"The U.S. Food and Drug Administration today approved Vizamyl (flutemetamol F 18 injection), a radioactive diagnostic drug for use with positron emission tomography (PET) imaging of the brain in adults being evaluated for Alzheimer's disease (AD) "...
Vizamyl is indicated for Positron Emission Tomography (PET) imaging of the brain to estimate β-amyloid neuritic plaque density in adult patients with cognitive impairment who are being evaluated for Alzheimer's Disease (AD) and other causes of cognitive decline. A negative Vizamyl scan indicates sparse to no neuritic plaques and is inconsistent with a neuropathological diagnosis of AD at the time of image acquisition; a negative scan result reduces the likelihood that a patient's cognitive impairment is due to AD. A positive Vizamyl scan indicates moderate to frequent amyloid neuritic plaques; neuropathological examination has shown this amount of amyloid neuritic plaque is present in patients with AD, but may also be present in patients with other types of neurologic conditions as well as in older people with normal cognition. Vizamyl is an adjunct to other diagnostic evaluations.
Limitations Of Use
- A positive Vizamyl scan does not establish a diagnosis of AD or other cognitive disorder.
- Safety and effectiveness of Vizamyl have not been
- Predicting development of dementia or other neurologic condition.
- Monitoring responses to therapies.
DOSAGE AND ADMINISTRATION
Radiation Safety -Drug Handling
Vizamyl is a radioactive drug and should be handled with safety measures to minimize radiation exposure during administration [see WARNINGS AND PRECAUTIONS]. Use waterproof gloves and effective shielding, including lead-glass syringe shields when handling and administering Vizamyl. To minimize radiation dose to the bladder, encourage patients to hydrate before and after Vizamyl administration in order to permit frequent voiding. Encourage patients to void before and after imaging with Vizamyl and frequently thereafter for 24 hours following Vizamyl administration.
Radiopharmaceuticals, including Vizamyl, should be used by or under the control of physicians who are qualified by specific training and experienced in the safe use and handling of radioactive materials, and whose experience and training have been approved by the appropriate governmental agency authorized to license the use of radiopharmaceuticals.
Recommended Dosing And Administration Procedures
The recommended dose for Vizamyl is 185 megabecquerels (MBq) [5 millicuries (mCi)] in a maximum dose volume of 10 mL, administered as a single intravenous bolus within 40 seconds. The maximum mass dose is 20 micrograms. Follow the injection with an intravenous flush of 5 to 15 mL of 0.9% sterile sodium chloride injection.
- Use aseptic technique and radiation shielding to withdraw and administer Vizamyl solution.
- Calculate the necessary volume to administer based on calibration time and dose using a suitably calibrated instrument.
- Visually inspect Vizamyl for particulate matter and discoloration prior to administration. Do not administer Vizamyl if it contains particulate matter or is discolored [see DESCRIPTION].
- Do not dilute Vizamyl.
- Dispose of unused product in a safe manner in compliance with applicable regulations [see HOW SUPPLIED/Storage and Handling].
Imaging Acquisition Guidelines
A 20-minute PET image should be acquired starting 90 minutes after Vizamyl injection, using a PET scanner in 3-D mode with appropriate data corrections. Position the patient supine with the brain (including the cerebellum) within a single field of view. The patient's head should be tilted so that the anterior commissure-posterior commissure (AC-PC) plane is at right angles to the bore-axis of the PET scanner, with the head positioned in a suitable head support. Reducing head movement with tape or other flexible head restraints may be employed.
Iterative or filtered back-projection reconstruction is recommended with a slice thickness of 2 to 4 mm, matrix size of 128 x 128 with pixel sizes of approximately 2 mm. Where a post-smoothing filter is applied, a full width half maximum (FWHM) of not more than 5 mm is recommended; filter FWHM should be chosen to optimize the signal-to-noise ratio while preserving the sharpness of the reconstructed image.
Image Orientation And Display
Orient axial and coronal images to show symmetry of brain structures, with equal heights of structures bilaterally. Orient sagittal images so that the head and neck are neither flexed nor extended; the anterior and posterior aspects of the corpus callosum should be parallel to the AC-PC line as shown in Figure 2.
- Display images with all planes (axial, sagittal and coronal planes) linked by crosshairs.
- Select a color scale that provides a progression of low through high intensity (e.g., rainbow or Sokoloff). The selected color scale should (1) provide colors that allow the reader to discriminate intensity levels above and below the intensity level of the pons, (2) provide a color for regions with little or no amyloid binding such as the cerebellar cortex, and (3) provide a range of at least five distinct colors above 50 to 60% of the peak intensity.
- Display the reference scale. Adjust the color scale to set the pons to approximately 90% maximum intensity. The cerebellar cortex should represent approximately 20-30% of peak intensity on both negative and positive Vizamyl scans.
- Briefly display axial brain slices from bottom to top and look for signs of atrophy.
- Systematically review the following brain regions (recommended plane) for flutemetamol F 18 uptake as described in Image Interpretation below: o Frontal lobes (axial, with optional sagittal plane view)
Vizamyl images should be interpreted only by readers who successfully complete the electronic or in-person training program provided by the manufacturer [see WARNINGS AND PRECAUTIONS]. The objective of Vizamyl image interpretation is to provide an estimate of the brain β-amyloid neuritic plaque density, not to make a clinical diagnosis. Image interpretation is performed independently of a patient's clinical features and relies upon recognition of image features in certain brain regions.
Image interpretation is based upon the distribution of radioactive signal within the brain; clinical information is not a component of image assessment [see WARNINGS AND PRECAUTIONS]. Images are designated as positive or negative either by comparing radioactivity in cortical grey matter with activity in adjacent white matter, or based on the intensity in the five regions mentioned above. Signal uptake in the cerebellum does not contribute to scan interpretation (for example, a positive scan may show retained cerebellar grey-white contrast even when the cortical grey-white contrast is lost). Images should be viewed with the minimum image intensity set to zero and the maximum set such that the signal level in the easily identifiable pons is at 90% of maximum.
Negative scans show more radioactivity in white matter than in grey matter, creating clear grey-white matter contrast.
Specifically, a negative scan would have the following characteristics:
frontal, lateral temporal, inferolateral parietal lobes:
gradual gradient from bright intensity of the white matter to lower intensity
at the periphery of the brain; distinct sulci with concave surfaces (white
matter sulcal pattern),
posterior cingulate and precuneus: grey matter uptake below 50-60% of peak intensity; gap of lower intensity separates two hemispheres on coronal view, and striatum: approximately 50% of peak intensity or lower in the region between the higher intensities of the thalamus and frontal white matter (striatal “gap”) Positive
scans show at least one cortical region with reduction or loss of the normally distinct grey-white matter contrast. These scans have one or more regions with increased cortical grey matter signal (above 50-60% peak intensity) and/or reduced (or absent) grey-white matter contrast (white matter sulcal pattern is less distinct). A positive scan may have one or more regions in which grey matter radioactivity is as intense or exceeds the intensity in adjacent white matter. Specifically, a positive scan would have the following characteristics:
frontal, lateral temporal, or inferolateral parietal
lobes: high intensity seen to the periphery of the brain, with sharp reduction
of intensity at the brain margin; sulci not distinct due to fill-in by high
intensity grey matter resulting in a convex surface at the edge of the brain,
posterior cingulate and precuneus: grey matter uptake above 50-60% of peak intensity; high grey matter intensity that closes the gap between the two hemispheres on coronal view,
striatum: intensity above 50-60% of peak intensity; gap between thalamus and frontal white matter not distinct If any one of the brain regions systematically reviewed for flutemetamol F 18 uptake (see Image Orientation and Display above) is positive in either hemisphere, then the scan is considered positive. Otherwise, the scan is considered negative.
Among patients with clinically important β-amyloid neuritic plaques in the brain, the temporal lobes, parietal lobes, and striatum may not be as affected compared to other brain regions. Therefore, in some images, flutemetamol F 18 signal in these regions may not be as intense as in the frontal lobes or the posterior cingulate and precuneus regions.
Atrophy may affect the interpretability of scans, particularly in the frontal, temporal and parietal lobes [see WARNINGS AND PRECAUTIONS]. For cases in which atrophy is apparent or suspected and there is uncertainty as to the location of the grey matter on the PET scan, examine the striatum for flutemetamol F 18 signal as it is less affected by atrophy than other regions of the brain.
Other factors that may affect the ability to interpret Vizamyl images include patient factors such as brain pathology, surgical changes, post-radiation therapy changes, and implants. Some scans may be difficult to interpret due to image noise, suboptimal patient positioning, or over-smoothing of the reconstructed image.
Figure 1: Axial view of negative (left) and positive (right) Vizamyl scans. The axial slices which cut through the frontal pole and inferior aspect of the splenium are shown using a rainbow color scale. The left image shows a white matter sulcal pattern at the frontal (f) and lateral temporal (lt) regions with a color intensity that tapers to the periphery, as well as less radioactivity in the striatal region(s). The right image shows absence of the white matter sulcal pattern with intensity radiating to a sharply defined convex edge, as well as more radioactivity in the striatum. In both the frontal and lateral temporal regions, the intensity is higher in the grey matter regions of the right image compared to those of the left image.
Figure 2: Sagittal view of negative (left) and positive (right) Vizamyl scans. The sagittal slices are slightly off midline in one hemisphere and shown using a rainbow color scale. In the posterior cingulate (pc) region, which is superior and posterior to the corpus callosum (cc), the left image shows intensity below 50% of peak intensity whereas the right image shows intensity above 60% of peak intensity. The pons (p) is set to approximately 90% of the maximum intensity.
Figure 3: Coronal view of negative (left) and positive (right) Vizamyl scans. The coronal slices are located posterior to the corpus callosum. The left image shows a white matter sulcal pattern in the inferior parietal (ip) regions that is not evident in the right image. Relative to the left image, the right image shows increased intensity in the posterior cinguli (pc) and increased radial extent of high intensity to the lateral surfaces of the parietal lobes particularly evident in the inferior parietal regions.
The estimated absorbed radiation doses for adult patients following intravenous injection of Vizamyl are shown in Table 1. Values were calculated from human biodistribution data using OLINDA/EXM software and assuming emptying of the urinary bladder at 3.5 hour intervals.
The adult effective dose resulting from a 185-MBq (5-mCi) Vizamyl administration is 5.92 mSv. The use of a CT scan to calculate attenuation correction for reconstruction of Vizamyl images (as done in PET/CT imaging) will add radiation exposure at the level of approximately 0.1 mSv effective dose. Diagnostic head CT scans using helical scanners administer an average of 2.2 ± 1.3 mSv effective dose. The actual radiation dose is operator and scanner dependent.
Table 1: Adult Estimated Radiation Absorbed Vizamyl
Doses in Organs/Tissues
|Organ/Tissue||Absorbed Radiation Dose Per Unit
|Lower large intestine wall||42|
|Small intestine wall||102|
|Upper large intestine wall||117|
|Urinary bladder wall||145|
|Effective Dose||32 (microSv/MBq)|
Dosage Forms And Strengths
Vizamyl injection is available in a 10-mL or 30-mL multi-dose vial containing a clear, colorless to slightly yellow solution at a strength of 150 MBq/mL [4.05 mCi/ mL] of flutemetamol F 18 at reference date and time.
Storage And Handling
Vizamyl is supplied in a 10-mL or a 30-mL multi-dose glass vial with 1-10 mL and 1-30 mL fill volume respectively. Each vial is enclosed in an appropriate radiation shield. The total concentration is 150 MBq/mL (4.05 mCi/mL) of flutemetamol F 18 at reference date and time. 10-mL sterile multi-dose vial with variable fill volume: NDC 17156-067-10 30-mL sterile multi-dose vial with variable fill volume: NDC 17156-067-30
Store Vizamyl at 2° to 30°C (36° to 86°F). The product does not contain a preservative. Store Vizamyl within radiation shielding. Do not use Vizamyl after the expiry date and time stated on the label.
Vizamyl must not be diluted. This preparation is for use by persons licensed by the Nuclear Regulatory Commission or the relevant regulatory authority of an Agreement State.
Manufactured for GE Healthcare, Medi-Physics, Inc., Arlington Heights, IL 60004 U.S.A. Revised: April 2016This monograph has been modified to include the generic and brand name in many instances.
Last reviewed on RxList: 4/20/2016
Additional Vizamyl Information
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