in patients with known or suspected abnormalities found by other testing modalities, or in patients with an existing diagnosis of cancer. 1.2 cardiology for the identification of left ventricular myocardium with residual glucose metabolism and reversible loss of systolic function in patients with coronary artery disease and left ventricular dysfunction, when used together with myocardial perfusion imaging. 1.3 neurology for the identification of regions of abnormal glucose metabolism associated with foci of epileptic seizures.

jection from its container and administer by intravenous injection ( 2 ). the recommended dose: for adults is 5 – 10 mci (185 – 370 mbq), in all indicated clinical settings ( 2.1 ). for pediatric patients is 2.6 mci in the neurology setting ( 2.2 ). initiate imaging within 40 minutes following drug injection; acquire static emission images 30 – 100 minutes from time of injection ( 2 ). 2.1 recommended dose for adults within the oncology, cardiology and neurology settings, the recommended dose for adults is 5 – 10 mci (185 – 370 mbq) as an intravenous injection. 2.2 recommended dose for pediatric patients within the neurology setting, the recommended dose for pediatric patients is 2.6 mci, as an intravenous injection. the optimal dose adjustment on the basis of body size or weight has not been determined [ see use in special populations (8.4) ]. 2.3 patient preparation to minimize the radiation absorbed dose to the bladder, encourage adequate hydration. encourage the patient to drink water or other fluids (as tolerated) in the 4 hours before their pet study. encourage the patient to void as soon as the imaging study is completed and as often as possible thereafter for at least one hour. screen patients for clinically significant blood glucose abnormalities by obtaining a history and/or laboratory tests [ see warnings and precautions (5.2) ]. prior to fludeoxyglucose f 18 pet imaging in the oncology and neurology settings, instruct patient to fast for 4 – 6 hours prior to the drug’s injection. in the cardiology setting, administration of glucose-containing food or liquids (e.g., 50 – 75 grams) prior to fludeoxyglucose f 18 injection facilitates localization of cardiac ischemia. 2.4 radiation dosimetry the estimated human absorbed radiation doses (rem/mci) to a newborn (3.4 kg), 1-year old (9.8 kg), 5-year old (19 kg), 10-year old (32 kg), 15-year old (57 kg), and adult (70 kg) from intravenous administration of fludeoxyglucose f 18 injection are shown in table 1. these estimates were calculated based on human 1 data and using the data published by the international commission on radiological protection 2 for fludeoxyglucose f 18. the dosimetry data show that there are slight variations in absorbed radiation dose for various organs in each of the age groups. these dissimilarities in absorbed radiation dose are due to developmental age variations (e.g., organ size, location, and overall metabolic rate for each age group). the identified critical organs (in descending order) across all age groups evaluated are the urinary bladder, heart, pancreas, spleen, and lungs. table 1. estimated absorbed radiation doses (rem/mci) after intravenous administration of fludeoxyglucose f 18 injection a organ newborn (3.4kg) 1-year old (9.8kg) 5-year old (19kg) 10-year old (32kg) 15-year old (57kg) adult (70kg) bladder wall b 4.3 1.7 0.93 0.60 0.40 0.32 heart wall 2.4 1.2 0.70 0.44 0.29 0.22 pancreas 2.2 0.68 0.33 0.25 0.13 0.096 spleen 2.2 0.84 0.46 0.29 0.19 0.14 lungs 0.96 0.38 0.20 0.13 0.092 0.064 kidneys 0.81 0.34 0.19 0.13 0.089 0.074 ovaries 0.80 0.8 0.19 0.11 0.058 0.053 uterus 0.79 0.35 0.19 0.12 0.076 0.062 lli wall* 0.69 0.28 0.15 0.097 0.060 0.051 liver 0.69 0.31 0.17 0.11 0.076 0.058 gallbladder wall 0.69 0.26 0.14 0.093 0.059 0.049 small intestine 0.68 0.29 0.15 0.096 0.060 0.047 uli wall** 0.67 0.27 0.15 0.090 0.057 0.046 stomach wall 0.65 0.27 0.14 0.089 0.057 0.047 adrenals 0.65 0.28 0.15 0.095 0.061 0.048 testes 0.64 0.27 0.14 0.085 0.052 0.041 red marrow 0.62 0.26 0.14 0.089 0.057 0.047 thymus 0.61 0.26 0.14 0.086 0.056 0.044 thyroid 0.61 0.26 0.13 0.080 0.049 0.039 muscle 0.58 0.25 0.13 0.078 0.049 0.039 bone surface 0.57 0.24 0.12 0.079 0.052 0.041 breast 0.54 0.22 0.11 0.068 0.043 0.034 skin 0.49 0.20 0.10 0.060 0.037 0.030 brain 0.29 0.13 0.09 0.078 0.072 0.070 other tissues 0.59 0.25 0.13 0.083 0.052 0.042 a mirdose 2 software was used to calculate the radiation absorbed dose. b the dynamic bladder model with a uniform voiding frequency of 1.5 hours was used. *lli = lower large intestine; **uli = upper large intestine 2.5 radiation safety – drug handling use waterproof gloves, effective radiation shielding, and appropriate safety measures when handling fludeoxyglucose f 18 injection to avoid unnecessary radiation exposure to the patient, occupational workers, clinical personnel and other persons. radiopharmaceuticals should be used by or under the control of physicians who are qualified by specific training and experience in the safe use and handling of radionuclides, and whose experience and training have been approved by the appropriate governmental agency authorized to license the use of radionuclides. calculate the final dose from the end of synthesis (eos) time using proper radioactive decay factors. assay the final dose in a properly calibrated dose calibrator before administration to the patient [ see description (11.2) ]. the dose of fludeoxyglucose f 18 used in a given patient should be minimized consistent with the objectives of the procedure, and the nature of the radiation detection devices employed. 2.6 drug preparation and administration calculate the necessary volume to administer based on calibration time and dose. aseptically withdraw fludeoxyglucose f 18 injection from its container. inspect fludeoxyglucose f 18 injection visually for particulate matter and discoloration before administration, whenever solution and container permit. do not administer the drug if it contains particulate matter or discoloration; dispose of these unacceptable or unused preparations in a safe manner, in compliance with applicable regulations. use fludeoxyglucose f 18 injection within 12 hours from the eos. 2.7 imaging guidelines initiate imaging within 40 minutes following fludeoxyglucose f 18 injection administration. acquire static emission images 30 – 100 minutes from the time of injection.

yglucose f 18 injection a organ newborn (3.4kg) 1-year old (9.8kg) 5-year old (19kg) 10-year old (32kg) 15-year old (57kg) adult (70kg) bladder wall b 4.3 1.7 0.93 0.60 0.40 0.32 heart wall 2.4 1.2 0.70 0.44 0.29 0.22 pancreas 2.2 0.68 0.33 0.25 0.13 0.096 spleen 2.2 0.84 0.46 0.29 0.19 0.14 lungs 0.96 0.38 0.20 0.13 0.092 0.064 kidneys 0.81 0.34 0.19 0.13 0.089 0.074 ovaries 0.80 0.8 0.19 0.11 0.058 0.053 uterus 0.79 0.35 0.19 0.12 0.076 0.062 lli wall* 0.69 0.28 0.15 0.097 0.060 0.051 liver 0.69 0.31 0.17 0.11 0.076 0.058 gallbladder wall 0.69 0.26 0.14 0.093 0.059 0.049 small intestine 0.68 0.29 0.15 0.096 0.060 0.047 uli wall** 0.67 0.27 0.15 0.090 0.057 0.046 stomach wall 0.65 0.27 0.14 0.089 0.057 0.047 adrenals 0.65 0.28 0.15 0.095 0.061 0.048 testes 0.64 0.27 0.14 0.085 0.052 0.041 red marrow 0.62 0.26 0.14 0.089 0.057 0.047 thymus 0.61 0.26 0.14 0.086 0.056 0.044 thyroid 0.61 0.26 0.13 0.080 0.049 0.039 muscle 0.58 0.25 0.13 0.078 0.049 0.039 bone surface 0.57 0.24 0.12 0.079 0.052 0.041 breast 0.54 0.22 0.11 0.068 0.043 0.034 skin 0.49 0.20 0.10 0.060 0.037 0.030 brain 0.29 0.13 0.09 0.078 0.072 0.070 other tissues 0.59 0.25 0.13 0.083 0.052 0.042 a mirdose 2 software was used to calculate the radiation absorbed dose. b the dynamic bladder model with a uniform voiding frequency of 1.5 hours was used. *lli = lower large intestine; **uli = upper large intestine

devices employed.

nancy outcomes based on the radiation dose from fludeoxyglucose f 18 injection and the gestational timing of exposure. the estimated background risk of major birth defects and miscarriage for the indicated population is unknown. all pregnancies have a background risk of birth defect, loss, or other adverse outcomes. in the u.s. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies are 2-4% and 15-20%, respectively. data human data data from published case series and case reports describe fludeoxyglucose f 18 injection crossing the placental barrier and visualization of radioactivity throughout the body of the fetus. the estimated fetal absorbed radiation dose from the maximum labeled dose (370 mbq) of fludeoxyglucose f 18 was 10mgy with first trimester exposure to pet alone and 20mgy with first trimester exposure to pet/ct scan combination. long-term adverse radiation effects to a child exposed to fludeoyxglucose f 18 injection in utero are unknown. no adverse fetal effects or radiation-related risks have been identified for diagnostic procedures involving less than 50mgy, which represents less than 20mgy fetal doses. 8.2 lactation risk summary a published case report and case series show the presence of fludeoxyglucose f 18 injection in human milk following administration. there are no data on the effects of fludeoxyglucose f 18 injection on the breastfed infant or the effects on milk production. exposure of fludeoxyglucose f 18 injection to a breastfed infant can be minimized by temporary discontinuation of breastfeeding (see clinical considerations). the developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for fludeoxyglucose f 18 injection, any potential adverse effects on the breastfed child from fludeoxyglucose f 18 injection or from the underlying maternal condition. clinical considerations to decrease radiation exposure to the breastfed infant, advise a lactating woman to pump and discard breastmilk and avoid close (breast) contact with the infant for at least 9 hours after the administration of fludeoxyglucose f 18 injection. 8.4 pediatric use the safety and effectiveness of fludeoxyglucose f 18 injection in pediatric patients with epilepsy is established on the basis of studies in adult and pediatric patients. in pediatric patients with epilepsy, the recommended dose is 2.6 mci. the optimal dose adjustment on the basis of body size or weight has not been determined. in the oncology or cardiology settings, the safety and effectiveness of fludeoxyglucose f 18 injection have not been established in pediatric patients.

.s. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies are 2-4% and 15-20%, respectively. data human data data from published case series and case reports describe fludeoxyglucose f 18 injection crossing the placental barrier and visualization of radioactivity throughout the body of the fetus. the estimated fetal absorbed radiation dose from the maximum labeled dose (370 mbq) of fludeoxyglucose f 18 was 10mgy with first trimester exposure to pet alone and 20mgy with first trimester exposure to pet/ct scan combination. long-term adverse radiation effects to a child exposed to fludeoyxglucose f 18 injection in utero are unknown. no adverse fetal effects or radiation-related risks have been identified for diagnostic procedures involving less than 50mgy, which represents less than 20mgy fetal doses.

regions of increased uptake of fludeoxyglucose f 18 reflect greater than normal rates of glucose metabolism. 12.2 pharmacodynamics fludeoxyglucose f 18 injection is rapidly distributed to all organs of the body after intravenous administration. after background clearance of fludeoxyglucose f 18 injection, optimal pet imaging is generally achieved between 30 to 40 minutes after administration. in cancer, the cells are generally characterized by enhanced glucose metabolism partially due to (1) an increase in activity of glucose transporters, (2) an increased rate of phosphorylation activity, (3) a reduction of phosphatase activity or, (4) a dynamic alteration in the balance among all these processes. however, glucose metabolism of cancer as reflected by fludeoxyglucose f 18 accumulation shows considerable variability. depending on tumor type, stage, and location, fludeoxyglucose f 18 accumulation may be increased, normal, or decreased. also, inflammatory cells can have the same variability of uptake of fludeoxyglucose f 18. in the heart, under normal aerobic conditions, the myocardium meets the bulk of its energy requirements by oxidizing free fatty acids. most of the exogenous glucose taken up by the myocyte is converted into glycogen. however, under ischemic conditions, the oxidation of free fatty acids decreases, exogenous glucose becomes the preferred myocardial substrate, glycolysis is stimulated, and glucose taken up by the myocyte is metabolized immediately instead of being converted into glycogen. under these conditions, phosphorylated fludeoxyglucose f 18 accumulates in the myocyte and can be detected with pet imaging. in the brain, cells normally rely on aerobic metabolism. in epilepsy, the glucose metabolism varies. generally, during a seizure, glucose metabolism increases. interictally, the seizure focus tends to be hypometabolic. 12.3 pharmacokinetics distribution: in four healthy male volunteers, receiving an intravenous administration of 30 seconds in duration, the arterial blood level profile for fludeoxyglucose f 18 decayed triexponentially. the effective half-life ranges of the three phases were 0.2-0.3 minutes, 10-13 minutes with a mean and standard deviation (std) of 12 ± (1) min, and 80-95 minutes with a mean and std of 88 ± (4) min. plasma protein binding of fludeoxyglucose f 18 has not been studied. metabolism: fludeoxyglucose f 18 is transported into cells and phosphorylated to [f-18]-fdg-6- phosphate at a rate proportional to the rate of glucose utilization within that tissue. [f 18]-fdg-6-phosphate presumably is metabolized to 2-deoxy-2-[f 18]fluoro-6-phospho-d-mannose([f 18]fdm-6-phosphate). fludeoxyglucose f 18 injection may contain several impurities (e.g., 2-deoxy-2-chloro-d-glucose (cldg)). biodistribution and metabolism of cldg are presumed to be similar to fludeoxyglucose f 18 and would be expected to result in intracellular formation of 2-deoxy-2-chloro-6-phospho-d-glucose (cldg-6-phosphate) and 2-deoxy-2-chloro-6-phospho-d-mannose (cldm-6-phosphate). the phosphorylated deoxyglucose compounds are dephosphorylated and the resulting compounds (fdg, fdm, cldg, and cldm) presumably leave cells by passive diffusion. fludeoxyglucose f 18 and related compounds are cleared from non-cardiac tissues within 3 to 24 hours after administration. clearance from the cardiac tissue may require more than 96 hours. fludeoxyglucose f 18 that is not involved in glucose metabolism in any tissue is then excreted in the urine. elimination: fludeoxyglucose f 18 is cleared from most tissues within 24 hours and can be eliminated from the body unchanged in the urine. within 33 minutes, a mean of 3.9% of the administrated radioactive dose was measured in the urine. the amount of radiation exposure of the urinary bladder at two hours post-administration suggests that 20.6% (mean) of the radioactive dose was present in the bladder. special populations: the pharmacokinetics of fludeoxyglucose f 18 injection have not been studied in renally-impaired, hepatically impaired or pediatric patients. fludeoxyglucose f 18 is eliminated through the renal system. avoid excessive radiation exposure to this organ system and adjacent tissues. the effects of fasting, varying blood sugar levels, conditions of glucose intolerance, and diabetes mellitus on fludeoxyglucose f 18 distribution in humans have not been ascertained [ see warnings and precautions (5.2) ].

ake of fludeoxyglucose f 18 reflect greater than normal rates of glucose metabolism.

bulk of its energy requirements by oxidizing free fatty acids. most of the exogenous glucose taken up by the myocyte is converted into glycogen. however, under ischemic conditions, the oxidation of free fatty acids decreases, exogenous glucose becomes the preferred myocardial substrate, glycolysis is stimulated, and glucose taken up by the myocyte is metabolized immediately instead of being converted into glycogen. under these conditions, phosphorylated fludeoxyglucose f 18 accumulates in the myocyte and can be detected with pet imaging. in the brain, cells normally rely on aerobic metabolism. in epilepsy, the glucose metabolism varies. generally, during a seizure, glucose metabolism increases. interictally, the seizure focus tends to be hypometabolic.

d be expected to result in intracellular formation of 2-deoxy-2-chloro-6-phospho-d-glucose (cldg-6-phosphate) and 2-deoxy-2-chloro-6-phospho-d-mannose (cldm-6-phosphate). the phosphorylated deoxyglucose compounds are dephosphorylated and the resulting compounds (fdg, fdm, cldg, and cldm) presumably leave cells by passive diffusion. fludeoxyglucose f 18 and related compounds are cleared from non-cardiac tissues within 3 to 24 hours after administration. clearance from the cardiac tissue may require more than 96 hours. fludeoxyglucose f 18 that is not involved in glucose metabolism in any tissue is then excreted in the urine. elimination: fludeoxyglucose f 18 is cleared from most tissues within 24 hours and can be eliminated from the body unchanged in the urine. within 33 minutes, a mean of 3.9% of the administrated radioactive dose was measured in the urine. the amount of radiation exposure of the urinary bladder at two hours post-administration suggests that 20.6% (mean) of the radioactive dose was present in the bladder. special populations: the pharmacokinetics of fludeoxyglucose f 18 injection have not been studied in renally-impaired, hepatically impaired or pediatric patients. fludeoxyglucose f 18 is eliminated through the renal system. avoid excessive radiation exposure to this organ system and adjacent tissues. the effects of fasting, varying blood sugar levels, conditions of glucose intolerance, and diabetes mellitus on fludeoxyglucose f 18 distribution in humans have not been ascertained [ see warnings and precautions (5.2) ].

osis of cancer. positive fludeoxyglucose f 18 injection pet scans cannot replace pathology to establish a diagnosis of cancer. non-malignant conditions such as fungal infections, inflammatory processes and benign tumors have patterns of increased glucose metabolism that may give rise to false-positive scans. the efficacy of fludeoxyglucose f 18 injection pet imaging in cancer screening was not studied. 14.2 cardiology the efficacy of fludeoxyglucose f 18 injection for cardiac use was demonstrated in ten independent, prospective studies of patients with coronary artery disease and chronic left ventricular systolic dysfunction who were scheduled to undergo coronary revascularization. before revascularization, patients underwent pet imaging with fludeoxyglucose f 18 injection (74 – 370 mbq, 2 – 10 mci) and perfusion imaging with other diagnostic radiopharmaceuticals. doses of fludeoxyglucose f 18 injection ranged from 74-370 mbq (2-10 mci). segmental, left ventricular, wall-motion assessments of asynergic areas made before revascularization were compared in a blinded manner to assessments made after successful revascularization to identify myocardial segments with functional recovery. left ventricular myocardial segments were predicted to have reversible loss of systolic function if they showed fludeoxyglucose f 18 accumulation and reduced perfusion (i.e., flow-metabolism mismatch). conversely, myocardial segments were predicted to have irreversible loss of systolic function if they showed reductions in both fludeoxyglucose f 18 accumulation and perfusion (i.e., matched defects). findings of flow-metabolism mismatch in a myocardial segment may suggest that successful revascularization will restore myocardial function in that segment. however, false-positive tests occur regularly, and the decision to have a patient undergo revascularization should not be based on pet findings alone. similarly, findings of a matched defect in a myocardial segment may suggest that myocardial function will not recover in that segment, even if it is successfully revascularized. however, false-negative tests occur regularly, and the decision to recommend against coronary revascularization, or to recommend a cardiac transplant, should not be based on pet findings alone. the reversibility of segmental dysfunction as predicted with fludeoxyglucose f 18 pet imaging depends on successful coronary revascularization. therefore, in patients with a low likelihood of successful revascularization, the diagnostic usefulness of pet imaging with fludeoxyglucose f 18 injection is more limited. 14.3 neurology in a prospective, open label trial, fludeoxyglucose f 18 injection was evaluated in 86 patients with epilepsy. each patient received a dose of fludeoxyglucose f 18 injection in the range of 185-370 mbq (5-10 mci). the mean age was 16.4 years (range: 4 months - 58 years; of these, 42 patients were less than 12 years and 16 patients were less than 2 years old). patients had a known diagnosis of complex partial epilepsy and were under evaluation for surgical treatment of their seizure disorder. seizure foci had been previously identified on ictal eegs and sphenoidal eegs. fludeoxyglucose f 18 injection pet imaging confirmed previous diagnostic findings in 16% (14/87) of the patients; in 34% (30/87) of the patients, fludeoxyglucose f 18 injection pet images provided new findings. in 32% (27/87), imaging with fludeoxyglucose f 18 injection was inconclusive. the impact of these imaging findings on clinical outcomes is not known. several other studies comparing imaging with fludeoxyglucose f 18 injection results to subsphenoidal eeg, mri and/or surgical findings supported the concept that the degree of hypometabolism corresponds to areas of confirmed epileptogenic foci. the safety and effectiveness of fludeoxyglucose f 18 injection to distinguish idiopathic epileptogenic foci from tumors or other brain lesions that may cause seizures have not been established.

tive fludeoxyglucose f 18 injection pet scans cannot replace pathology to establish a diagnosis of cancer. non-malignant conditions such as fungal infections, inflammatory processes and benign tumors have patterns of increased glucose metabolism that may give rise to false-positive scans. the efficacy of fludeoxyglucose f 18 injection pet imaging in cancer screening was not studied.

atch). conversely, myocardial segments were predicted to have irreversible loss of systolic function if they showed reductions in both fludeoxyglucose f 18 accumulation and perfusion (i.e., matched defects). findings of flow-metabolism mismatch in a myocardial segment may suggest that successful revascularization will restore myocardial function in that segment. however, false-positive tests occur regularly, and the decision to have a patient undergo revascularization should not be based on pet findings alone. similarly, findings of a matched defect in a myocardial segment may suggest that myocardial function will not recover in that segment, even if it is successfully revascularized. however, false-negative tests occur regularly, and the decision to recommend against coronary revascularization, or to recommend a cardiac transplant, should not be based on pet findings alone. the reversibility of segmental dysfunction as predicted with fludeoxyglucose f 18 pet imaging depends on successful coronary revascularization. therefore, in patients with a low likelihood of successful revascularization, the diagnostic usefulness of pet imaging with fludeoxyglucose f 18 injection is more limited.

deoxyglucose f 18 injection results to subsphenoidal eeg, mri and/or surgical findings supported the concept that the degree of hypometabolism corresponds to areas of confirmed epileptogenic foci. the safety and effectiveness of fludeoxyglucose f 18 injection to distinguish idiopathic epileptogenic foci from tumors or other brain lesions that may cause seizures have not been established.

label. use fludeoxyglucose f 18 injection within 12 hours from the eos time.