n administered by nebulizer for inhalation.

to cardiopulmonary resuscitation equipment and personnel. 5.2 image interpretation risks in lung ventilation studies in patients with obstructive pulmonary disease there may be deposition of particles in the proximal airways influencing image quality and interfering with diagnostic interpretation, therefore to ensure diagnostic quality, careful use of the nebulizer to assure optimal particle delivery is essential. if interfering particle deposition occurs, consider additional diagnostic options. 5.3 radiation exposure risk technetium tc 99m contributes to a patient’s overall long-term cumulative radiation exposure. long-term cumulative radiation exposure is associated with an increased risk of cancer. ensure safe handling and preparation procedures to protect patients and health care workers from unintentional radiation exposure. use the lowest dose of technetium tc 99m pentetate necessary for imaging. encourage patients to drink fluids and void as frequently as possible after intravenous administration [see dosage and administration ( 2.1 , 2.3 )] . radiation risks associated with the use of technetium tc 99m pentetate are greater in pediatric patients than in adults due to greater radiosensitivity and longer life expectancy. 5.4 bronchospasm in lung ventilation studies as with other inhaled medications, inhalation of technetium tc 99m pentetate solution may result in acute bronchoconstriction, especially in patients with heightened bronchoreactivity, such as patients with asthma or other lung or allergic disorders. monitor all patients for bronchoconstriction.

ore than one dose. table 1 tc 99m labeled draximage ® dtpa injection – intravenous administration, adults indication route of administration dose image acquisition brain imaging intravenous injection 370 mbq to 740 mbq (10 mci to 20 mci) immediate dynamic imaging. obtain at least one blood-pool image in same position as flow. delayed images can be obtained 1 hour later. renal visualization and perfusion assessment intravenous injection 370 mbq to 740 mbq (10 mci to 20 mci) immediate dynamic imaging. static imaging 1 to 30 minutes after injection. renal visualization with estimation of glomerular filtration rate intravenous injection 111 mbq to 185 mbq (3 mci to 5 mci) immediate dynamic imaging. static imaging 1 to 30 minutes after injection. estimation of glomerular filtration rate (with no renal imaging) intravenous injection 7.4 mbq to 18.5 mbq (0.2 mci to 0.5 mci) blood sampling only is performed. table 2 tc 99m labeled draximage ® dtpa injection – intravenous administration, pediatric patients indication route of administration dose image acquisition renal visualization and perfusion assessment intravenous injection 3.7 mbq/kg to 7.4 mbq/kg (0.1 mci/kg to 0.2 mci/kg) minimum 37 mbq (1 mci) maximum 185 mbq (5 mci) immediate dynamic imaging. static imaging 1 to 30 minutes after injection. estimation of glomerular filtration rate (with no renal imaging) intravenous injection 7.4 mbq to 18.5 mbq (0.2 mci to 0.5 mci) blood sampling only is performed. table 3 tc 99m labeled draximage ® dtpa – aerosol inhalation administration * for lung imaging performed after perfusion imaging, target count rate should be approximately three times that of perfusion count rate. indication route of administration dose image acquisition lung ventilation adults aerosol inhalation 925 mbq to 1850 mbq (25 mci to 50 mci) in the nebulizer to achieve a lung dose of approximately 18.5 mbq to 37 mbq (0.5 mci to 1.0 mci) for lung imaging performed prior to perfusion imaging, the target administered dose to the lungs is achieved after 3 to 5 minutes of inhalation or at an imaging count rate of 50,000 to 100,000 per minute * . lung ventilation pediatric patients aerosol inhalation 925 mbq (25 mci) in the nebulizer to achieve a lung dose of approximately 18.5 mbq (0.5 mci) for lung imaging performed prior to perfusion imaging, the target administered dose to the lungs is achieved at an imaging count rate of approximately 10,000 to 50,000 per minute * . 2.3 administration instructions use aseptic technique for all drug preparation and handling. visually inspect the tc 99m labeled draximage ® dtpa injection after reconstitution for particulate matter prior to administration. do not use or administer if there is evidence of foreign matter or the solution is not clear. measure the patient dose by a radioactivity calibration system immediately prior to administration. intravenous use instruct the patient to increase fluid intake and to void frequently for the next 4 to 6 hours after tc 99m labeled draximage ® dtpa administration by injection to minimize the radiation dose to the bladder. inhalation use use the selected nebulizer in accordance with the manufacturer’s instructions. instruct the patient to rinse their mouth and expectorate after tc 99m labeled draximage ® dtpa administration by inhalation to minimize the radiation dose to the mouth and esophagus. 2.4 instructions for drug preparation the prepared solution can either be administered via intravenous injection or aerosolized by nebulizer for inhalation use. before reconstitution, inspect the integrity of the vial. add 2 to 10 ml [maximum amount 18.5 gigabecquerels (500 mci)] of sodium pertechnetate tc 99m injection usp to the reaction vial. the volume of pertechnetate added should be balanced by the removal of the same volume of air. cover the vial shield and invert to mix the contents. assay the preparation in a calibrator, record the radio assay information on the label with radiation warning symbol, and affix it to the reaction vial. after reconstitution, store the solution at 25 °c (77 °f) in a lead shield and discard after 12 hours; excursions permitted between 15 °c and 30 °c (59 °f and 86°f). allow the preparation to stand for 15 minutes before determining the radiochemical purity of tc 99m labeled draximage ® dtpa injection. after reconstitution, do not vent the vial. 2.5 determination of radiochemical purity obtain the following: two itlc-sg (1 x 10 cm) 0.9% sodium chloride injection usp (for determination of reduced hydrolyzed technetium) acetone (for determination of free pertechnetate) two glass test tubes (18 mm x 150 mm) with stoppers step 1: system a : add 1 ml of 0.9% sodium chloride injection usp in an 18 mm x 150 mm test tube. place the stopper and allow the atmosphere in the tube to equilibrate for 1 minute. system b : repeat with acetone in a separate test tube. step 2: mark each chromatographic strip with a pencil mark 1.5 cm (see figure 1 and figure 2 ) from one end of the strip (mark as origin). place one drop (approximately 0.01 to 0.02 ml) of the technetium tc 99m pentetate injection at the origin. for system a (saline), do not allow the strip to dry. for system b (acetone), dry the strip using a gentle stream of nitrogen gas. step 3: place each strip with the origin end towards the bottom of the previously equilibrated test tube to develop (the origin must be above the surface of the solvent). place stopper in the test tube and keep upright. step 4: when the solvent front has reached the top of the strip, remove the strip with forceps and allow it to dry. step 5: system a – determination of reduced hydrolyzed technetium: in system a (saline), reduced hydrolyzed technetium ( 99m tco 2 ) stays at the origin (r f 0 to 0.1), while the bound technetium and free pertechnetate ( 99m tco 4 – ) migrates to the solvent front (r f 0.85 to 1.0). cut the dried strip 3 cm from the origin. the short piece is marked as part i and the long piece is marked as part ii . count the pieces in a counter and determine the percentage of reduced hydrolyzed technetium according to the following formula: figure 1 system a diagram system b – determination of free pertechnetate: in system b (acetone), the bound technetium ( 99m tc) and reduced hydrolyzed technetium ( 99m tco 2 ) stay at the origin (r f 0 to 0.1), while free pertechnetate ( 99m tco 4 – ) migrates to the solvent front (r f 0.85 to 1.0). cut the dried strip 2 cm from the solvent front end. the short piece is marked part iii and the long piece is marked part iv . count the pieces in a counter and determine the percentage of free pertechnetate according to the following formula: figure 2 system b diagram step 6: determine the radiochemical purity according to the following formula: use technetium tc 99m pentetate injection only if the radiochemical purity is 90% or greater. eq1 figure_1 eq2 figure2 step-6-formula 2.6 radiation dosimetry the estimated radiation absorbed dose to various organs from an intravenous injection of tc 99m pentetate in patients with normal and abnormal renal function is shown respectively in table 4 and table 5 . table 4 estimated radiation absorbed dose for technetium tc 99m pentetate injection in patients with normal renal function following intravenous injection absorbed dose per unit activity administered (mcgy/mbq) organ adult 15 years 10 years 5 years 1 year adrenals 1.4 1.8 2.7 4.0 7.2 bone surfaces 2.4 2.9 4.3 6.1 10 brain 0.86 1.1 1.7 2.8 4.9 breast 0.72 0.92 1.3 2.2 4.1 gallbladder wall 1.5 2.1 3.8 5.0 6.1 gastrointestinal tract esophagus 1.0 1.3 1.9 3.0 5.4 stomach wall 1.3 1.7 2.8 4.0 6.8 small intestine wall 2.5 3.1 4.9 7.0 10 colon wall 3.1 3.9 6.0 8.1 11 upper large intestine wall 2.1 2.8 4.3 6.5 9.2 lower large intestine wall 4.3 5.4 8.2 10 13 heart wall 1.2 1.5 2.2 3.3 5.9 kidneys 4.4 5.3 7.5 11 18 liver 1.2 1.6 2.5 3.8 6.4 lungs 1.0 1.3 2.0 3.0 5.5 muscles 1.6 2.0 3.0 4.3 6.8 ovaries 4.2 5.3 7.7 10 13 pancreas 1.4 1.8 2.8 4.3 7.4 red marrow 1.5 1.8 2.7 3.7 5.7 skin 0.87 1.0 1.7 2.6 4.4 spleen 1.3 1.6 2.6 3.9 6.8 testes 2.9 4.0 6.8 9.4 13 thymus 1.0 1.3 1.9 3.0 5.4 thyroid 1.0 1.3 2.1 3.3 6.0 urinary bladder wall 62 78 110 150 170 uterus 7.9 9.6 15 18 22 remaining organs 1.7 2.1 3.0 4.2 6.6 effective dose per unit activity (mcsv/mbq) 4.9 6.3 9.4 12 16 table 5 estimated radiation absorbed dose for technetium tc 99m pentetate injection in patients with abnormal renal function following intravenous injection absorbed dose per unit activity administered (mcgy/mbq) organ adult 15 years 10 years 5 years 1 year adrenals 4.1 5.1 7.6 11 21 bone surfaces 6.0 7.1 11 15 28 brain 2.8 3.5 5.7 9.1 16 breast 2.3 3.0 4.2 6.8 13 gallbladder wall 4.2 5.7 9.2 13 16 gastrointestinal tract esophagus 3.3 4.2 6.2 9.6 17 stomach wall 3.8 5.0 7.9 11 19 small intestine wall 4.5 5.6 8.5 13 22 colon wall 4.5 5.8 8.7 13 22 upper large intestine wall 4.3 5.6 8.1 13 21 lower large intestine wall 4.9 6.1 9.5 13 23 heart wall 3.7 4.7 7.0 10 18 kidneys 7.7 9.2 13 19 32 liver 3.7 4.6 7.1 11 19 lungs 3.3 4.2 6.2 9.5 17 muscles 3.2 4.0 6.1 9.1 17 ovaries 5.0 6.2 9.2 14 23 pancreas 4.3 5.3 8.0 12 21 red marrow 3.4 4.2 6.4 9.3 16 skin 2.2 2.6 4.2 6.7 12 spleen 3.8 4.7 7.3 11 19 testes 3.5 4.5 6.9 10 18 thymus 3.3 4.2 6.2 9.6 17 thyroid 3.4 4.2 6.7 11 19 urinary bladder wall 21 27 39 50 66 uterus 6.1 7.4 11 16 25 remaining organs 3.3 4.1 6.3 9.7 17 effective dose per unit activity (mcsv/mbq) 4.6 5.8 8.7 13 21 the estimated radiation absorbed dose to various organs from the inhalation of tc 99m pentetate injection is shown in table 6 . table 6 estimated radiation absorbed dose for technetium tc 99m pentetate injection administered by inhalation absorbed dose per unit activity administered (mcgy/mbq) organ adult 15 years 10 years 5 years 1 year adrenals 2.1 2.9 4.4 6.7 12 bone surfaces 1.9 2.4 3.5 5.3 9.8 breast 1.9 1.9 3.3 4.8 7.8 gastrointestinal tract stomach wall 1.7 2.2 3.5 5.1 8.9 small intestine wall 2.1 2.6 4.1 6.3 11 upper large intestine wall 1.9 2.4 3.8 6.1 10 lower large intestine wall 3.2 4.2 6.3 8.8 15 kidneys 4.1 5.1 7.2 11 19 liver 1.9 2.5 3.7 5.5 9.7 lungs 17 26 36 54 100 ovaries 3.3 4.1 6.1 8.9 15 pancreas 2.1 2.6 4.0 6.1 11 red marrow 2.7 3.4 4.7 6.2 9.6 spleen 1.9 2.4 3.6 5.6 9.9 testes 2.1 3.1 5.2 7.9 15 thyroid 0.99 1.7 2.7 4.4 7.8 urinary bladder wall 47 58 84 120 230 uterus 5.9 7.2 11 16 27 other tissue 1.8 2.2 3.2 4.9 8.6 effective dose per unit activity (mcsv/mbq) 5.9 8.0 11 17 31

( 6 ). to report suspected adverse reactions, contact jubilant draximage inc. at 1-888-633-5343 or fda at 1-800-fda-1088 or www.fda.gov/medwatch .

n clinically recognized pregnancies are 2% to 4% and 15% to 20%, respectively. data human data limited published literature describes technetium tc 99m pentetate crossing the placental barrier. no adverse fetal effects or radiation-related risks have been identified for diagnostic procedures involving less than 50 mgy, which represents less than 10 mgy fetal doses. 8.2 lactation risk summary there are limited data available in scientific literature on the presence of technetium tc 99m pentetate in human milk. there are no data available on the effects of technetium tc 99m pentetate on the breastfed infant or the effects on milk production. based on the united states nuclear regulatory commission guidelines for breast feeding interruption after exposure to radiopharmaceuticals, breastfeeding interruption is not recommended for technetium 99m pentetate at levels less than 1000 mbq (30 mci). the developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for technetium tc 99m pentetate, any potential adverse effects on the breastfed child from technetium tc 99m pentetate or from the underlying maternal condition. 8.4 pediatric use technetium tc 99m pentetate is indicated for lung ventilation and evaluation of pulmonary embolism when paired with perfusion imaging and for renal visualization, assessment of renal perfusion, and estimation of glomerular filtration rate in pediatric patients ages birth to less than 17 years of age. pediatric use is supported by evidence from controlled studies in adults and dosing and safety are based on clinical experience. the radiation risk of technetium tc 99m pentetate is greater in pediatric patients than adults [see warnings and precautions, ( 5.3 )]. 8.5 geriatric use no formal studies of technetium tc 99m pentetate in the elderly were performed to determine whether they respond differently from younger subjects. other reported clinical experience has not identified differences in responses between the elderly and younger patients. in general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

ncies are 2% to 4% and 15% to 20%, respectively. data human data limited published literature describes technetium tc 99m pentetate crossing the placental barrier. no adverse fetal effects or radiation-related risks have been identified for diagnostic procedures involving less than 50 mgy, which represents less than 10 mgy fetal doses.

ents with normal lungs, the deposition of technetium tc 99m pentetate is homogeneous throughout the lungs. in patients with airway disease, the deposition patterns become inhomogeneous with irregular deposition of technetium tc 99m pentetate in the airways and alveolar regions of the lung. 12.3 pharmacokinetics after an intravenous administration, the pharmacokinetics of technetium tc 99m pentetate were studied by monitoring radioactivity in serial venous blood samples for 7 hours post-administration. the mean plasma clearance rate was 6.8 (l/h) and the mean plasma elimination half-life (t½) was 2.1 hours. the mean volume of distribution at steady state conditions calculated with clearance and mean residence time was 17 l. this relatively low volume of distribution after intravenous administration suggests that technetium tc 99m pentetate distributes to the extracellular fluid only. the rate of elimination of technetium tc 99m pentetate from the systemic circulation appears to be constant over an approximately 20-fold intravenous dose range. absorption following inhalation technetium tc 99m pentetate was absorbed (t max < 2 hours after inhalation) and distributed across the lung epithelium (bioavailability approximately 70%) and into the systemic circulation. distribution following intravenous administration, technetium tc 99m pentetate is distributed throughout the extracellular fluid space and is cleared from the body by the kidney. the steady-state volume of distribution (vss) was 17 l following an intravenous administration. technetium tc 99m pentetate distribution appears to be limited to the extravascular compartment. a variable percentage of the technetium tc 99m pentetate binds to the serum proteins; this ranges from 3.7% following a single injection to approximately 10% if the material is continuously infused. although the chelate gives useful information on the glomerular filtration rate, the variable percent which is protein bound leads to a measured renal clearance rate which is lower than that determined by inulin clearance. elimination metabolism technetium tc 99m pentetate is not metabolized. excretion after either intravenous administration or inhalation, excretion is by glomerular filtration. the mean fraction of intravenously administered technetium tc 99m pentetate excreted in urine over 24 hours was 102%.

tion following intravenous administration, technetium tc 99m pentetate is distributed throughout the extracellular fluid space and is cleared from the body by the kidney. the steady-state volume of distribution (vss) was 17 l following an intravenous administration. technetium tc 99m pentetate distribution appears to be limited to the extravascular compartment. a variable percentage of the technetium tc 99m pentetate binds to the serum proteins; this ranges from 3.7% following a single injection to approximately 10% if the material is continuously infused. although the chelate gives useful information on the glomerular filtration rate, the variable percent which is protein bound leads to a measured renal clearance rate which is lower than that determined by inulin clearance. elimination metabolism technetium tc 99m pentetate is not metabolized. excretion after either intravenous administration or inhalation, excretion is by glomerular filtration. the mean fraction of intravenously administered technetium tc 99m pentetate excreted in urine over 24 hours was 102%.

reement state.