Potassium Iodide


Article Author:
Jeronimo Torti


Article Editor:
Ricardo Correa


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
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Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/18/2019 7:05:40 PM

Indications

Potassium iodide (KI) is a medication and dietary supplement. As a dietary supplement, it has utility in patients with low iodine intake, a more frequent occurrence in developing countries. As a prescribed medication, it is used to treat severe hyperthyroidism, cutaneous inflammatory dermatoses, nuclear emergencies, and to protect the thyroid gland when using radiopharmaceuticals.

In severe hyperthyroidism or refractory hyperthyroidism, patients receive KI for short-term use in the following situations[1][2][3][4][5]:

  • In the preoperative preparation for thyroidectomy in Graves disease.
  • Thyroid storm, because iodine blocks the release of T4 and T3 from the gland within hours.
  • As serves as adjunctive therapy for Graves disease, used in combined treatment with antithyroid drugs and KI improves the short-term control of Graves hyperthyroidism.  Furthermore, it is helpful after the administration of radioiodine in Graves disease, especially in patients who wish to avoid taking or who are allergic to thionamides.

Concerning emergency radiation, the U.S. Nuclear Regulatory Commission (NRC) and the American Thyroid Association (ATA) require states to consider including KI as a protective measure. Its utilization is necessary when within a 10-mile radius of a nuclear along with adequate prevention methods such as evacuation, sheltering, and avoiding contaminated foods, in the event of a nuclear accident. Furthermore, they state that KI must be available to state and local governments.[6] The guidance titled “Potassium Iodide as a Thyroid Blocking Agent in Radiation Emergencies" from the Food Drug Administration (FDA) of the United States prioritizes age, which is the primary factor for determining risk for radioiodine-induced thyroid cancer after radiation exposure. Those at highest risk are infants, children, and pregnant and nursing females.  The recommendation is to treat this population at the lowest threshold of the predicted radioactive dose to the thyroid.  Any person over 18 years old and up to 40 years old should receive treatment at a slightly higher limit.  Lastly, anyone over 40 years old should have KI treatment only if the predicted exposure level is high enough to destroy the thyroid, inducing lifelong hypothyroidism. KI works best if used within 3 to 4 hours of exposure. In the event of a nuclear accident, KI pills, taken once daily, decrease thyroid uptake of radioactive iodine. It almost protects the thyroid completely if administered within 12 hours before radioactive iodine exposure; after exposure, the degree of protection declines (80, 40, and 7 percent after 2, 8, and 24 hours, respectively).[7]

In regards to patients with dermatoses, the two best indications in this group are neutrophilic dermatoses and panniculitis. Especially for lymphocutaneous and cutaneous sporotrichosis, Itraconazole is the drug of choice for the treatment. However, patients who don't respond to itraconazole at 200 mg/day, can receive KI together with other antimycotics as an alternative.[8] It is also successfully used for other inflammatory dermatoses. For instance, erythema nodosum, subacute nodular migratory panniculitis, nodular vasculitis, erythema multiforme, and Sweet syndrome.[9]

Mechanism of Action

KI has several mechanisms of action on thyroid function. In euthyroid patients, the Iodine has two effects in two different times. The most rapid (hours to days) effect, at pharmacologic doses of KI, is to decrease thyroglobulin proteolysis, thereby decreasing thyroid hormone secretion. The resulting slight reductions of T4 and T3 concentrations in serum cause transient increases of thyrotropin (TSH) concentrations in serum.[10] Secondly, KI inhibits thyroid hormone synthesis. The administration of KI leads to temporary inhibition of iodine organification in the thyroid gland, thereby decreasing thyroid hormone biosynthesis, a phenomenon called the Wolff-Chaikoff effect (WCE). However, within two to four weeks of continual exposure to excess iodine, organification, and thyroid hormone biosynthesis resume in a normal fashion, which is called escape from the Wolff-Chaikoff effect.[11][12] This phenomenon is produced by lower iodide uptake during the escape from the acute Wolff–Chaikoff effect. It results from a decrease in Na+/I– symporter (NIS) expression.[13] Exist abnormal autoregulation of the Iodine in the autoimmune thyroid disease. The iodine organification persists and can result in or exacerbate hypothyroidism in patients with Hashimoto thyroiditis, or ameliorate hyperthyroidism in Graves disease. Thus, patients with Graves hyperthyroidism are more sensitive than normal subjects to the inhibitory effect of pharmacologic doses of iodine, making iodine treatment effective in some patients. Also, pharmacologic amounts of iodine may acutely ameliorate hyperthyroidism by blocking thyroid hormone release.[4] Furthermore, it is used in preparation for thyroidectomy because it decreases the vascularity of the thyroid gland. Therefore, this decreases the risk of post-thyroidectomy hemorrhaging.[1][2] KI should be administered at least one hour after administration of thioamides to prevent new hormone synthesis since the new iodine substrate.

In the event of a nuclear accident, taken once daily KI can decrease the mortality and morbidity of thyroid cancers provoked by radioactive iodine exposure; this is because it directly blocks the radioiodine uptake in the thyroid gland. KI floods the thyroid with non-radioactive iodine, preventing the uptake of the radioactive molecules, which subsequently get excreted in the urine.[14]

The precise mechanism by which KI acts against inflammatory dermatoses is unknown. The dermatoses treatable with KI usually display neutrophils in the early stages. Research demonstrates that iodine, as well as dapsone, can suppress the production of toxic oxygen intermediates by polymorphonuclear cells and thus exert its anti-inflammatory effect.[15] The precise mechanism by which KI kills fungi is also unknown. It is unclear whether KI works against fungi by a fungicidal mechanism or by enhancing the body's immunologic and nonimmunologic defense mechanisms. However, it is possible to assume that it has an important anti-inflammatory role, since the patients that show better response also present systemic symptoms and increased C-reactive protein. It usually improves fast, with fever, pain and erythema reduction in two days and complete remission in up to two weeks.[9]

Administration

The dose of KI used to treat dermatoses is much higher than that in thyrotoxicosis (250 mg 3 times daily) or in radiation (100 to 150 mg single dose). Physicians typically begin treatment of inflammatory dermatoses with an oral dosage of 300 mg (approximately six drops of super saturated potassium iodide (SSKI)) 3 times daily, followed by weekly increases as tolerated. In the case of mycoses, the administration is often higher, beginning at 600 mg (approximately 12 drops of SSKI) orally three times each day and often increased to 6 g (approximately 127 drops of SSKI) daily if tolerated.

Most presentations are given orally, usually with juice or milk, to protect against gastrointestinal irritation. However, there are some exceptions. There are several FDA-approved KI products, including tablets (65 and 130 mg) and oral solutions (65 mg/mL).

Additionally, there exist another two liquid presentations that are prescribed orally:

  • SSKI with 35 to 50 mg of iodine per drop and KI with about 24 mg per drop. It is usually administrated orally and mixed with juice or milk due to the bitter taste, especially in infants. 
  • Potassium iodide-iodine (Lugol solution [5 to 8 mg of iodine per drop]) is usually given orally with the recommended dosage of 3 to 5 drops three times daily. Although iodine is typically well tolerated, reports exist of local esophageal or duodenal mucosal injury and hemorrhage, particularly in the treatment of thyroid storm.[16][17] For patients unable to take oral medication, Lugol solution can be added directly to intravenous fluids because it is sterile.[18] An alternative is to give the iodine solution per rectum.[19]

Adverse Effects

Adverse effects are unlikely when KI is used at low doses and for a short time (less than two weeks). The most common side effects are on the digestive system, predominantly being gastrointestinal intolerance and its bitter (metallic) taste; thus it is recommended that it be taken with juice or milk to protect against gastrointestinal irritation.[9] However, there may occur important side effects when high doses are administered, especially for the treatment of infectious skin disorders.

The acute side effects include diarrhea, nausea, vomiting, and stomach pain that can be ameliorated with gastrointestinal protection and by avoiding rapid dosage increases. Nevertheless, prolonged use can cause Iodism or potassium toxicity. Iodism is an iodide poisoning syndrome characterized by soreness of the teeth and gums, severe headache, conjunctival hyperemia, lacrimation, blurred vision, rhinorrhea, and sialorrhea.  Concurrent use of KI with impaired renal function or other potassium-containing medications, potassium-sparing diuretics, and angiotensin-converting enzyme inhibitors (ACE inhibitors) may result in hyperkalemia.[8][9]

Because the patients receive large amounts of iodine in the drug, it could affect the metabolism of the thyroid gland. It can produce a WCE and produce hypothyroidism. However, there are autoregulation mechanisms that help maintain the normal function of the gland in euthyroid patients. The imbalance of thyroid hormones occurs when autoregulation is defective or absent. If it is just defective, the resulting WCE is inevitable, TSH increases, and hypothyroidism and goiter ensue. Failure to escape this condition, with resulting hypothyroidism, can result from with the administration of KI in patients with Hashimoto's thyroiditis, euthyroid patients previously treated by thyroid surgery or radioactive iodine for Graves' disease, patients taking certain drugs that inhibit thyroid function (eg, lithium, phenazone, and, possibly, sulfonamides), patients previously treated with interferon alfa for chronic viral hepatitis,[20] and patients with a history of amiodarone-induced thyrotoxicosis, subacute thyroiditis, or Graves disease. When autoregulation is absent, Jod-Basedow disease occurs. The absence of autoregulation is typically only seen in areas where iodine deficiency with long-standing goiters occur. This alteration produces an excess of thyroid hormone resulting in thyrotoxicosis.[9]

Allergic reactions such as angioedema and urticaria, should be a consideration during the administration of KI, like any drug. The use of KI can also cause an uncommon lesion in the skin called Ioderma, which is characterized by a severe acneiform, vesicular pustular, hemorrhagic, or urticarial lesions. Other systemic side effects of SSKI include urticaria, fever, eosinophilia, jaundice, pruritus, angioedema, and bronchospasm. In this case, the treatment is high-dose corticosteroid therapy.[21]

Contraindications

KI is contraindicated in patients who have thyroid disease or are using any drug that could alter the thyroid function.[22] Contraindications also include patients with an allergy to iodine. It should be avoided in patients with chronic renal failure because of the presence of potassium. Furthermore, it should be avoided in patients using potassium-sparing diuretics or angiotensin-converting-enzyme inhibitors to prevent hyperkalemia.[23] Immunocompromised patients such as patients with cancer, cirrhosis, AIDS, and autoimmune diseases, or poorly managed diabetics, transplant patients, and those using corticosteroids should not use KI because it affects the immune system.[23] It should not be indicated in pregnant or nursing women because it causes neonatal hypothyroidism, thyromegaly, fetal airway obstruction, and prolonged labor. Also, it is a pregnancy category D drug.[9]

Monitoring

For all who prescribe KI, previous knowledge of the WCE, of the patients’ potassium levels, and their renal function is imperative. It is recommended to inquire about any history of thyroid disease, autoimmune disease, or drugs that the patient is using. Unless there is a suspicion of thyroid disease, the baseline thyroid function test is not indicated. If KI use is for more than one month, it is recommended to do a screening test of TSH to ensure that the patients are not in hypothyroidism. If iodide-induced hypothyroidism is detected, these changes are reversible by discontinuing the administration of KI.[9] Furthermore, according to the guidance of the FDA, thyroid function should be monitored in pregnant or breastfeeding women, neonates, and young infants if repeat doses are necessary following radioactive iodine exposure. The FDA strongly recommends monitoring neonates and infants for potential hypothyroidism, particularly when:

  • Nursing mothers who receive greater than 1 dose of KI
  • Infants under 1 month of age receiving any KI
  • Neonates who receive more than 1 dose of KI
  • Neonates or infants, whose at-risk mothers do not switch from breast milk to formula or other foods 

Toxicity

If iodide-induced hypothyroidism is detected, these changes are reversible by discontinuing the administration of KI. In a study of 7 patients with iodide-induced hypothyroidism, serum T4, T3, and TSH concentrations returned to normal within one month of iodide withdrawal.[22]

The drug-induced-hyperkalemia is a medical urgency of which the physician should be aware. Prompt management is necessary with immediate (under 3 minutes) treatment: ECG monitoring is advisable, changes suggest potassium level greater than 7 mmol/L. Therefore, calcium gluconate administration is the recommended intervention in that case. Within minutes (under 30 minutes) the treatment is the combination of insulin-dextrose and beta-2 receptor agonists.  Within hours (subacute) the management is sodium bicarbonate if the patient has acidosis, loop diuretics, and/or dialysis in patients with advanced Stage 5 kidney disease (eGFR less than 15 mL/min/1.73 m2) or patients with very high potassium values (i.e., greater than 6.0 mmol/L).[24]

In the case of iodism or ioderma, it is treatable with withdrawal and high doses of corticosteroids.[21]

Enhancing Healthcare Team Outcomes

Physicians, nurses, and pharmacists in many parts of the world continue to use KI drug because of its effectiveness, and low cost or they can use it as a second-line drug when the first line agent fails, is contraindicated, or cause intolerable side effects or severe allergic reaction to other drugs. It is imperative to know the side effect of KI, particularly when treating dermatoses for extended periods, which requires monitoring the patient to prevent adverse effects, especially those related to thyroid disease. Furthermore, it is imperative to know the implication that this drug has in the prevention of exposure to radiation since clinicians have a brief window in which to apply it to patients and prevent thyroid cancer. Additionally, it is the public health’s responsibility to be aware of there capacity to store and administrate KI on time in the case of a nuclear emergency.  


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Potassium Iodide - Questions

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A 32-year-old female comes for a consult because she has been having nausea, vomiting, metallic taste, toothaches, gum pain, headache and increased salivation for 1-week. On physical examination, she has coryza, irritation, and swelling of the eyes, and productive cough with pulmonary edema. She has a history of granulomatosis with polyangiitis treated with prednisolone and potassium iodide for the skin lesions for 3 months. Which is the possible cause of these new symptoms?



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A 56-year-old woman with rheumatoid disease and Grave´s disease history was being prepared for total thyroidectomy. Unfortunately, the patient disregarded the instructions and took the equivalent of three doses of one of these medications at once without any fluid. She suddenly develops acneiform eruptions with papulovesicular rash involving the oral mucosa and her extremities, sparing the trunk. Which of the following drugs is responsible for this eruption?



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A 25-year-old male with a history of Graves disease presents to the emergency department due to severe shortness of breath. The patient is somnolence with an oxygen saturation of 88% and a heart rate of 150/min with atrial fibrillation. TSH was found to be 0.001 mU/L with free T4 7.5 ng/dL. Treatment with propylthiouracil is initiated. Which of the following is the next best step in the management of this patient?



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A 72-year-old male with a history of hypertension and congestive heart failure presents to the clinic for follow up after a recent diagnosis of sporotrichosis treated for one week with itraconazole and potassium iodide. His other outpatient medications include enalapril, carvedilol, and spironolactone. He reports weakness, fatigue, and nausea. On physical exam, he has depressed deep tendon reflexes. Which of the following is the next best step in the management of this patient?



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A 26-years-old male, with no history of thyroid disease, has been taking potassium iodide for a week due to the fear of possible radiation exposure at 30 miles for his home. He now follows up at the clinic with a TSH 10 microU/mL (Ref: 0.5-5.0 microU/mL) and free T4 0.9 microgram/dL (Ref: 5-12 microgram/dL). Which of the following is the next best step in the management of this patient?



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A 32-year-old male with longstanding Graves disease presents with 105 °F of temperature, anxiety, delirium, psychosis and agitation, 24 hours after a motor vehicle collision. Which of the following is the best initial management plan for this patient?



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A 65-year-old male presents to the emergency department with progressive generalized weakness, myalgia, fatigue, and episodes of palpitations for 12 days. He has a history of diabetes mellitus, hypertension, and nodular vasculitis. Current medications include metformin, sitagliptin, enalapril, isoniazid, rifampin, naproxen, prednisolone, and potassium iodide. He also reports not urinating for one day. Associated symptoms include disorientation, weakness, and fatigue. The electrocardiogram (ECG) shows loss of P wave, prolonged QRS complexes, ectopic beats and escape rhythms. Which of the following is the next best step in the management of this patient?



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Potassium Iodide - References

References

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Piantanida E, Preoperative management in patients with Graves' disease. Gland surgery. 2017 Oct;     [PubMed]
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