planning, avoiding breast-feeding after receiving any amount of I-131 and also use of consent forms,” Greenlee said.

Most respondents reported routine screening for pregnancy before treatment, with more than 90% using serum or urine testing. Nevertheless, Richard T. Kloos, MD, secretary and chief operating officer of the ATA, said in an accompanying editorial that 9.5% reported only screening “sometimes.” Further, it was “surprising” that some physicians accepted verbal and written patient statements of not being pregnant. The fact that one respondent reported never screening for pregnancy was also “quite concerning.”

In addition, at 90%, respondents more often recommended delaying parenthood for at least 6 months to women than men (60%), according to the researchers.

“Even more disconcerting is that 7% of respondents recommended avoiding breast-feeding only when the therapeutic activity was >30 mCi, while 27% reported that they did not advise patients to avoid breast-feeding, and half of the respondents apparently did not see a need to avoid breast-feeding beyond the first 48 hours after radioiodine treatment,” said Kloos, who is also co-director of The Ohio State University Thyroid Cancer Unit and professor in the divisions of endocrinology and nuclear medicine.

Consent forms are also important because they provide patients with verbal and written information that outlines in layman’s terms risks related to I-131 during a stressful time in their lives, Kloos said, adding that although most respondents used consent forms, 30% to 40% did not include information about breast-feeding or risk for salivary gland damage.

To reconcile these issues, the ATA will publish a document — developed by a multidisciplinary group of physicians — that standardizes safety recommendations: “Radiation Safety in the Treatment of Patients with Thyroid Diseases by Radioiodine (I-131) Practice Recommendations of the American Thyroid Association.”

“We hope that our companion paper will provide uniform safety precaution recommendations that can be used by all providers, including those referring patients for I-131 treatment and those administering I-131 treatment so that patients have consistency of advice from all providers,” Greenlee said. – by Melissa Foster

For more information:

• Greenlee C. Thyroid. 2011;21:151-160.
• Kloos RT. Thyroid. 2011;21:97-99.

Disclosure: Dr. Greenlee reports no relevant financial disclosures. The ATA opinions were approved by the ATA board of directors.

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