【中文通用名称】碘佛醇注射液
【英文通用名称】Ioversol 　　
【中文其他名称】碘维索尔, 安射力, 安射力320, 碘佛醇注射液, 安射力350 　　
【英文其他名称】Optiray, Loversol, Ioversol Injection 　【产品所属分类】其它药物\诊断用药\X线造影剂 　　
【功能/功效】 　　
1.本药主要用于各种血管造影检查，包括：脑血管造影、周围动脉造影、肾动脉造影和主动脉造影、心血管造影(冠状动脉造影、动脉及静脉性数字减影血管造影)等。 　　
2.用于静脉性尿路造影以及CT增强扫描(包括头部和体部CT)等。
注意事项： 　　
1.禁忌症 尚不明确。 　　
2.慎用
(1)有碘过敏史者。
(2)有高危因素的老年人或幼儿。
(3)支气管哮喘患者。
(4)心功能不全者。
(5)肝功能不全者。
(6)肾功能不全者(或血清肌酐超过3mg/dl时)。
(7)甲状腺功能亢进患者。 　　
3.药物对妊娠的影响 尚不明确。 　　
4.药物对哺乳的影响 尚不明确。

【不良反应】
包括头痛、恶心、呕吐、荨麻疹、胸闷、热感、疼痛等，一般较少，且多数轻微，但和其它碘造影剂一样也可能发生严重反应，如支气管痉挛甚至过敏性休克。
【给药说明： 　　
1.造影剂和皮质激素存在化学配伍禁忌，故不能混合在一个注射器内使用。 　　
2.在造影前应使病人体内保持足够水分。 　　
3.周围动脉造影注射的动脉必须有搏动，对闭塞性血栓性脉管炎或严重缺血性疾患伴向上蔓延感染，进行造影应极谨慎。 　　4.主动脉造影可能引起邻近器官损伤、胸膜穿破、肾损伤。采用腰部技术可能导致腹膜后出血、脊髓损伤及横断性脊髓炎症状。冠脉造影应对心电图及生命指征进行监测。 　　
5.患者患有血栓、静脉炎、严重缺血、局部感染或静脉系统完全堵塞时，建议在透视下操作，以防止注射时造影剂溢出血管外。 6.本药为非离子型造影剂，抑制血凝的作用比离子型弱，但在进行血管造影时，对操作步骤、时间长短、注射次数、导管及注射器材料仍应予以注意，尽量缩短血液与注射器、导管接触时间，以防可能发生的凝血现象。 　　
7.发生较重不良反应时，除对症治疗外，应给予抗过敏药物、肾上腺素、吸氧等。发生支气管痉挛致呼吸困难时可给予气管插管。在高危病人，预防用药(地塞米松)可有一定帮助。 　　
8.病人做完造影后宜观察1小时，因偶有延迟反应。 　　
9.产品有冻结或结晶出现时则不可使用。 　　
10.过量注射应立即进行对症治疗。本药不与血浆结合，因此可透析清除。

【用法与用量】　　
成人 　　
·常规剂量 　　
·血管造影 以下剂量可重复，总剂量一般不超过200-250ml。 1.脑血管造影：显示颈动脉或椎动脉需2-12ml，使用碘佛醇240或碘佛醇320均可。 　　
2.主动脉造影：用碘佛醇320，每次60ml。 　　
3.髂总股动脉造影：每次40ml。 　　
4.锁骨下动脉肱动脉造影：每次20ml。 　　
5.腹腔动脉造影：每次45ml。 　　
6.肠系膜动脉造影：每次45ml。 　　
7.肾动脉造影：每次9ml。 　　
8.冠状动脉及左室造影：用碘佛醇320，左冠状动脉8ml；右冠状动脉6ml；左室造影40ml。 　　
·动脉数字减影血管造影(IA-DSA) IA-DSA的用量应少于一般造影剂量的50%，具体的剂量取决于注射部位。一般采用：颈动脉6-10ml；椎动脉4-8ml；主动脉25-50ml；锁骨下动脉2-10ml；腹主动脉主要分支2-20ml。如必需，可重复注射，总剂量不超过200-250ml。 　　
·CT增强扫描 　　
1.头部CT：碘佛醇320，50-150ml；或碘佛醇240，100-250ml，注射结束后可立即扫描。 　　
2.体部CT：碘佛醇320团注25-75ml，点滴50-150ml；或碘佛醇240团注35-100ml，点滴70-200ml。 　　
·静脉数字减影血管造影(IV-DSA) 根据检查部位，每次注射剂量通常为30-50ml，可重复注射，总剂量不超过200-250ml。 　·静脉尿路造影 碘佛醇320，50-75ml；或碘佛醇240，75-100ml。 　　
儿童 　　
·常规剂量 　　
·血管造影 用碘佛醇320，一般单次注射1.25ml(范围1-1.5ml)/kg。多次注射时总量不应超过5ml/kg。 　　·CT增强扫描 　　
1.头部CT：用碘佛醇320一般每次1ml(范围1-3ml)/kg，注射结束后可立即扫描。 　　
2.体部CT：用碘佛醇320一般每次1ml(范围1-3ml)/kg。 　　
·静脉数字减影血管造影(IV-DSA) 用碘佛醇320每次1-1.5ml/kg，总剂量不超过3ml/kg。
【禁忌】尚不明确。
【制剂与规格】 　　
碘佛醇注射剂
(1)碘含量1ml:160mgI(碘佛醇160)。
(2)碘含量1ml:240mgI(碘佛醇240)。
(3)碘含量1ml:300mgI(碘佛醇300)。
(4)碘含量1ml:320mgI(碘佛醇320)。
(5)碘含量1ml:350mgI(碘佛醇350)。 　　
【贮法】在37℃时，可贮存1个月；贮存时间超过1个月，则在30℃下避光贮藏。

注册证号: H20100445
注册证号备注:
原注册证号:
产品名称（中文）: 碘佛醇注射液
产品名称（英文） : Ioversol Injection
商品名（中文）: 安射力350
商品名（英文）: Optiray
剂型（中文）: 注射剂
规格（中文）: 50ml:17.5g(I)
注册证号备注:
包装规格（中文）: 20支/箱
生产厂商（中文）:
生产厂商（英文）: Mallinckrodt Inc.
厂商地址（中文）:
厂商地址（英文）: Raleigh, NC 27616
厂商国家（中文）: 美国
厂商国家（英文）: U.S.A.
分包装批准文号:
发证日期: 2010-06-18
有效期截止日: 2015-06-17
分包装企业名称:
分包装企业地址:
分包装文号批准日期:
分包装文号有效期截止日:
产品类别: 化学药品
药品本位码: 86979058000563
药品本位码备注:
公司名称（中文）:
公司名称（英文）: Mallinckrodt Inc.
地址（中文）:
地址（英文）: 675 McDonnell Blvd Hazelwood. MO 63042
国家（中文）: 美国
国家（英文）: U.S.A.

DESCRIPTION

OPTIRAY (ioversol injection) formulations are sterile, nonpyrogenic, aqueous solutions intended for intravascular administration as diagnostic radiopaque media. Each bottle is to be used as a Pharmacy Bulk Package for dispensing multiple single dose preparations utilizing a suitable transfer device.

Ioversol is designated chemically as N,N '-Bis (2,3-dihydroxypropyl)-5-[N-(2-hydroxyethyl) -glycolamido] -2,4,6-triiodoisophthalamide and has the following structural formula:

The molecular weight of ioversol is 807.11 and the organically bound iodine content is 47.2%. Ioversol is nonionic and does not dissociate in solution.

Each milliliter of OPTIRAY Pharmacy Bulk Package - 350 (ioversol injection 74%) contains 741 mg of ioversol with 3.6 mg of tromethamine as a buffer and 0.2 mg of edetate calcium disodium as a stabilizer. OPTIRAY Pharmacy Bulk Package - 350 provides 35% (350 mg/mL) organically bound iodine.

Each milliliter of OPTIRAY Pharmacy Bulk Package - 320 (ioversol injection 68%) contains 678 mg of ioversol with 3.6 mg of tromethamine as a buffer and 0.2 mg of edetate calcium disodium as a stabilizer. OPTIRAY Pharmacy Bulk Package - 320 provides 32% (320 mg/mL) organically bound iodine.

Each milliliter of OPTIRAY Pharmacy Bulk Package - 300 (ioversol injection 64%) contains 636 mg of ioversol with 3.6 mg of tromethamine as a buffer and 0.2 mg of edetate calcium disodium as a stabilizer. OPTIRAY Pharmacy Bulk Package - 300 provides 30% (300 mg/mL) organically bound iodine.

The pH of the OPTIRAY formulations has been adjusted to 6.0 to 7.4 with hydrochloric acid or sodium hydroxide. All solutions are sterilized by autoclaving and contain no preservatives. Unused portions should be discarded. OPTIRAY solutions are sensitive to light and therefore should be protected from exposure.

Some physical and chemical properties of these formulations are listed below:

	OPTIRAY	OPTIRAY	OPTIRAY
	300	320	350
Ioversol content	636	678	741
(mg/mL)
Iodine content	300	320	350
(mg I/mL)
Osmolality	651	702	792
(mOsm/kg water)
Viscosity (cps)
at 25 °C	8.2	9.9	14.3
at 37 °C	5.5	5.8	9.0
Specific Gravity
at 37 °C	1.352	1.371	1.405

The OPTIRAY formulations are clear, colorless to pale yellow solutions containing no undissolved solids. Crystallization does not occur at room temperature. The products are supplied in containers from which the air has been displaced by nitrogen. OPTIRAY solutions have osmolalities 2.3 to 2.8 times that of plasma (285 mOsm/kg water) as shown in the above table and are hypertonic under conditions of use.

CLINICAL PHARMACOLOGY

The pharmacokinetics of ioversol intravascularly administered in normal subjects conform to an open two compartment model with first order elimination (a rapid alpha phase for drug distribution and a slower beta phase for drug elimination). Based on the blood clearance curves for 12 healthy volunteers (6 receiving 50 mL and 6 receiving 150 mL of OPTIRAY 320), the biological half-life was 1.5 hours for both dose levels and there was no evidence of any dose related difference in the rate of elimination.

Ioversol is excreted mainly through the kidneys following intravascular administration. In patients with impaired renal function, the elimination half-life is prolonged. In the absence of renal dysfunction, the mean half-life for urinary excretion following a 50 mL dose was 118 minutes (105 to 156) and following a 150 mL dose was 105 minutes (74 to 141). Greater than 95% of the administered dose was excreted within the first 24 hours, with the peak urine concentration occurring in the first 2 hours after administration. Fecal elimination was negligible.

Ioversol does not bind to serum or plasma proteins to any extent and no significant metabolism, deiodination or biotransformation occurs.

OPTIRAY probably crosses the placental barrier in humans by simple diffusion. It is not known to what extent ioversol is excreted in human milk.

Intravascular injection of ioversol opacifies those vessels in the path of the flow of the contrast medium, permitting radiographic visualization of the internal structures until significant hemodilution occurs.

Ioversol may be visualized in the renal parenchyma within 30 to 60 seconds following rapid intravenous injection. Opacification of the calyces and pelves in patients with normal renal function becomes apparent within 1 to 3 minutes, with optimum contrast occurring within 5 to 15 minutes.

Animal studies indicate that ioversol does not cross the blood-brain barrier or cause endothelial damage to any significant extent.

OPTIRAY enhances computed tomographic imaging through augmentation of radiographic efficiency. The degree of density enhancement is directly related to the iodine content in an administered dose; peak iodine blood levels occur immediately following rapid intravenous injection. Blood levels fall rapidly within 5 to 10 minutes and the vascular compartment half-life is approximately 20 minutes. This can be accounted for by the dilution in the vascular and extravascular fluid compartments which causes an initial sharp fall in plasma concentration. Equilibration with the extracellular compartments is reached in about 10 minutes; thereafter, the fall becomes exponential.

The pharmacokinetics of ioversol in both normal and abnormal tissue have been shown to be variable. Contrast enhancement appears to be greatest immediately after bolus administration (15 seconds to 120 seconds). Thus, greatest enhancement may be detected by a series of consecutive two-to-three second scans performed within 30 to 90 seconds after injection (i.e., dynamic computed tomographic imaging). Utilization of a continuous scanning technique (i.e., dynamic CT scanning) may improve enhancement and diagnostic assessment of tumor and other lesions such as abscess, occasionally revealing unsuspected or more extensive disease. For example, a cyst may be distinguished from a vascularized solid lesion when precontrast and enhanced scans are compared; the nonperfused mass shows unchanged x-ray absorption (CT number). A vascularized lesion is characterized by an increase in CT number in the few minutes after a bolus of intravascular contrast agent; it may be malignant, benign, or normal tissue, but would probably not be a cyst, hematoma, or other nonvascular lesion.

Because unenhanced scanning may provide adequate diagnostic information in the individual patient, the decision to employ contrast enhancement, which may be associated with risk and increased radiation exposure, should be based upon a careful evaluation of clinical, other radiological, and unenhanced CT findings.

CT Scanning Of The Head

In contrast enhanced computed tomographic head imaging, OPTIRAY does not accumulate in normal brain tissue due to the presence of the normal blood-brain barrier. The increase in x-ray absorption in the normal brain is due to the presence of contrast agent within the blood pool. A break in the blood-brain barrier such as occurs in malignant tumors of the brain allows for the accumulation of contrast medium within the interstitial tissue of the tumor. Adjacent normal brain tissue does not contain the contrast medium.

Maximum contrast enhancement in tissue frequently occurs after peak blood iodine levels are reached. A delay in maximum contrast enhancement can occur. Diagnostic contrast enhanced images of the brain have been obtained up to 1 hour after intravenous bolus administration. This delay suggests that radiographic contrast enhancement is at least in part dependent on the accumulation of iodine containing medium within the lesion and outside the blood pool, although the mechanism by which this occurs is not clear. The radiographic enhancement of nontumoral lesions, such as arteriovenous malformations and aneurysms, is probably dependent on the iodine content of the circulating blood pool.

In patients where the blood-brain barrier is known or suspected to be disrupted, the use of any radiographic contrast medium must be assessed on an individual risk to benefit basis. However, compared to ionic media, nonionic media are less toxic to the central nervous system.

CT Scanning Of The Body

In contrast enhanced computed tomographic body imaging (nonneural tissue), OPTIRAY diffuses rapidly from the vascular into the extravascular space. Increase in x-ray absorption is related to blood flow, concentration of the contrast medium, and extraction of the contrast medium by interstitial tissue of tumors since no barrier exists. Contrast enhancement is thus due to the relative differences in extravascular diffusion between normal and abnormal tissue, quite different from that in the brain.

INDICATIONS AND USAGE

OPTIRAY 350 is indicated in adults for peripheral and coronary arteriography and left ventriculography. OPTIRAY 350 is also indicated for contrast enhanced computed tomographic imaging of the head and body, intravenous excretory urography, intravenous digital subtraction angiography and venography. OPTIRAY 350 is indicated in children for angiocardiography.

OPTIRAY 320 is indicated in adults for angiography throughout the cardiovascular system. The uses include cerebral, coronary, peripheral, visceral and renal arteriography, venography, aortography, and left ventriculography. OPTIRAY 320 is also indicated for contrast enhanced computed tomographic imaging of the head and body, and intravenous excretory urography.

OPTIRAY 320 is indicated in children for angiocardiography, contrast enhanced computed tomographic imaging of the head and body, and intravenous excretory urography.

OPTIRAY 300 is indicated for cerebral angiography and peripheral arteriography. OPTIRAY 300 is also indicated for contrast enhanced computed tomographic imaging of the head and body, venography, and intravenous excretory urography.

CONTRAINDICATIONS

None.

WARNINGS SEVERE ADVERSE EVENTS — INADVERTENT INTRATHECAL ADMINISTRATION: Serious adverse reactions have been reported due to the inadvertent intrathecal administration of iodinated contrast media that are not indicated for intrathecal use. These serious adverse reactions include: death, convulsions, cerebral hemorrhage, coma, paralysis, arachnoiditis, acute renal failure, cardiac arrest, seizures, rhabdomyolysis, hyperthermia, and brain edema. Special attention must be given to insure that this drug product is not administered intrathecally. Nonionic iodinated contrast media inhibit blood coagulation, in vitro, less than ionic contrast media. Clotting has been reported when blood remains in contact with syringes containing nonionic contrast media. Serious, rarely fatal, thromboembolic events causing myocardial infarction and stroke have been reported during angiographic procedures with both ionic and nonionic contrast media. Therefore, meticulous intravascular administration technique is necessary, particularly during angiographic procedures, to minimize thromboembolic events. Numerous factors, including length of procedure, catheter and syringe material, underlying disease state, and concomitant medications may contribute to the development of thromboembolic events. For these reasons, meticulous angiographic techniques are recommended including close attention to guidewire and catheter manipulation, use of manifold systems and/or three-way stopcocks, frequent catheter flushing with heparinized saline solutions and minimizing the length of the procedure. The use of plastic syringes in place of glass syringes has been reported to decrease but not eliminate the likelihood of in vitro clotting. Serious or fatal reactions have been associated with the administration of iodine-containing radiopaque media. It is of utmost importance to be completely prepared to treat any contrast medium reaction. As with any contrast medium, serious neurologic sequelae, including permanent paralysis, can occur following cerebral arteriography, selective spinal arteriography and arteriography of vessels supplying the spinal cord. A cause-effect relationship to the contrast medium has not been established since the patients' pre-existing condition and procedural technique are causative factors in themselves. The arterial injection of a contrast medium should never be made following the administration of vasopressors since they strongly potentiate neurologic effects. Caution must be exercised in patients with severely impaired renal function, combined renal and hepatic disease, severe thyrotoxicosis, myelomatosis, or anuria, particularly when large doses are administered. Intravascularly administered iodine-containing radiopaque media are potentially hazardous in patients with multiple myeloma or other paraproteinemia, particularly in those with therapeutically resistant anuria. Myeloma occurs most commonly in persons over age 40. Although neither the contrast agent nor dehydration has been proved separately to be the cause of anuria in myelomatous patients, it has been speculated that the combination of both may be causative. The risk in myelomatous patients is not a contraindication to the procedure; however, special precautions, including maintenance of normal hydration and close monitoring, are required. Partial dehydration in the preparation of these patients prior to injection is not recommended since this may predispose the patient to precipitation of the myeloma protein. Administration of radiopaque materials to patients known or suspected of having pheochromocytoma should be performed with extreme caution. If, in the opinion of the physician, the possible benefits of such procedures outweigh the considered risks, the procedures may be performed; however, the amount of radiopaque medium injected should be kept to an absolute minimum. The blood pressure should be assessed throughout the procedure, and measures for treatment of a hypertensive crisis should be available. Contrast media may promote sickling in individuals who are homozygous for sickle cell disease when administered intravascularly. Reports of thyroid storm following the intravascular use of iodinated radiopaque agents in patients with hyperthyroidism or with an autonomously functioning thyroid nodule, suggest that this additional risk be evaluated in such patients before use of any contrast medium.

PRECAUTIONS

General

Diagnostic procedures which involve the use of iodinated intravascular contrast agents should be carried out under the direction of personnel skilled and experienced in the particular procedure to be performed. A fully equipped emergency cart, or equivalent supplies and equipment, and personnel competent in recognizing and treating adverse reactions of all types should always be available. Since severe delayed reactions have been known to occur, emergency facilities and competent personnel should be available for at least 30 to 60 minutes after administration.

Preparatory dehydration is dangerous and may contribute to acute renal failure in patients with advanced vascular disease, diabetic patients, and in susceptible nondiabetic patients (often elderly with pre-existing renal disease). Patients should be well hydrated prior to and following the administration of OPTIRAY.

The possibility of a reaction, including serious, life-threatening, fatal, anaphylactoid or cardiovascular reactions, should always be considered (See ADVERSE REACTIONS). Increased risk is associated with a history of previous reaction to a contrast medium, a known sensitivity to iodine and known allergies (i.e., bronchial asthma, hay fever and food allergies) or hypersensitivities.

The occurrence of severe idiosyncratic reactions has prompted the use of several pretesting methods. However, pretesting cannot be relied upon to predict severe reactions and may itself be hazardous to the patient. It is suggested that a thorough medical history with emphasis on allergy and hypersensitivity, prior to the injection of any contrast medium, may be more accurate than pretesting in predicting potential adverse reactions. A positive history of allergies or hypersensitivity does not arbitrarily contraindicate the use of a contrast agent when a diagnostic procedure is thought essential, but caution should be exercised. Premedication with antihistamines or corticosteroids to avoid or minimize possible allergic reactions in such patients should be considered. Reports indicate that such pretreatment does not prevent serious life-threatening reactions, but may reduce both their incidence and severity.

General anesthesia may be indicated in the performance of some procedures in selected patients; however, a higher incidence of adverse reactions has been reported in these patients, and may be attributable to the inability of the patient to identify untoward symptoms or to the hypotensive effect of anesthesia which can prolong the circulation time and increase the duration of exposure to the contrast agent.

In angiographic procedures, the possibility of dislodging plaques or damaging or perforating the vessel wall should be considered during catheter manipulations and contrast medium injection. Test injections to insure proper catheter placement are suggested.

Angiography should be avoided whenever possible in patients with homocystinuria because of the risk of inducing thrombosis and embolism.

Patients with congestive heart failure should be observed for several hours following the procedure to detect delayed hemodynamic disturbances which may be associated with a transitory increase in the circulating osmotic load.

Selective coronary arteriography should be performed only in selected patients and those in whom the expected benefits outweigh the procedural risk. The inherent risks of angiocardiography in patients with chronic pulmonary emphysema must be weighed against the necessity for performing this procedure.

Extreme caution during injection of a contrast medium is necessary to avoid extravasation. This is especially important in patients with severe arterial or venous disease.

Information for Patients

Patients receiving iodinated intravascular contrast agents should be instructed to:

1. Inform your physician if you are pregnant.
2. Inform your physician if you are diabetic or if you have multiple myeloma, pheochromocytoma, homozygous sickle cell disease or known thyroid disorder. (See WARNINGS).
3. Inform your physician if you are allergic to any drugs or food, or if you had any reactions to previous injections of dyes used for x-ray procedures. (See PRECAUTIONS, General).
4. Inform your physician about any other medications you are currently taking including non-prescription drugs.

Drug Interactions

Renal toxicity has been reported in a few patients with liver dysfunction who were given oral cholecystographic agents followed by intravascular contrast agents. Administration of any intravascular contrast agent should therefore be postponed in patients who have recently received a cholecystographic contrast agent.

Other drugs should not be mixed with ioversol injection.

Drug / Laboratory Test Interactions

The results of PBI and radioactive iodine uptake studies, which depend on iodine estimation, will not accurately reflect thyroid function for up to 16 days following administration of iodinated contrast media. However, thyroid function tests not depending on iodine estimations, e.g., T3 resin uptake and total or free thyroxine (T4) assays are not affected.

Carcinogenesis, Mutagenesis, Impairment of Fertility

No long term animal studies have been performed to evaluate carcinogenic potential. However, animal studies suggest that this drug is not mutagenic and does not affect fertility.

Pregnancy Category B

No teratogenic effects attributable to ioversol have been observed in teratology studies performed in animals. There are, however, no adequate and well controlled studies in pregnant women. It is not known whether ioversol crosses the placental barrier or reaches fetal tissues. However, many injectable contrast agents cross the placental barrier in humans and appear to enter fetal tissue passively. Because animal teratology studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed. X-ray procedures involve a certain risk related to the exposure of the fetus.

Nursing Mothers

It is not known whether ioversol is excreted in human milk. However, many injectable contrast agents are excreted unchanged in human milk. Although it has not been established that serious adverse reactions occur in nursing infants, caution should be exercised when intravascular contrast media are administered to nursing women because of potential adverse reactions, and consideration should be given to temporarily discontinuing nursing.

Pediatric Use

Safety and effectiveness in children have been established for the use of OPTIRAY 350 and OPTIRAY 320 in angiocardiography, and for OPTIRAY 320 in contrast enhanced computed tomographic imaging of the head and body, and intravenous excretory urography.

Safety and effectiveness in newborns have not been established.

ADVERSE REACTIONS

Adverse reactions following the use of OPTIRAY formulations are usually mild to moderate, of short duration and resolve spontaneously (without treatment). However, serious, life-threatening and fatal reactions, mostly of cardiovascular origin, have been associated with the administration of iodine-containing contrast media.

Injections of contrast media are often associated with sensations of warmth and pain. In controlled double-blind clinical studies, significantly less warmth and pain were associated with the injection of OPTIRAY than with iothalamate meglumine, diatrizoate meglumine, and diatrizoate meglumine and diatrizoate sodium.

When OPTIRAY was used for coronary arteriography and ventriculography in double-blind clinical trials, electrocardiographic and hemodynamic changes occurred with less frequency and severity with ioversol injection than with diatrizoate meglumine and diatrizoate sodium.

Following coronary artery and left ventricular injection, electrocardiographic parameters were affected less with OPTIRAY (ioversol injection) than with diatrizoate meglumine and diatrizoate sodium injection. These parameters included the following: bradycardia, tachycardia, T-wave amplitude, ST depression and ST elevation.

OPTIRAY has also been shown to cause fewer changes in cardiac function and systemic blood pressure than conventional ionic media. These include cardiac output, left ventricular systolic and end-diastolic pressure, right ventricular systolic and pulmonary artery systolic pressures and decreases in systolic and diastolic blood pressures.

The following table of incidence of reactions is based upon clinical trials with OPTIRAY formulations in 2,098 patients. This listing includes all adverse reactions which were coincidental to the administration of ioversol regardless of their direct attributability to the drug or the procedure. Adverse reactions are listed by organ system and in decreasing order of occurrence. Significantly more severe reactions are listed before others in a system regardless of frequency.

Regardless of the contrast medium employed, the overall incidence of serious adverse reaction is higher with coronary arteriography than with other procedures. Cardiac decompensation, serious arrhythmias, myocardial ischemia or myocardial infarction may occur during coronary arteriography and left ventriculography.

Pediatrics - In controlled clinical trials involving 159 patients for pediatric angiocardiography, contrast enhanced computed tomographic imaging of the head and body, and intravenous excretory urography, adverse reactions reported were as follows: fever (1.3%), nausea (0.6%), muscle spasm (0.6%), LV pressure changes (0.6%).

Postmarketing Experience

The following adverse reactions have been spontaneously reported during post-approval use of OPTIRAY. Because these reactions are reported voluntarily from a population of uncertain size, in which patients may have received concomitant medication, it is not always possible to reliably estimate frequency or establish a causal relationship to drug exposure.

Cardiac Disorders: cardiac arrest, cyanosis, extrasystole, palpitation, ventricular fibrillation.

Ear and Labyrinth Disorders: tinnitus.

Eye Disorders: allergic conjunctivitis (including eye irritation, ocular hyperemia, watery eyes, swelling of conjunctiva), temporary blindness.

Gastrointestinal Disorders: abdominal pain, diarrhea, dysphagia, salivary hypersecretion, tongue edema.

Immune System Disorders: anaphylactic shock, anaphylactoid (hypersensitivity) reaction.

Musculoskeletal, Connective Tissue and Bone Disorders: acute renal failure, anuria, dysuria, micturition urgency.

Nervous System Disorders: amnesia, aphasia, dysgeusia, dyskinesia, hypoesthesia, loss of consciousness, seizure, somnolence, tremor.

Psychiatric Disorders: agitation, anxiety, confusional state.

Respiratory, Thoracic and Mediastinal Disorders: asthma, bronchospasm, dysphonia, laryngeal spasm, respiratory arrest, rhinitis, throat irritation.

Skin and Subcutaneous Tissue Disorders: hyperhidrosis, pallor, rash, Stevens-Johnson Syndrome.

Vascular Disorders: phlebitis, shock, thrombosis, vasospasm.

General Adverse Reactions to Contrast Media

The following adverse reactions are possible with any parenterally administered iodinated contrast medium. Severe life-threatening reactions and fatalities, mostly of cardiovascular origin, have occurred. Most deaths occur during injection or 5 to 10 minutes later; the main feature being cardiac arrest with cardiovascular disease as the main aggravating factor. Isolated reports of hypotensive collapse and shock are found in the literature. Based upon clinical literature, reported deaths from the administration of conventional iodinated contrast agents range from 6.6 per 1 million (0.00066 percent) to 1 in 10,000 patients (0.01 percent).

The reported incidence of adverse reactions to contrast media in patients with a history of allergy is twice that of the general population. Patients with a history of previous reactions to a contrast medium are three times more susceptible than other patients. However, sensitivity to contrast media does not appear to increase with repeated examinations.

Adverse reactions to injectable contrast media fall into two categories: chemotoxic reactions and idiosyncratic reactions.

Chemotoxic reactions result from the physiochemical properties of the contrast medium, the dose and the speed of injection. All hemodynamic disturbances and injuries to organs or vessels perfused by the contrast medium are included in this category.

Idiosyncratic reactions include all other reactions. They occur more frequently in patients 20 to 40 years old. Idiosyncratic reactions may or may not be dependent on the dose injected, the speed of injection, the mode of injection and the radiographic procedure. Idiosyncratic reactions are subdivided into minor, intermediate and severe. The minor reactions are self-limited and of short duration; the severe reactions are life-threatening and treatment is urgent and mandatory.

In addition to the adverse reactions reported for ioversol, the following additional adverse reactions have been reported with the use of other contrast agents and are possible with any water soluble, iodinated contrast agent.

Nervous: convulsions, aphasia, paralysis, visual field losses which are usually transient but may be permanent, coma and death.

Cardiovascular: angioneurotic edema, peripheral edema, vasodilation, thrombosis and rarely thrombophlebitis, disseminated intravascular coagulation and shock.

Skin: maculopapular rash, erythema, conjunctival symptoms, ecchymosis and tissue necrosis.

Respiratory: choking, dyspnea, wheezing which may be an initial manifestation of more severe and infrequent reactions including asthmatic attack, laryngospasm and bronchospasm, apnea and cyanosis. Rarely these allergic-type reactions can progress into anaphylaxis with loss of consciousness, coma, severe cardiovascular disturbances and death.

Miscellaneous: hyperthermia, temporary anuria or other nephropathy.

Other reactions may also occur with the use of any contrast agent as a consequence of the procedural hazard; these include hemorrhage or pseudoaneurysms at the puncture site, brachial plexus palsy following axillary artery injections, chest pain, myocardial infarction, and transient changes in hepatorenal chemistry tests. Arterial thrombosis, displacement of arterial plaques, venous thrombosis, dissection of the coronary vessels and transient sinus arrest are rare complications.

(Adverse reactions for specific procedures receive comment in the Indications, Usage and Procedural Information section.)

OVERDOSAGE

The adverse effects of overdosage are life-threatening and affect mainly the pulmonary and cardiovascular system. Treatment of an overdosage is directed toward the support of all vital functions and prompt institution of symptomatic therapy.

Ioversol does not bind to plasma or serum protein and is therefore, dialyzable.

The intravenous LD50 values (gI/kg) for ioversol in animals were: 17 (mice), and 15 (rats).

DOSAGE AND ADMINISTRATION

General

As with all radiopaque contrast agents, only the lowest dose necessary to obtain adequate visualization should be used. A lower dose may reduce the possibility of an adverse reaction. Most procedures do not require use of either the maximum volume or the highest concentration of OPTIRAY. The combination of volume and concentration of OPTIRAY to be used should be carefully individualized accounting for factors such as age, body weight, size of the vessel and the rate of blood flow within the vessel. Other factors such as anticipated pathology, degree and extent of opacification required, structure(s) or area to be examined, disease processes affecting the patient, and equipment and technique to be employed should be considered.

It is desirable that intravascularly administered iodinated contrast agents be at or close to body temperature when injected.

If during administration a reaction occurs, the injection should be stopped until the reaction has subsided.

Patients should be well hydrated prior to and following OPTIRAY (ioversol injection) administration.

INDIVIDUAL INDICATIONS, USAGE AND PROCEDURAL INFORMATION

GENERAL ANGIOGRAPHY

Visualization of the cardiovascular system may be accomplished by any accepted radiological technique.

Cerebral Arteriography

Additional Precautions and Adverse Reactions: Extreme caution is advised in patients with advanced arteriosclerosis, severe hypertension, cardiac decompensation, senility, recent cerebral thrombosis or embolism, and migraine. Cardiovascular reactions that may occur with some frequency are bradycardia and either an increase or decrease in systemic blood pressure. Neurological reactions that may occur are: seizures, drowsiness, transient paresis, and mild disturbances in vision.

Central nervous system reactions with OPTIRAY in controlled clinical studies in cerebral arteriography that were considered drug-related and occurred with frequencies greater than 1% were: headache, bradycardia, blood pressure fluctuation, disorientation, nausea and vertigo.

Dosage and Administration: OPTIRAY 300 or OPTIRAY 320 is recommended for this procedure. The usual individual injection for visualization of the carotid or vertebral arteries is 2 to 12 mL, repeated as necessary. Aortic arch injection for a simultaneous four vessel study requires 20 to 50 mL. Total procedural doses should not usually exceed 200 mL.

Peripheral Arteriography

Additional Precautions: Pulsation should be present in the artery to be injected. In thromboangiitis obliterans, or ascending infection associated with severe ischemia, angiography should be performed with extreme caution, if at all.

Dosage and Administration: OPTIRAY 300, OPTIRAY 320 or OPTIRAY 350 is recommended for this procedure. The usual individual injection volumes for visualization of various peripheral arteries are as follows:

These doses may be repeated as necessary. Total procedural doses should not usually exceed 250 mL.

Visceral and Renal Arteriography and Aortography

Additional Precautions and Adverse Effects: In aortography, depending on the technique employed, the risks of this procedure also include the following: injury to the aorta and neighboring organs, pleural puncture, renal damage including infarction and acute tubular necrosis with oliguria and anuria, retroperitoneal hemorrhage from the translumbar approach and spinal cord injury and pathology associated with the syndrome of transverse myelitis.

Under conditions of slowed aortic circulation there is an increased likelihood for aortography to cause muscle spasm. Occasional serious neurologic complications, including paraplegia, have also been reported in patients with aortoiliac obstruction, femoral artery obstruction, abdominal compression, hypotension, hypertension, spinal anesthesia, and injection of vasopressors to increase contrast. In these patients the concentration, volume, and number of repeat injections of the medium should be maintained at a minimum with appropriate intervals between injections. The position of the patient and catheter tip should be carefully monitored.

Entry of a large aortic dose into the renal artery may cause, even in the absence of symptoms, albuminuria, hematuria, and an elevated creatinine and urea nitrogen. Rapid and complete return of function usually follows.

Dosage and Administration: OPTIRAY 320 is recommended for visceral arteriography, renal arteriography, and aortography procedures. The usual individual injection volumes for visualization for the aorta and various visceral arteries are as follows:

These doses may be repeated as necessary. Total procedural doses should not usually exceed 250 mL.

Coronary Arteriography and Left Ventriculography

Additional Precautions: Mandatory prerequisites to the procedure are specialized personnel, ECG monitoring apparatus and adequate facilities for immediate resuscitation and cardioversion. Electrocardiograms and vital signs should be routinely monitored throughout the procedure.

Adverse Reactions: There were no cardiovascular system reactions with OPTIRAY in controlled clinical studies in coronary arteriography with left ventriculography that were considered drug-related and occurred with a frequency greater than 1%.

Dosage and Administration: OPTIRAY 320 or OPTIRAY 350 is recommended for this procedure. The usual individual injection volumes for visualization of the coronary arteries and left ventricle are:

These doses may be repeated as necessary. Total procedural dose for the combined procedures should not usually exceed 250 mL. When large individual volumes are administered, as in ventriculography and aortography, it has been suggested that several minutes be permitted to elapse between each injection to allow for subsidence of possible hemodynamic disturbances.

Pediatric Angiocardiography

Additional Precautions: Mandatory prerequisites to the procedure are specialized personnel, ECG monitoring apparatus and adequate facilities for immediate resuscitation and cardioversion. Electrocardiograms and vital signs should be routinely monitored throughout the procedure. Pediatric patients at higher risk of experiencing adverse events during contrast medium administration may include those having asthma, a sensitivity to medication and/or allergens, congestive heart failure, a serum creatinine greater than 1.5 mg/dL, or those less than 12 months of age.

Dosage and Administration: OPTIRAY 350 or OPTIRAY 320 is recommended for this procedure. The usual single ventricular injection of OPTIRAY 350 or OPTIRAY 320 is 1.25 mL/kg of body weight with a range of 1 mL/kg to 1.5 mL/kg. When multiple injections are given, the total administered dose should not exceed 5 mL/kg up to a total volume of 250 mL.

Venography

Additional Precautions: Special care is required when venography is performed in patients with suspected thrombosis, phlebitis, severe ischemic disease, local infection or a totally obstructed venous system. In order to minimize extravasation during injection, fluoroscopy is recommended.

Dosage and Administration: OPTIRAY 300, OPTIRAY 320 or OPTIRAY 350 is recommended for this procedure. The usual dose is 50 to 100 mL per extremity with smaller or larger volumes indicated in some cases. Dosage should not usually exceed 250 mL.

Following the procedure, the venous system should be flushed with Sodium Chloride Injection U.S.P. or 5% Dextrose in Water (D5W). Massage and elevation are also helpful for clearing the contrast medium from the extremity.

COMPUTED TOMOGRAPHY

OPTIRAY 350, OPTIRAY 320 or OPTIRAY 300 is recommended for head imaging.

OPTIRAY 350, OPTIRAY 320 or OPTIRAY 300 is recommended for body imaging.

Head Imaging

Tumors: OPTIRAY may be useful to investigate the presence and extent of certain malignancies such as: gliomas including malignant gliomas, glioblastomas, astrocytomas, oligodendrogliomas and gangliomas, ependymomas, medulloblastomas, meningiomas, neuromas, pinealomas, pituitary adenomas, craniopharyngiomas, germinomas, and metastatic lesions. The usefulness of contrast enhancement for the investigation of the retrobulbar space and in cases of low grade or infiltrative glioma has not been demonstrated. In calcified lesions, there is less likelihood of enhancement. Following therapy, tumors may show decreased or no enhancement. The opacification of the inferior vermis following contrast media administration has resulted in false-positive diagnosis in a number of otherwise normal studies.

Nonneoplastic Conditions: OPTIRAY may be beneficial in the image enhancement of nonneoplastic lesions. Cerebral infarctions of recent onset may be better visualized with contrast enhancement, while some infarctions are obscured if contrast medium is used. The use of iodinated contrast media results in enhancement in about 60% of cerebral infarctions studied from one to four weeks from the onset of symptoms.

Sites of active infection may also be enhanced following contrast medium administration.

Arteriovenous malformations and aneurysms will show contrast enhancement. For these vascular lesions the enhancement is probably dependent on the iodine content of the circulating blood pool. Hematomas and intraparenchymal bleeders seldom demonstrate contrast enhancement. However, in cases of intraparenchymal clot, for which there is no obvious clinical explanation, contrast media administration may be helpful in ruling out the possibility of associated arteriovenous malformation.

Dosage and Administration: Adults: For adults, the usual dosage is 50 to 150 mL of OPTIRAY 350, OPTIRAY 320 or OPTIRAY 300. Scanning may be performed immediately after completion of the intravenous administration. Dosage should not usually exceed 150 mL of OPTIRAY 350, OPTIRAY 320 or OPTIRAY 300.

Children: The dosage recommended for use in children is 1 mL/kg to 3 mL/kg of OPTIRAY 320.

Body Imaging

OPTIRAY may be useful for enhancement of computed tomographic images for detection and evaluation of lesions in the liver, pancreas, kidneys, aorta, mediastinum, pelvis, abdominal cavity, and retroperitoneal space.

Enhancement of computed tomography with OPTIRAY may be of benefit in establishing diagnoses of certain lesions in these sites with greater assurance than is possible with CT alone. In other cases, the contrast agent may allow visualization of lesions not seen with CT alone (i.e., tumor extension) or may help to define suspicious lesions seen with unenhanced CT (i.e., pancreatic cyst).

Dosage and Administration: Adults: OPTIRAY 350, OPTIRAY 320 or OPTIRAY 300 may be administered by bolus injection, by rapid infusion, or by a combination of both. The usual doses are summarized below:

Dosage should not usually exceed 150 mL of OPTIRAY 350, OPTIRAY 320 or OPTIRAY 300.

Children: The dosage recommended for use in children is 1 mL/kg to 3 mL/kg of OPTIRAY 320, with a usual dose of 2 mL/kg.

INTRAVENOUS DIGITAL SUBTRACTION ANGIOGRAPHY

Intravenous digital subtraction angiography (IV DSA) is a radiographic modality which allows dynamic imaging of the arterial system following intravenous injection of iodinated x-ray contrast media through the use of image intensification, enhancement of the iodine signal and digital processing of the image data. Temporal subtraction of the images obtained prior to and during the “first arterial pass” of the injected contrast medium yields images which are devoid of bone and soft tissue.

IV DSA is most frequently used to examine the heart, including coronary by-pass grafts; the pulmonary arteries; arteries of the brachiocephalic circulation; the aortic arch; the abdominal aorta and its major branches; the iliac arteries; and the arteries of the extremities.

Patient Preparation

No special patient preparation is required for IV DSA. However, it is advisable to insure that patients are well hydrated prior to examination.

Precautions

In addition to the general precautions previously described, the risks associated with IV DSA include those usually attendant with catheter procedures and include intramural injections, vessel dissection and tissue extravasation. The potential risk is reduced when small test injections of contrast medium are made under fluoroscopic observation to insure that the catheter tip is properly positioned and, in the case of peripheral placement, that the vein is of adequate size.

Patient motion, including respiration and swallowing, can result in misregistration leading to image degradation and non-diagnostic studies.

Usual Dosage

OPTIRAY 350 may be injected centrally, in either the superior or inferior vena cava or right atrium; or peripherally into an appropriate arm vein. For central injections, catheters may be introduced at the antecubital fossa into either the basilic or cephalic vein or at the leg into the femoral vein and advanced to the distal segment of the corresponding vena cava. For peripheral injections, the catheter is introduced at the antecubital fossa into an appropriate size arm vein. In order to reduce the potential for extravasation during peripheral injection, a catheter of approximately 20 cm in length should be employed.

Depending on the area to be imaged, the usual dose range per injection is 30 to 50 mL. Injections may be repeated as necessary. The total procedural dose should not exceed 250 mL.

Injection rates will vary depending on the site of catheter placement and vessel size. Central catheter injections are usually made at a rate of between 10 and 30 mL/second. Peripheral injections are usually made at a rate of between 12 and 20 mL/second. Since the injected medium can sometimes remain in the arm vein for an extended period, it is advisable to flush the vein immediately following injection with an appropriate volume (20 to 25 mL) of Sodium Chloride Injection U.S.P. or 5% Dextrose in Water (D5W).

INTRAVENOUS UROGRAPHY

Dosage and Administration: OPTIRAY 350, OPTIRAY 320 or OPTIRAY 300 is recommended for routine and high dose excretory urography. Preparatory dehydration is dangerous and may contribute to acute renal failure (See PRECAUTIONS, General).

Adults: The usual dose for routine excretory urography in adults is 50 to 75 mL of OPTIRAY 350, OPTIRAY 320 or OPTIRAY 300. Higher dosages may be indicated to achieve optimum results where poor visualization is anticipated (e.g., elderly patients or patients with impaired renal function). In these patients, high dose urography may be preferred, using OPTIRAY 350 at a dose of 1.4 mL/kg (maximum 140 mL), OPTIRAY 320 at a dose of 1.5 to 2 mL/kg (maximum 150 mL), or OPTIRAY 300 at a dose of 1.6 mL/kg (maximum 150 mL).

Children: OPTIRAY 320 at doses of 0.5 mL/kg to 3 mL/kg of body weight has produced diagnostic opacification of the excretory tract. The usual dose for children is 1 mL/kg to 1.5 mL/kg. Dosage for infants and children should be administered in proportion to age and body weight. The total administered dose should not exceed 3 mL/kg.

DRUG HANDLING OPTIRAY, PHARMACY BULK PACKAGE

As with all contrast media, other drugs should not be mixed with ioversol solutions because of the potential for chemical incompatibility.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration and should not be used if particulates are observed or marked discoloration has occurred.

If nondisposable equipment is used, scrupulous care should be taken to prevent residual contamination with traces of cleansing agents.

Directions for Proper Use of OPTIRAY, Pharmacy Bulk Package

1. The container closure may be penetrated only one time, utilizing a suitable sterile transfer device or dispensing set which allows measured distribution of the contents.
2. The transferring of OPTIRAY from the Pharmacy Bulk Package is restricted to a suitable work area, such as a laminar flow hood, utilizing aseptic technique.
3. The withdrawal of container contents should be accomplished without delay. However, should this not be possible, a maximum time of 4 hours from initial closure entry is permitted to complete fluid transfer operations.
4. Temperature of container after the closure has been entered should not exceed 25°C (77°F).

HOW SUPPLIED

Storage: Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. These products are sensitive to light and must be protected from strong daylight or direct exposure to the sun. If product is frozen or if crystallization occurs, the bottle and contents should be discarded.

The transferring of OPTIRAY from the OPTIRAY Pharmacy Bulk Package should be performed in a suitable work area, such as a laminar flow hood, utilizing aseptic technique. The container closure may be penetrated only one time, utilizing a suitable transfer device. The withdrawal of container contents should be accomplished without delay. However, if this is not possible, a maximum time of 4 hours from initial closure entry is permitted to complete fluid transfer operations. Temperature of container after the closure has been entered should not exceed 25°C (77°F).

As with all contrast media, glass containers should be inspected prior to use to ensure that breakage or other damage has not occurred during shipping and handling. All containers should be inspected for closure integrity. Damaged containers should not be used.

OPTIRAY is a trademark of Mallinckrodt Inc.

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Healthcare

Mallinckrodt

MKR 13PB0610
Revised 06/10
Printed in U.S.A.

PACKAGE LABEL - PRINCIPAL DISPLAY PANEL - Optiray 350 PBP, 500 mL bottle label

For Intravascular Use
Sterile Solution

Optiray™ Pharmacy Bulk Package - 350

500 mL
NDC 0019-1333-61

IOVERSOL INJECTION 74%
350 mg/mL Organically Bound Iodine

NOT FOR INTRATHECAL USE

Rx only

Pharmacy Bulk Package - Not for Direct Infusion

Protect from light • Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Discard contents if product is frozen or if crystallization occurs. Each mL contains 741 mg ioversol, 3.6 mg tromethamine as a buffer and 0.2 mg edetate calcium disodium as a stabilizer. The pH is adjusted with hydrochloric acid or sodium hydroxide.
Usual Dosage: See Package Insert for indications, dosage and dispensing information. Once bottle has been penetrated, withdrawal of contents should be completed without delay. Discard the container no later than 4 hours after initial entry.

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MALLINCKRODT