Lantheus Medical Imaging, Inc.

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Lantheus Medical Imaging, Inc. Drugs

Xenon

Xenon

Xenon Xe 133 gas is administered by inhalation from closed respirator systems or spirometers.

The suggested activity range employed for inhalation by the average adult patient (70 kg) is:

Pulmonary function including imaging: 74-1110MBq (2-30mCi) in 3 liters of air.

Cerebral blood flow: 370-1110MBq (10-30mCi) in 3 liters of air.

The patient dose should be measured by a suitable radioactivity calibration system immediately prior to administration.

RADIATION DOSIMETRY

The estimated absorbed radiation doses2 to an average patient (70 kg) for pulmonary perfusion and cerebral blood flow studies from a maximum dose of 1110 MBq (30mCi) of Xenon Xe 133 in 3 liters of air are shown in Table 4.
Table 4. Radiation Doses Effective Whole Half-Time Lungs* Brain Body * 99% of activity is in lungs. mGy/1110MBq (rads/30mCi) Pulmonary Perfusion 2 min. 2.5(0.25) 0.014(0.0014) 0.027(0.0027) Cerebral Flow 5 min. 6.3(0.63) 0.035(0.0035) 0.068(0.0068) 2 Method of Calculation: A Schema for Absorbed-Dose Calculation for Biologically Distributed Radionuclides, Supplement No. 1, MIRD pamphlet No. 1, J. Nucl. Med., p.7 (1968).
Cardiolite

Cardiolite

For Myocardial Imaging: The suggested dose range for I.V. administration of CARDIOLITE® in a single dose to be employed in the average patient (70 Kg) is 370 - 1110 MBq (10 - 30 mCi).

For Breast Imaging: The recommended dose range for I.V. administration of MIRALUMA® is a single dose of 740 - 1110 MBq (20 - 30 mCi).

2.1 Image Acquisition

Breast Imaging: It is recommended that images are obtained with a table overlay to separate breast tissue from the myocardium and liver, and to exclude potential activity that may be present in the opposite breast. For lateral images, position the patient prone with the isolateral arm comfortably above the head, shoulders flat against the table, head turned to the side and relaxed, with the breast imaged pendent through an overlay cutout. The breast should not be compressed on the overlay. For anterior images, position the patient supine with both arms behind the head. For either lateral or anterior images, shield the chest and abdominal organs, or remove them from the field of view.

For complete study, sets of images should be obtained five minutes after the injection, and in the following sequence:

Beginning five minutes after the injection of Technetium Tc99m Sestamibi:
ten-minute lateral image of breast with abnormality ten-minute lateral image of contralateral breast ten-minute anterior image of both breasts
2.2 Radiation Dosimetry

The radiation doses to organs and tissues of an average patient (70 Kg) per 1110 MBq (30 mCi) of Technetium Tc99m Sestamibi injected intravenously are shown in Table 1.0.
Table 1.0. Radiation Absorbed Doses from Tc99m Sestamibi Estimated Radiation Absorbed Dose Radiation dosimetry calculations performed by Radiation Internal Dose Information Center, Oak Ridge Institute for Science and Education, PO Box 117, Oak Ridge, TN 37831-0117. REST 2.0 hour void 4.8 hour void Organ rads/30 mCi mGy/1110 MBq rads/30 mCi mGy/1110 MBq Breasts 0.2 2.0 0.2 1.9 Gallbladder Wall 2.0 20.0 2.0 20.0 Small Intestine 3.0 30.0 3.0 30.0 Upper Large Intestine Wall 5.4 55.5 5.4 55.5 Lower Large Intestine Wall 3.9 40.0 4.2 41.1 Stomach Wall 0.6 6.1 0.6 5.8 Heart Wall 0.5 5.1 0.5 4.9 Kidneys 2.0 20.0 2.0 20.0 Liver 0.6 5.8 0.6 5.7 Lungs 0.3 2.8 0.3 2.7 Bone Surfaces 0.7 6.8 0.7 6.4 Thyroid 0.7 7.0 0.7 7.0 Ovaries 1.5 15.5 1.6 15.5 Testes 0.3 3.4 0.4 3.9 Red Marrow 0.5 5.1 0.5 5.0 Urinary Bladder Wall 2.0 20.0 4.2 41.1 Total Body 0.5 4.8 0.5 4.8 STRESS 2.0 hour void 4.8 hour void Organ rads/30 mCi mGy/1110 MBq rads/30 mCi mGy/1110 MBq Breasts 0.2 2.0 0.2 1.8 Gallbladder Wall 2.8 28.9 2.8 27.8 Small Intestine 2.4 24.4 2.4 24.4 Upper Large Intestine Wall 4.5 44.4 4.5 44.4 Lower Large Intestine Wall 3.3 32.2 3.3 32.2 Stomach Wall 0.6 5.3 0.5 5.2 Heart Wall 0.5 5.6 0.5 5.3 Kidneys 1.7 16.7 1.7 16.7 Liver 0.4 4.2 0.4 4.1 Lungs 0.3 2.6 0.2 2.4 Bone Surfaces 0.6 6.2 0.6 6.0 Thyroid 0.3 2.7 0.2 2.4 Ovaries 1.2 12.2 1.3 13.3 Testes 0.3 3.1 0.3 3.4 Red Marrow 0.5 4.6 0.5 4.4 Urinary Bladder Wall 1.5 15.5 3.0 30.0 Total Body 0.4 4.2 0.4 4.2
2.3 Instructions For Preparation

Preparation of the Technetium Tc99m Sestamibi from the Kit for the Preparation of Technetium Tc99m Sestamibi is done by the following aseptic procedure:

General Procedure:
a. Prior to adding the Sodium Pertechnetate Tc99m Injection to the vial, inspect the vial carefully for the presence of damage, particularly cracks, and do not use the vial if found. Tear off a radiation symbol and attach it to the neck of the vial. b. Waterproof gloves should be worn during the preparation procedure. Remove the plastic disc from the vial and swab the top of the vial closure with alcohol to sanitize the surface.
Boiling Water Bath Procedure:
c. Place the vial in a suitable radiation shield with a fitted radiation cap. d. With a sterile shielded syringe, aseptically obtain additive-free, sterile, non-pyrogenic Sodium Pertechnetate Tc99m Injection [925 - 5550 MBq, (25 - 150 mCi)] in approximately 1 to 3 mL. e. Aseptically add the Sodium Pertechnetate Tc99m Injection to the vial in the lead shield. Without withdrawing the needle, remove an equal volume of headspace to maintain atmospheric pressure within the vial. f. Shake vigorously, about 5 to 10 quick upward-downward motions. g. Remove the vial from the lead shield and place upright in an appropriately shielded and contained boiling water bath, such that the vial is suspended above the bottom of the bath, and boil for 10 minutes. Timing for 10 minutes is begun as soon as the water begins to boil again. Do not allow the boiling water to come in contact with the aluminum crimp. h. Remove the vial from the water bath, place in the lead shield and allow to cool for fifteen minutes.
Recon-o-Stat (thermal cycler) Procedure:
c. Place the vial in the thermal cycler radiation shield. d. With a sterile shielded syringe, aseptically obtain additive-free, sterile, non-pyrogenic Sodium Pertechnetate Tc99m Injection [925 - 5550 MBq, (25 - 150 mCi)] in approximately 1 to 3 mL. e. Aseptically add the Sodium Pertechnetate Tc99m Injection to the vial in the lead shield. Without withdrawing the needle, remove an equal volume of headspace to maintain atmospheric pressure within the vial. f. Shake vigorously, about 5 to 10 quick upward-downward motions. g. Place shield on sample block. While slightly pressing downward, give the shield a quarter turn to make certain there is a firm fit between the shield and the sample block. h. Press the proceed button to initiate the program (the thermal cycler automatically heats & cools the vial and contents). Please see the Recon-o-Stat Instruction Manual for further details.
General Procedure (cont.):
i. Using proper shielding, the vial contents should be visually inspected. Use only if the solution is clear and free of particulate matter and discoloration. j. Assay the reaction vial using a suitable radioactivity calibration system. Record the Technetium Tc99m concentration, total volume, assay time and date, expiration time and lot number on the vial shield label and affix the label to the shield. k. Store the reaction vial containing the Technetium Tc99m Sestamibi at 15° to 25°C (59° - 77°F) until use; at such time the product should be aseptically withdrawn. Technetium Tc99m Sestamibi should be used within six hours of preparation. The vial contains no preservative. Note: Adherence to the above product reconstitution instructions is recommended. The potential for cracking and significant contamination exists whenever vials containing radioactive material are heated. Product should be used within 6 hours after preparation. Final product with radiochemical purity of at least 90% was used in the clinical trials that established safety and effectiveness. The radiochemical purity was determined by the following method.
2.4 Determination of Radiochemical Purity in Technetium Tc99m Sestamibi
Obtain a Baker-Flex Aluminum Oxide coated, plastic TLC plate, #1 B-F, pre-cut to 2.5 cm × 7.5 cm. Dry the plate or plates at 100°C for 1 hour and store in a desiccator. Remove pre-dried plate from the desiccator just prior to use. Apply 1 drop of ethanol1 using a 1 mL syringe with a 22-26 gauge needle, 1.5 cm from the bottom of the plate. THE SPOT SHOULD NOT BE ALLOWED TO DRY. Add 2 drops of Technetium Tc99m Sestamibi solution, side by side on top of the ethanol1 spot. Return the plate to a desiccator and allow the sample spot to dry (typically 15 minutes). The TLC tank is prepared by pouring ethanol1 to a depth of 3-4 mm. Cover the tank and let it equilibrate for ~10 minutes. Develop the plate in the covered TLC tank in ethanol1 for a distance of 5 cm from the point of application. Cut the TLC plate 4 cm from the bottom and measure the Tc99m activity in each piece by appropriate radiation detector. Calculate the % Tc99m Sestamibi as: % Tc99m Sestamibi = µCi Top Piece × 100 µCi Both Pieces Figure 1.0 TLC Plate Diagram 1 The ethanol used in this procedure should be 95% or greater. Absolute ethanol (99%) should remain at ≥ 95% ethanol content for one week after opening if stored tightly capped, in a cool dry place.
Thallous Chloride Tl 20...

Thallous Chloride Tl 201

DOSAGE AND ADMINISTRATION: The recommended adult dose of intravenous Thallous Chloride Tl 201 Injection for planar myocardial imaging is 37 to 74 MBq (1-2 mCi). The recommended intravenous doses for SPECT myocardial imaging are 74 to 111 MBq (2-3 mCi). The efficacy of a 1.0 mCi dose SPECT imaging has not been well established.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

The patient dose should be measured by a suitable radioactivity calibration system immediately prior to administration.

For patients undergoing resting thallium studies, imaging is optimally begun within 10-20 minutes after injection. Several investigators have reported improved myocardial-to-background ratios when patients are injected in the fasting state, in an upright posture, or after briefly ambulating. The upright position reduces the hepatic and gastric Thallium TI 201 concentration.

Best results with thallium imaging performed in conjunction with exercise stress testing appear to be obtained if the thallium is administered when the patient reaches maximum stress and when the stress is continued for 30 seconds to one minute after injection. Imaging should begin within ten minutes post-injection since target-to-background ratio is optimum by that time. Several investigators have reported significant decreases in the target-to-background ratios of lesions attributable to transient ischemia by two hours after the completion of stress Imaging.

For the localization of parathyroid hyperactivity, Thallous Chloride Tl 201 Injection may be administered before, with or after a minimal dose of a thyroid imaging agent such as sodium pertechnetate Tc99m or sodium iodide I 123 to enable thyroid subtraction imaging.

RADIATION DOSIMETRY
Table 4 Radiation Dose Estimates for Thallous Chloride Tl 201 Injection (plus contaminants) Estimate Radiation Dose Organ MGy/MBq Rad/mCi Adrenals .065 0.24 Brain .061 0.22 Breasts .036 0.13 GB Wall .084 0.31 LLI Wall .34 1.3 Small Intestine .45 1.7 Stomach .19 0.69 ULI .33 1.2 Heart Wall .28 1.0 Kidneys .46 1.7 Liver .099 0.37 Lungs .048 0.18 Muscle .047 0.17 Ovaries .10 0.38 Pancreas .075 0.28 Marrow .056 0.21 Bone Surfaces .089 0.33 Skin .034 0.13 Spleen .18 0.66 Testes .83 3.1 Thymus .047 0.17 Thyroid .62 2.3 Urinary Bladder wall .053 0.20 Uterus .086 0.32 Effective Dose Equiv. .36 mSv/MBq 1.3 rem/mCi
Based on data gathered in humans by Krahwinkel et al. (J Nucl Med 29(9):1582-1586, 1988) and data gathered in humans by Gupta et al. (Int J Nucl Med & Biol 8:211-213, 1981).

Bladder voiding interval 4.8hr. Contaminants assumed: TI-200 (0.3%), TI-202 (0.84%), Pb-203 (0.2%). Includes dose from TI-201 Auger electrons. Estimate calculated using phantom of Cristy & Eckerman (Report ORNL/TM-8381/V1 & V7). Radiation Internal Dose Information Center.
Gallium

Gallium

The recommended adult (70 kg) dose of Gallium Citrate Ga 67 Injection is 74-185 MBq (2-5 mCi). Gallium Citrate Ga 67 Injection is intended for intravenous administration only.

Approximately 10% of the administered dose is excreted in the feces during the first week after injection. Daily laxatives and/or enemas are recommended during the first week after injection until the final images are obtained in order to cleanse the bowel of radioactive material and minimize the possibility of false positive studies.

Studies indicate the optimal tumor to background concentration ratios are often obtained about 48 hours post-injection. However, considerable biological variability may occur in individuals, and acceptable images may be obtained as early as 6 hours and as late as 120 hours after injection.

The patient dose should be measured by a suitable radioactivity calibration system immediately prior to administration.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit.

Waterproof gloves should be worn during the handling procedures. With a shielded sterile syringe, aseptically withdraw the material for use. The expiration date of the drug is fourteen days after the date of calibration.

RADIATION DOSIMETRY

The estimated absorbed radiation doses2 from an intravenous injection of 185 MBq (5 mCi) of Gallium Citrate Ga 67 are shown in Table 4.
TABLE 4. Dosimetry of Gallium Citrate Ga 67 Injection for Maximal Dose of 185 MBq (5 mCi) mGy/185 MBq Rads/5mCi Whole Body 13.0 1.30 Skeleton 22.0 2.20 Liver 23.0 2.30 Bone Marrow 29.0 2.90 Spleen 26.5 2.65 Kidney 20.5 2.05 Ovaries 14.0 1.40 Testes 12.0 1.20 Gastrointestinal Tract Stomach 11.0 1.10 Small Intestine 18.0 1.80 Upper Large Intestine 28.0 2.80 Lower Large Intestine 45.0 4.50 2 MIRD Dose Estimate Report No.2, J. Nucl. Med. 14:755-6 (1973).
Ablavar

Ablavar

2.1 Dosing Guidelines

Administer ABLAVAR as an intravenous bolus injection, manually or by power injection, at a dose of 0.12 mL/kg body weight (0.03 mmol/kg) over a period of time up to 30 seconds followed by a 25-30 mL normal saline flush. (See Table 1 for weight-adjusted dose volumes).
TABLE 1. Weight-Adjusted Volumes for the 0.03 mmol/kg Dose Body Weight Volume Kilograms (kg) Pounds (lb) Milliliters (mL) 40 88 4.8 50 110 6.0 60 132 7.2 70 154 8.4 80 176 9.6 90 198 10.8 100 220 12.0 110 242 13.2 120 264 14.4 130 286 15.6 140 308 16.8 150 330 18.0 160 352 19.2
Inspect the ABLAVAR vial visually for particulate matter and discoloration prior to administration. Do not use the solution if it is discolored or particulate matter is present.

ABLAVAR is intended for single use only and should be used immediately upon opening. Discard any unused portion of the ABLAVAR vial.

Do not mix intravenous medications or parenteral nutrition solutions with ABLAVAR. Do not administer any other medications in the same intravenous line simultaneously with ABLAVAR.

2.2 Imaging Guidelines

ABLAVAR imaging is completed in two stages: the dynamic imaging stage and the steady-state imaging stage. Both stages are essential for adequate evaluation of the arterial system, and dynamic imaging always precedes steady-state imaging. During interpretation of the steady-state images, ABLAVAR within the venous system may limit or confound the detection of arterial lesions.

To assess the initial distribution of ABLAVAR within the arterial system, begin dynamic imaging immediately upon injection. Begin steady state imaging after dynamic imaging has been completed, generally 5 to 7 minutes following ABLAVAR administration. At this time point, ABLAVAR is generally distributed throughout the blood. In clinical trials, steady-state imaging was completed within approximately one hour following ABLAVAR injection.
Quadramet

Quadramet

The recommended dose of QUADRAMET® is 1.0 mCi/kg, administered intravenously over a period of one minute through a secure in-dwelling catheter and followed with a saline flush. Dose adjustment in patients at the extremes of weight have not been studied. Caution should be exercised when determining the dose in very thin or very obese patients.

The dose should be measured by a suitable radioactivity calibration system, such as a radioisotope dose calibrator, immediately before administration.

The dose of radioactivity to be administered and the patient should be verified before administering QUADRAMET®. Patients should not be released until their radioactivity levels and exposure rates comply with federal and local regulations.

The patient should ingest (or receive by i.v. administration) a minimum of 500 mL (2 cups) of fluids prior to injection and should void as often as possible after injection to minimize radiation exposure to the bladder.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit. The solution should not be used if it is cloudy or if it contains particulate matter.

QUADRAMET® contains calcium and may be incompatible with solutions that contain molecules that can complex with and form calcium precipitates.

QUADRAMET® should not be diluted or mixed with other solutions.

Thaw at room temperature before administration and use within 8 hours of thawing.

Radiation Dosimetry

The estimated absorbed radiation doses to an average 70 kg adult patient from an i.v. injection of QUADRAMET® are shown in Table 7. The dosimetry estimates were based on clinical biodistribution studies using methods developed for radiation dose calculations by the Medical Internal Radiation Dose (MIRD) Committee of the Society of Nuclear Medicine.

Radiation exposure is based on a urinary voiding interval of 4.8 hours. Radiation dose estimates for bone and marrow assume that radioactivity is deposited on bone surfaces, as noted in autoradiograms of biopsy bone samples in 7 patients who received QUADRAMET®. Although electron emissions from 153Sm are abundant, with energies up to 810 keV, rapid blood clearance of QUADRAMET® and low energy and abundant photon emissions generally result in low radiation doses to those parts of the body where the complex does not localize.

When blastic osseous lesions are present, significantly enhanced localization of the radiopharmaceutical will occur, with correspondingly higher doses to the lesions compared with normal bones and other organs. (See Clinical Pharmacology, Skeletal Uptake and Pharmacodynamics Sections).
TABLE 7 RADIATION ABSORBED DOSES

70 kg ADULT

Target Organ

    Rad/mCi

mGy/MBq

Bone Surfaces

    25.0

    6.76

Red Marrow

    5.70

    1.54

Urinary Bladder Wall

    3.60

    0.097

Kidneys

    0.065

    0.018

Whole Body

    0.040

    0.011

Lower large intestine

    0.037

    0.010

Ovaries

    0.032

    0.0086

Muscle

    0.028

    0.0076

Small Intestine

    0.023

    0.0062

Upper Large Intestine

    0.020

    0.0054

Testes

    0.020

    0.0054

Liver

    0.019

    0.0051

Spleen

    0.018

    0.0049

Stomach

    0.015

    0.0041
Fludeoxyglucose F-18

Fludeoxyglucose F-18

Fludeoxyglucose F 18 Injection emits radiation. Use procedures to minimize radiation exposure. Calculate the final dose from the end of synthesis (EOS) time using proper radioactive decay factors. Assay the final dose in a properly calibrated dose calibrator before administration to the patient [see Description (11.2)].

2.1 Recommended Dose for Adults

Within the oncology, cardiology and neurology settings, the recommended dose for adults is 5 - 10 mCi (185 - 370 MBq) as an intravenous injection.

2.2 Recommended Dose for Pediatric Patients

Within the neurology setting, the recommended dose for pediatric patients is 2.6 mCi, as an intravenous injection. The optimal dose adjustment on the basis of body size or weight has not been determined [see Use in Special Populations (8.4)].

2.3 Patient Preparation
To minimize the radiation absorbed dose to the bladder, encourage adequate hydration. Encourage the patient to drink water or other fluids (as tolerated) in the 4 hours before their PET study. Encourage the patient to void as soon as the imaging study is completed and as often as possible thereafter for at least one hour. Screen patients for clinically significant blood glucose abnormalities by obtaining a history and/or laboratory tests [see Warnings and Precautions (5.2)]. Prior to Fludeoxyglucose F 18 PET imaging in the oncology and neurology settings, instruct patient to fast for 4 - 6 hours prior to the drug's injection. In the cardiology setting, administration of glucose-containing food or liquids (e.g., 50 - 75 grams) prior to Fludeoxyglucose F 18 Injection facilitates localization of cardiac ischemia.
2.4 Radiation Dosimetry

The estimated human absorbed radiation doses (rem/mCi) to a newborn (3.4 kg), 1-year old (9.8 kg), 5-year old (19 kg), 10-year old (32 kg), 15-year old (57 kg), and adult (70 kg) from intravenous administration of Fludeoxyglucose F 18 Injection are shown in Table 2-1. These estimates were calculated based on human data and using the data published by the International Commission on Radiological Protection for Fludeoxyglucose 18F.1,2 The dosimetry data show that there are slight variations in absorbed radiation dose for various organs in each of the age groups. These dissimilarities in absorbed radiation dose are due to developmental age variations (e.g., organ size, location, and overall metabolic rate for each age group). The identified critical organs (in descending order) across all age groups evaluated are the urinary bladder, heart, pancreas, spleen, and lungs.
Table 2-1 Estimated Absorbed Radiation Doses (rem/mCi) After Intravenous Administration of Fludeoxyglucose F 18 Injection* Organ Newborn(3.4 kg) 1-year old(9.8 kg) 5-year old(19 kg) 10-year old(32 kg) 15-year old(57 kg) Adult(70 kg) * MIRDOSE 2 software was used to calculate the radiation absorbed dose. Assumptions on the biodistribution based on data from Gallagher et al. and Jones et al. 3,1 † The dynamic bladder model with a uniform voiding frequency of 1.5 hours was used. ‡ LLI = lower large intestine; § ULI = upper large intestine Bladder wall† 4.3 1.7 0.93 0.60 0.40 0.32 Heart wall 2.4 1.2 0.70 0.44 0.29 0.22 Pancreas 2.2 0.68 0.33 0.25 0.13 0.096 Spleen 2.2 0.84 0.46 0.29 0.19 0.14 Lungs 0.96 0.38 0.20 0.13 0.092 0.064 Kidneys 0.81 0.34 0.19 0.13 0.089 0.074 Ovaries 0.80 0.80 0.19 0.11 0.058 0.053 Uterus 0.79 0.35 0.19 0.12 0.076 0.062 LLI wall‡ 0.69 0.28 0.15 0.097 0.060 0.051 Liver 0.69 0.31 0.17 0.11 0.076 0.058 Gallbladder wall 0.69 0.26 0.14 0.093 0.059 0.049 Small Intestine 0.68 0.29 0.15 0.096 0.060 0.047 ULI wall§ 0.67 0.27 0.15 0.090 0.057 0.046 Stomach wall 0.65 0.27 0.14 0.089 0.057 0.047 Adrenals 0.65 0.28 0.15 0.095 0.061 0.048 Testes 0.64 0.27 0.14 0.085 0.052 0.041 Red marrow 0.62 0.26 0.14 0.089 0.057 0.047 Thymus 0.61 0.26 0.14 0.086 0.056 0.044 Thyroid 0.61 0.26 0.13 0.080 0.049 0.039 Muscle 0.58 0.25 0.13 0.078 0.049 0.039 Bone Surfaces 0.57 0.24 0.12 0.079 0.052 0.041 Breast 0.54 0.22 0.11 0.068 0.043 0.034 Skin 0.49 0.20 0.10 0.060 0.037 0.030 Brain 0.29 0.13 0.09 0.078 0.072 0.070 Other tissues 0.59 0.25 0.13 0.083 0.052 0.042
2.5 Radiation Safety – Drug Handling
Use waterproof gloves, effective radiation shielding, and appropriate safety measures when handling Fludeoxyglucose F 18 Injection to avoid unnecessary radiation exposure to the patient, occupational workers, clinical personnel and other persons. Radiopharmaceuticals should be used by or under the control of physicians who are qualified by specific training and experience in the safe use and handling of radionuclides, and whose experience and training have been approved by the appropriate governmental agency authorized to license the use of radionuclides. Calculate the final dose from the end of synthesis (EOS) time using proper radioactive decay factors. Assay the final dose in a properly calibrated dose calibrator before administration to the patient [see Description (11.2)]. The dose of Fludeoxyglucose F 18 Injection used in a given patient should be minimized consistent with the objectives of the procedure, and the nature of the radiation detection devices employed.
2.6 Drug Preparation and Administration
Calculate the necessary volume to administer based on calibration time and dose. Aseptically withdraw Fludeoxyglucose F 18 Injection from its container. Inspect Fludeoxyglucose F 18 Injection visually for particulate matter and discoloration before administration, whenever solution and container permit. Do not administer the drug if it contains particulate matter or discoloration; dispose of these unacceptable or unused preparations in a safe manner, in compliance with applicable regulations. Use Fludeoxyglucose F 18 Injection within 12 hours from the EOS.
2.7 Imaging Guidelines
Initiate imaging within 40 minutes following Fludeoxyglucose F 18 Injection administration. Acquire static emission images 30 – 100 minutes from the time of injection.
Technelite

Technelite

DOSAGE AND ADMINISTRATION: Sodium Pertechnetate Tc 99m Injection is usually administered by intravascular injection. For imaging the urinary bladder and ureters (direct isotopic cystography), the Sodium Pertechnetate Tc 99m Injection is administered by direct instillation aseptically into the bladder via a urethral catheter, following which the catheter is flushed with approximately 200 mL of sterile saline directly into the bladder. The dosage employed varies with each diagnostic procedure. When imaging the nasolacrimal drainage system, instill the Sodium Pertechnetate Tc 99m Injection by the use of a device such as a micropipette or similar method which will ensure the accuracy of the dose.

The suggested dose range employed for various diagnostic indications in the average ADULT PATIENT (70kg) is:
Vesico-ureteral Imaging 18.5 to 37MBq (0.5 to 1mCi) Thyroid Gland Imaging 37 to 370MBq (1 to 10mCi) Salivary Gland Imaging 37 to 185MBq (1 to 5mCi) Nasolacrimal Drainage System Maximum 3.7MBq (100µCi)
The recommended dosage range in PEDIATRIC PATIENTS is:
Vesico-ureteral Imaging 18.5 to 37MBq (0.5 to 1mCi) Thyroid Gland Imaging 2.22 to 2.96MBq (60 to 80µCi)/kg body weight
The patient dose should be measured by a suitable radioactivity calibration system immediately prior to administration of the dose.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit. The solution to be administered as the patient dose should be clear and contain no particulate matter. Do not use an eluate of the TECHNELITE®, Technetium Tc 99m Generator later than one (1) working day after elution (12 hours).

RADIATION DOSIMETRY

The estimated absorbed radiation doses to an average ADULT and Pediatric patient from an intravenous injection of a maximum dose of 1110MBq (30 millicuries) of Sodium Pertechnetate Tc 99m Injection distributed uniformly in the total body are shown in Tables 5 and 6.
Table 5. Adult Absorbed Radiation Doses (mGy) from Intravenous Injection Organ Absorbed Radiation Dose (mGy) for a 1110 MBq (30mCi) dose To obtain radiation absorbed dose in rads (30 mCi dose) from the above table, divide individual organ values by a factor of 10 (does not apply for effective dose). Adrenals 4.1 Urinary Bladder Wall 20 Bone Surfaces 6.2 Brain 2.2 Breasts 2 Gallbladder Wall 8.3 Stomach Wall 29 Small Intestine 18 ULI Wall 63 LLI Wall 23 Heart Wall 3.5 Kidneys 6 Liver 4.7 Lungs 2.9 Muscle 3.6 Ovaries 11 Pancreas 6.3 Red Marrow 4.1 Skin 2 Spleen 4.8 Testes 3.1 Thymus 2.7 Thyroid 24 Uterus 9 Remaining Tissues 3.9 Effective Dose (mSv) 14 Table 6. Pediatric Absorbed Radiation Doses (mGy) from Intravenous Injection Age 15 years 10 years 5 years 1 year To obtain radiation absorbed dose in rads (30 mCi dose) from the above table, divide individual organ values by a factor of 10 (does not apply for effective dose). Administered activity in MBq (mCi) 1110(30) 740(20) 555(15) 370(10) Organ Adrenals 5.3 5.4 6.2 7.1 Urinary Bladder Wall 26 22 18 22 Bone Surfaces 7.6 7.5 8.1 10 Brain 2.8 3.1 3.7 4.5 Breasts 2.6 2.6 3.2 4.1 Gallbladder Wall 11 12 13 13 Stomach Wall 38 36 43 59 Small Intestine 22 23 26 30 ULI Wall 81 89 110 140 LLI Wall 31 33 40 48 Heart Wall 4.5 4.6 5.2 6.4 Kidneys 7.2 6.9 7.8 8.5 Liver 6 6.7 8 9.1 Lungs 3.8 3.8 4.4 5.3 Muscle 4.5 4.5 5 6 Ovaries 14 13 14 17 Pancreas 8.1 8.2 8.9 10 Red Marrow 5.1 5 5.2 6 Skin 2.5 2.6 3.2 3.8 Spleen 6 6 6.7 7.8 Testes 4.1 4.3 4.9 6 Thymus 3.6 3.5 4.2 5.3 Thyroid 40 41 67 81 Uterus 11 11 12 14 Remaining Tissues 4.8 4.8 5.4 6.4 Effective Dose (mSv) 19 19 23 29
The estimated absorbed radiation doses to an average ADULT from the instillation of Sodium Pertechnetate Tc 99m Injection for imaging the nasolacrimal drainage system are shown in Table 7.
Table 7. Absorbed Radiation Dose from Dacryoscintigraphy Using Sodium Pertechnetate Tc 99m Absorbed Dose Target Organ mGy/ 3.7MBq (rad/ 100µCi) * Assuming no blockage of drainage system Eye Lens: If lacrimal fluid turnover is 16%/min If lacrimal fluid turnover is 100%/min If drainage system is blocked Total Body* Ovaries* Testes* Thyroid* 0.140 0.022 4.020 0.011 0.030 0.009 0.130 0.014 0.002 0.402 0.001 0.003 0.001 0.013
In pediatric patients, an average 30 minute exposure to 37MBq (1 millicurie) of Sodium Pertechnetate Tc 99m Injection following instillation for direct cystography, results in an estimated absorbed radiation dose shown in Table 8.
Table 8. Pediatric Absorbed Radiation Dose from Cystography Age Bladder wall dose, mGy (rad) Gonadal dose,mGy (rad) 1 year 3.6 (0.36) 0.15 (0.015) 5 years 2.0 (0.2) 0.095 (0.0095) 10 years 1.3 (0.13) 0.066 (0.0066) 15 years 0.92 (0.092) 0.046 (0.0046)
Definity

Definity

DEFINITY® is intended for administration only after activation in the VIALMIX® apparatus. Before injection, this product must be activated and prepared according to the instructions outlined below. The VIALMIX® apparatus should be ordered from Lantheus Medical Imaging, 331 Treble Cove Road, North Billerica, MA, 01862. For customer orders call 1-800-299-3431.

DEFINITY® may be injected by either an intravenous (IV) bolus or infusion. The maximum dose is either two bolus doses or one single intravenous infusion. The safety of bolus and infusion dosing in combination or in sequence, has not been studied.

2.1 Bolus

The recommended bolus dose for activated DEFINITY® is 10 microliters (microL)/kg of the activated product by intravenous bolus injection within 30-60 seconds, followed by a 10 mL saline flush. If necessary, a second 10 microliters (microL)/kg dose followed by a second 10 mL saline flush may be administered 30 minutes after the first injection to prolong contrast enhancement.

2.2 Infusion

The recommended infusion dose for activated DEFINITY® is via an IV infusion of 1.3 mL added to 50 mL of preservative-free saline. The rate of infusion should be initiated at 4.0 mL/minute, but titrated as necessary to achieve optimal image enhancement, not to exceed 10 mL/minute.

2.3 Imaging

After baseline non-contrast echocardiography is completed, set the mechanical index for the ultrasound device at 0.8 or below [see WARNINGS AND PRECAUTIONS (5.4)]. Then inject activated DEFINITY® (as described above) and begin ultrasound imaging immediately. Evaluate the activated DEFINITY® echocardiogram images in combination with the non-contrast echocardiogram images.

In a crossover trial of 64 patients randomized to both bolus and infusion, the duration of clinically useful contrast enhancement for fundamental imaging was approximately 3.4 minutes after a 10 microL/kg bolus and was approximately 7.1 minutes during the continuous infusion of 1.3 mL activated DEFINITY® in 50 mL saline at a rate of 4 mL/min.

2.4 DEFINITY® Activation, Preparation and Handling Instructions
Allow the vial to warm to room temperature before starting the activation procedure. Activate DEFINITY® by shaking the vial for 45 seconds using a VIALMIX®.Note: illustrations of this procedure are contained in the VIALMIX® Users Guide.Do not use this drug unless it has completed a full 45 second activation cycle in the VIALMIX®. DEFINITY® will not be properly activated unless the full 45 second activation cycle is completed. Do not reactivate the vial if VIALMIX® did not complete a full 45 second cycle. Do not reactivate a successfully activated DEFINITY® vial (see step 3). Do not use a VIALMIX® that is not functioning properly. Refer to the "VIALMIX® User's Guide" for the "VIALMIX® calibration and replacement procedures" to ensure that a properly functioning VIALMIX® is used. Immediately after activation in the VIALMIX®, activated DEFINITY® appears as a milky white suspension and may be used immediately after activation. If the product is not used within 5 minutes of VIALMIX® activation, the microspheres should be resuspended by 10 seconds of hand agitation by inverting the vial before the product is withdrawn in a syringe. The activated DEFINITY® may be used for up to 12 hours from the time of VIALMIX®, but only after the microspheres are resuspended by hand agitation. Store the activated DEFINITY® at room temperature in the original product vial. Invert the vial and withdraw the activated milky white suspension using the Intellipin™ (Dispensing Pin), the PINSYNC™ (Vented Vial Adapter 13mm), or 18 to 20 gauge syringe needle. Withdraw the material from the middle of the liquid in the inverted vial. Do not inject air into the DEFINITY® VIAL. Use the product immediately after its withdrawal from the vial; do not allow the product to stand in the syringe.
For single use only: DEFINITY® does not contain bacterial preservative. Bacterial contamination with the risk of post-administration septicemia can occur following the puncture of the elastomeric septum. It is essential to follow directions for activation of DEFINITY® carefully and to adhere to strict aseptic procedures during preparation.
Kit For The Preparation...

Kit For The Preparation Of Technetium Tc99m Sestamibi

For Myocardial Imaging: The suggested dose range for I.V. administration of Technetium Tc99m Sestamibi in a single dose to be employed in the average patient (70 Kg) is 370-1110 MBq (10-30 mCi).

For Breast Imaging: The recommended dose range for I.V. administration of Technetium Tc99m Sestamibi is a single dose of 740-1110 MBq (20 - 30 mCi).

2.1 Image Acquisition

Breast Imaging: It is recommended that images are obtained with a table overlay to separate breast tissue from the myocardium and liver, and to exclude potential activity that may be present in the opposite breast. For lateral images, position the patient prone with the isolateral arm comfortably above the head, shoulders flat against the table, head turned to the side and relaxed, with the breast imaged pendent through an overlay cutout. The breast should not be compressed on the overlay. For anterior images, position the patient supine with both arms behind the head. For either lateral or anterior images, shield the chest and abdominal organs, or remove them from the field of view.

For complete study, sets of images should be obtained five minutes after the injection, and in the following sequence:

Beginning five minutes after the injection of Technetium Tc99m Sestamibi:
ten-minute lateral image of breast with abnormality ten-minute lateral image of contralateral breast ten-minute anterior image of both breasts
2.2 Radiation Dosimetry

The radiation doses to organs and tissues of an average patient (70 Kg) per 1110 MBq (30 mCi) of Technetium Tc99m Sestamibi injected intravenously are shown in Table 1.0.
Table 1.0. Radiation Absorbed Doses from Tc99m Sestamibi Estimated Radiation Absorbed Dose REST 2.0 hour void 4.8 hour void Organ rads/30 mCi mGy/1110 MBq rads/30 mCi mGy/1110 MBq Breasts 0.2 2.0 0.2 1.9 Gallbladder Wall 2.0 20.0 2.0 20.0 Small Intestine 3.0 30.0 3.0 30.0 Upper Large Intestine Wall 5.4 55.5 5.4 55.5 Lower Large Intestine Wall 3.9 40.0 4.2 41.1 Stomach Wall 0.6 6.1 0.6 5.8 Heart Wall 0.5 5.1 0.5 4.9 Kidneys 2.0 20.0 2.0 20.0 Liver 0.6 5.8 0.6 5.7 Lungs 0.3 2.8 0.3 2.7 Bone Surfaces 0.7 6.8 0.7 6.4 Thyroid 0.7 7.0 0.7 7.0 Ovaries 1.5 15.5 1.6 15.5 Testes 0.3 3.4 0.4 3.9 Red Marrow 0.5 5.1 0.5 5.0 Urinary Bladder Wall 2.0 20.0 4.2 41.1 Total Body 0.5 4.8 0.5 4.8 STRESS 2.0 hour void 4.8 hour void Organ rads/30 mCi mGy/1110 MBq rads/30 mCi mGy/1110 MBq Breasts 0.2 2.0 0.2 1.8 Gallbladder Wall 2.8 28.9 2.8 27.8 Small Intestine 2.4 24.4 2.4 24.4 Upper Large Intestine Wall 4.5 44.4 4.5 44.4 Lower Large Intestine Wall 3.3 32.2 3.3 32.2 Stomach Wall 0.6 5.3 0.5 5.2 Heart Wall 0.5 5.6 0.5 5.3 Kidneys 1.7 16.7 1.7 16.7 Liver 0.4 4.2 0.4 4.1 Lungs 0.3 2.6 0.2 2.4 Bone Surfaces 0.6 6.2 0.6 6.0 Thyroid 0.3 2.7 0.2 2.4 Ovaries 1.2 12.2 1.3 13.3 Testes 0.3 3.1 0.3 3.4 Red Marrow 0.5 4.6 0.5 4.4 Urinary Bladder Wall 1.5 15.5 3.0 30.0 Total Body 0.4 4.2 0.4 4.2
Radiation dosimetry calculations performed by Radiation Internal Dose Information Center, Oak Ridge Institute for Science and Education, PO Box 117, Oak Ridge, TN 37831-0117.

2.3 Instructions For Preparation

Preparation of the Technetium Tc99m Sestamibi is done by the following aseptic procedure:

General Procedure:
a. Prior to adding the Sodium Pertechnetate Tc99m Injection to the vial, inspect the vial carefully for the presence of damage, particularly cracks, and do not use the vial if found. Tear off a radiation symbol and attach it to the neck of the vial. b. Waterproof gloves should be worn during the preparation procedure. Remove the plastic disc from the vial and swab the top of the vial closure with alcohol to sanitize the surface.
Boiling Water Bath Procedure:
c. Place the vial in a suitable radiation shield with a fitted radiation cap. d. With a sterile shielded syringe, aseptically obtain additive-free, sterile, non-pyrogenic Sodium Pertechnetate Tc99m Injection [925-5550 MBq, (25-150 mCi)] in approximately 1 to 3 mL. e. Aseptically add the Sodium Pertechnetate Tc99m Injection to the vial in the lead shield. Without withdrawing the needle, remove an equal volume of headspace to maintain atmospheric pressure within the vial. f. Shake vigorously, about 5 to 10 quick upward-downward motions. g. Remove the vial from the lead shield and place upright in an appropriately shielded and contained boiling water bath, such that the vial is suspended above the bottom of the bath, and boil for 10 minutes. Timing for 10 minutes is begun as soon as the water begins to boil again. Do not allow the boiling water to come in contact with the aluminum crimp. h. Remove the vial from the water bath, place in the lead shield and allow to cool for fifteen minutes.
Recon-o-Stat (thermal cycler) Procedure:
c. Place the vial in the thermal cycler radiation shield. d. With a sterile shielded syringe, aseptically obtain additive-free, sterile, non-pyrogenic Sodium Pertechnetate Tc99m Injection [925-5550 MBq, (25-150 mCi)] in approximately 1 to 3 mL. e. Aseptically add the Sodium Pertechnetate Tc99m Injection to the vial in the lead shield. Without withdrawing the needle, remove an equal volume of headspace to maintain atmospheric pressure within the vial. f. Shake vigorously, about 5 to 10 quick upward-downward motions. g. Place shield on sample block. While slightly pressing downward, give the shield a quarter turn to make certain there is a firm fit between the shield and the sample block. h. Press the proceed button to initiate the program (the thermal cycler automatically heats & cools the vial and contents). Please see the Recon-o-Stat Instruction Manual for further details.
General Procedure (cont.):
i. Using proper shielding, the vial contents should be visually inspected. Use only if the solution is clear and free of particulate matter and discoloration. j. Assay the reaction vial using a suitable radioactivity calibration system. Record the Technetium Tc99m concentration, total volume, assay time and date, expiration time and lot number on the vial shield label and affix the label to the shield. k. Store the reaction vial containing the Technetium Tc99m Sestamibi at 15° to 25°C until use; at such time the product should be aseptically withdrawn. Technetium Tc99m Sestamibi should be used within six hours of preparation. The vial contains no preservative.
Note: Adherence to the above product reconstitution instructions is recommended.

The potential for cracking and significant contamination exists whenever vials containing radioactive material are heated.

Product should be used within 6 hours after preparation.

Final product with radiochemical purity of at least 90% was used in the clinical trials that established safety and effectiveness. The radiochemical purity was determined by the following method.

2.4 Determination of Radiochemical Purity in Technetium Tc99m Sestamibi
Obtain a Baker-Flex Aluminum Oxide coated, plastic TLC plate, #1 B-F, pre-cut to 2.5 cm × 7.5 cm. Dry the plate or plates at 100°C for 1 hour and store in a desiccator. Remove pre-dried plate from the desiccator just prior to use. Apply 1 drop of ethanol1 using a 1 mL syringe with a 22-26 gauge needle, 1.5 cm from the bottom of the plate. THE SPOT SHOULD NOT BE ALLOWED TO DRY. Add 2 drops of Technetium Tc99m Sestamibi solution, side by side on top of the ethanol1 spot. Return the plate to a desiccator and allow the sample spot to dry (typically 15 minutes). The TLC tank is prepared by pouring ethanol1 to a depth of 3-4 mm. Cover the tank and let it equilibrate for ~10 minutes. Develop the plate in the covered TLC tank in ethanol1 for a distance of 5 cm from the point of application. Cut the TLC plate 4 cm from the bottom and measure the Tc99m activity in each piece by appropriate radiation detector. Calculate the % Tc99m Sestamibi as:% Tc99m Sestamibi = µCi Top Piece µCi Both Pieces × 100 Figure 1 TLC Plate Diagram 1 The ethanol used in this procedure should be 95% or greater. Absolute ethanol (99%) should remain at ≥ 95% ethanol content for one week after opening if stored tightly capped, in a cool dry place.

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