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Nephrogenic Systemic Fibrosis (NSF)
Gadolinium-based contrast agents (GBCAs) increase the risk for nephrogenic systemic fibrosis (NSF) among patients with impaired elimination of the drugs. Avoid use of GBCAs among these patients unless the diagnostic information is essential and not available with non-contrast enhanced MRI or other modalities. The GBCA-associated NSF risk appears highest for patients with chronic, severe kidney disease (GFR < 30 mL/min/1.73m²) as well as patients with acute kidney injury. The risk appears lower for patients with chronic, moderate kidney disease (GFR 30-59 mL/min/1.73m²) and little, if any, for patients with chronic, mild kidney disease (GFR 6089 mL/min/1.73m²). NSF may result in fatal or debilitating fibrosis affecting the skin, muscle and internal organs. Report any diagnosis of NSF following EOVIST administration to Bayer Healthcare (1-888-842-2937) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch).
Screen patients for acute kidney injury and other conditions that may reduce renal function. Features of acute kidney injury consist of rapid (over hours to days) and usually reversible decrease in kidney function, commonly in the setting of surgery, severe infection, injury or drug-induced kidney toxicity. Serum creatinine levels and estimated GFR may not reliably assess renal function in the setting of acute kidney injury. For patients at risk for chronically reduced renal function (for example, age > 60 years, diabetes mellitus or chronic hypertension), estimate the GFR through laboratory testing.
Among the factors that may increase the risk for NSF are repeated or higher than recommended doses of a GBCA and degree of renal impairment at the time of exposure. Record the specific GBCA and the dose administrated to a patient. For patients at highest risk for NSF, do not exceed the recommended EOVIST dose and allow a sufficient period of time for elimination of the drug prior to any re-administration. For patients receiving hemodialysis, physicians may consider the prompt initiation of hemodialysis following the administration of a GBCA in order to enhance the contrast agent's elimination. The usefulness of hemodialysis in the prevention of NSF is unknown [see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION].
Anaphylactoid and anaphylactic reactions with cardiovascular, respiratory and cutaneous manifestations, ranging from mild to severe reactions, including shock have uncommonly occurred following EOVIST administration [see ADVERSE REACTIONS].
- Before EOVIST administration, assess all patients for any history of a reaction to contrast media, a history of bronchial asthma and/or a history of allergic disorders. These patients may have an increased risk for a hypersensitivity reaction to EOVIST; weigh the benefits of EOVIST MRI carefully against the risks in these clinical settings.
- Administer EOVIST only in situations where trained personnel and therapies are promptly available for the treatment of hypersensitivity reactions, including personnel trained in resuscitation.
Most hypersensitivity reactions to EOVIST have occurred within half an hour after administration. Delayed reactions (hours up to several days) may occur. Observe patients for signs and symptoms of hypersensitivity reactions during and following EOVIST administration. Treat these reactions with standard medications for hypersensitivity reactions.
Acute Kidney Injury
In patients with chronic renal impairment, acute kidney injury sometimes requiring dialysis has been observed with the use of some GBCAs. The risk of acute kidney injury might be lower with EOVIST due to its dual excretory pathways. Do not exceed the recommended dose.
Extravasation And Injection Site Reactions
Ensure catheter and venous patency before the injection of EOVIST. Extravasation into tissues during EOVIST administration may result in local tissue reactions. Strictly avoid intramuscular administration of EOVIST because it may cause myocyte necrosis and inflammation [see Nonclinical Toxicology].
Interference With Laboratory Tests
Serum iron determination using complexometric methods (for example, Ferrocine complexation method) may result in falsely high or low values for up to 24 hours after EOVIST administration [see ADVERSE REACTIONS].
Interference With Visualization Of Liver Lesions
Severe renal or hepatic failure may impair EOVIST imaging performance. In patients with end-stage renal failure, hepatic contrast was markedly reduced and was attributed to elevated serum ferritin levels. In patients with abnormally high ( > 3 mg/dL) serum bilirubin, reduced hepatic contrast was observed. If EOVIST is used in these patients, complete MR imaging no later than 60 minutes after EOVIST administration and use a paired non-contrast and contrast MRI image set for diagnosis.
Carcinogenesis, Mutagenesis, Impairment Of Fertility
No carcinogenicity studies of EOVIST have been conducted.
Gadoxetate disodium was not mutagenic in in vitro reverse mutation tests in bacteria, or in chromosome aberration tests in human peripheral blood lymphocytes, and was negative in an in vivo micronucleus test in mice after intravenous injection of doses up to 4 mmol/kg.
Gadoxetate disodium had no effect on fertility and general reproductive performance of male and female rats when given in doses 6.5 times the human dose (based on body surface area).
Use In Specific Populations
Pregnancy Category C. There are no adequate and well-controlled studies of EOVIST in pregnant women. While it is unknown if EOVIST crosses the human placenta, other gadolinium products do cross the placenta in humans and results in fetal exposure. Limited published human data on exposure to other gadolinium products during pregnancy did not show adverse effects in exposed neonates. Embryotoxicity occurred in pregnant rabbits that received daily gadoxetate disodium at 26 times the recommended human dose (mmol/m² basis), and maternal toxicity occurred in pregnant rats at doses 32 times the human dose (mmol/m² basis). EOVIST should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Animal reproductive and developmental toxicity studies were done in rats and rabbits. Gadoxetate disodium was not teratogenic when given intravenously during organogenesis to pregnant rats at doses up to 32 times the recommended single human dose (mmol/m² basis).
However, an increase in preimplantation loss was noted at 3.2 times the human dose (mmol/m² basis). Compared to untreated controls, rates of postimplantation loss and absorption increased and litter size decreased when pregnant rabbits received gadoxetate disodium at doses 26 times the recommended human single dose (mmol/m² basis). This occurred without evidence of maternal toxicity. Because pregnant animals received repeated daily doses of EOVIST, their overall exposure was significantly higher than that achieved with the standard single dose administered to humans.
It is not known whether EOVIST is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when EOVIST is administered to a nursing woman. Based on pharmacokinetics of EOVIST, women with normal renal function may resume nursing with milk produced 10 hours or more following EOVIST administration with minimal risk for the presence of EOVIST within the milk.
In lactating rats given 0.1 mmol/kg [153Gd] gadoxetate disodium, less than 0.5% of the total administered radioactivity was transferred to the neonates via maternal milk, mostly within 2 hours.
The safety and effectiveness of EOVIST have not been established in pediatric patients.
In clinical studies of EOVIST, 37% of the patients were 65 years of age and over, while 7% were 75 years of age and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, use of EOVIST in an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal or cardiac function and of concomitant disease or other drug therapy.
In a clinical pharmacology study, slight to moderate differences in pharmacokinetic parameters of gadoxetate disodium (increased AUC and terminal half-life, decreased total clearance) were found in a group of geriatric volunteers in comparison to non-geriatric volunteers. No clinically relevant differences in liver contrast enhancement were found [see CLINICAL PHARMACOLOGY].
In a clinical pharmacology study in groups of patients with mild or moderate hepatic impairment, a slight to moderate increase in plasma AUC, half-life and urinary excretion, as well as decrease in hepatobiliary excretion was observed in comparison to healthy subjects with normal liver function. Hepatic contrast signal did not differ among the groups.
Severe hepatic impairment may impair EOVIST imaging performance [see WARNINGS AND PRECAUTIONS and CLINICAL PHARMACOLOGY]. In patients with severe hepatic impairment, especially in patients with abnormally high ( > 3 mg/dL) serum bilirubin levels, the AUC was increased up to 60% and the elimination half-life was increased up to 49%. The hepatobiliary excretion substantially decreased to about 5% of the administered dose and reduced hepatic contrast signal was observed.
A dose adjustment is not necessary for patients with hepatic impairment.
In clinical studies, 489 patients had a diagnosis of liver cirrhosis (Child-Pugh category A, n=270; category B, n=98; category C, n=24; unknown category, n=97). No difference in diagnostic performance and safety was observed among these patients.
In a clinical pharmacology study in a group of patients with moderate renal impairment, a moderate increase in AUC and terminal half-life was observed in comparison to healthy volunteers with normal renal function. Hepatic contrast did not differ among the groups.
End-stage renal failure may impair EOVIST imaging performance [see WARNINGS AND PRECAUTIONS and CLINICAL PHARMACOLOGY]. In a study of patients with end-stage renal failure, the terminal half-life was prolonged about 12-fold and the AUC was increased about 6fold. Hepatic contrast was markedly reduced in these patients, which was attributed to significantly elevated serum ferritin levels [see WARNINGS AND PRECAUTIONS and CLINICAL PHARMACOLOGY]. Approximately 30% of the injected dose was removed by dialysis in a single 3-hour dialysis session, which started one hour after an EOVIST dose. EOVIST was almost completely eliminated via dialysis and biliary excretion within the observation period of 6 days, predominantly within the first 3 days.This monograph has been modified to include the generic and brand name in many instances.
Last reviewed on RxList: 12/6/2016
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