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Antidotes & Toxicology Pregnancy: Use if benefit outweighs risk — cyanide poisoning is life-threatening; no human teratogenicity data

Sodium Thiosulfate

Brand names: Sodium Thiosulfate Injection

Adult dose

Dose: 12.5 g (50 mL of 25% solution)
Route: IV
Frequency: Single dose
Max: 12.5 g
Infuse over 10–20 minutes. Always give after sodium nitrite or alone if nitrite contraindicated. Repeat at half dose if symptoms persist

Paediatric dose

Dose: 400 mg/kg (1.65 mL/kg of 25% solution) mg/kg
Route: IV
Frequency: Single dose
Max: 12.5 g
Seek specialist opinion; pair with sodium nitrite at paediatric dose

Dose adjustments

Renal

Use with caution — thiocyanate accumulates in renal failure and is neurotoxic; monitor thiocyanate levels

Hepatic

No specific adjustment

Paediatric weight-based calculator

Seek specialist opinion; pair with sodium nitrite at paediatric dose

Clinical pearls

  • Mechanism: provides sulfur donor substrate for mitochondrial enzyme rhodanese — catalyses conversion of cyanide + thiosulfate to thiocyanate (100x less toxic than cyanide) + sulfite; thiocyanate then excreted renally
  • Can be used ALONE (without nitrite) if nitrite is contraindicated (CO poisoning, G6PD deficiency) — less effective alone but safer
  • Secondary use: cisplatin nephrotoxicity prophylaxis in some oncology protocols; also used as diagnostic agent for iodine uptake in thyroid studies
  • NPIS protocol: sodium nitrite 300 mg followed immediately by sodium thiosulfate 12.5 g; repeat half doses if clinical deterioration
  • Thiocyanate toxicity (prolonged nitroprusside infusions): nausea, confusion, muscle weakness — check levels after 48h of nitroprusside infusion; haemodialysis if thiocyanate above 200 mg/L
  • MHRA: licensed for cyanide poisoning in combination with sodium nitrite; also licensed for use with cisplatin in paediatric oncology protocols

Contraindications

  • No absolute contraindications when used for cyanide poisoning
  • Avoid if plasma thiocyanate above 120 mg/L (toxicity risk)

Side effects

  • Thiocyanate toxicity with prolonged use: nausea, vomiting, fatigue, psychosis, hypothyroidism
  • Hypotension
  • Nausea and vomiting
  • Muscle cramps

Interactions

  • Sodium nitroprusside (co-administration provides prophylaxis against cyanide toxicity during prolonged nitroprusside infusions)
  • Digoxin (thiosulfate may reduce digoxin absorption from gut)

Monitoring

  • Clinical response to cyanide poisoning treatment
  • Thiocyanate levels (if prolonged use or renal impairment)
  • Renal function
  • Methaemoglobin level (from co-administered nitrite)

Reference: BNFc; BNF 90; NPIS Toxbase; Clinical Toxicology 2007;45(3):271-277. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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