Dotagita 0.5 Mmol/Ml Solution For Injection
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Dotagita 0.5 mmol/ml solution for injection
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
1 ml solution for injection contains 279.32 mg gadoteric acid (as meglumine salt), equivalent to 0.5 mmol.
5 ml solution for injection contains 1396.6 mg gadoteric acid (as meglumine salt), equivalent to 2.5 mmol.
10 ml solution for injection contains 2793.2 mg gadoteric acid (as meglumine salt), equivalent to 5 mmol.
15 ml solution for injection contains 4189.8 mg gadoteric acid (as meglumine salt), equivalent to 7.5 mmol.
20 ml solution for injection contains 5586.4 mg gadoteric acid (as meglumine salt), equivalent to 10 mmol.
60 ml solution for injection contains 16759.2 mg gadoteric acid (as meglumine salt), equivalent to 30 mmol.
For the full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Solution for injection
A clear, colourless to pale yellow solution practically free from visible particles, with pH of 6.9-7.8 and an osmolality of 900-1700mOsm/kg-1.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
This medicinal product is for diagnostic use only.
Enhancement of contrast in Magnetic Resonance Imaging for a better visualization/delineation:
- of lesions of the brain, spine, and surrounding tissues
- whole body MRI including lesions of the liver, kidneys, pancreas, pelvis, lungs, heart, breast, and musculoskeletal system
- of lesions or stenoses of the non-coronary arteries (MR Angiography)
Paediatric population (0-18 years)
- Magnetic resonance imaging (MRI) for cerebral and spinal disease
- Whole-body MRI
4.2 Posology and method of administration
Posology
Encephalic and spinal MRI:
In neurological examinations, the recommended dose is 0.1 mmol/kg body weight, corresponding to 0.2 ml/kg body weight. In some cases, after administration of 0.1 mmol/kg body weight to patients with brain tumors, an additional dose of 0.2 mmol/kg body weight corresponding to 0.4 ml/kg body weight may improve tumor characterisation and facilitate decision making.
MRI of other organs and Angiography:
The recommended dose for intravenous injection is 0.1 mmol/kg (i.e. 0.2 ml/kg) to provide diagnostically adequate contrast.
Angiography: In exceptional circumstances (e.g. failure to gain satisfactory images of an extensive vascular territory) administration of a second consecutive injection of 0.1 mmol/kg body weight, equivalent to 0.2 ml/kg body weight may be justified. However, if the use of 2 consecutive doses of Dotagita is anticipated prior to commencing angiography, use of 0.05 mmol/kg body weight, equivalent to 0.1 ml/kg body weight for each dose may be of benefit, depending on the imaging equipment available.
Special populations Impaired renal _ function
The adult dose applies to patients with mild to moderate renal impairment (GFR > 30 ml/min/1.73m2).
Dotagita should only be used in patients with severe renal impairment (GFR < 30 ml/min/1.73m2) and in patients in the perioperative liver transplantation period after careful risk/benefit assessment and if the diagnostic information is essential and not available with non-contrast enhanced MRI (see section 4.4). If it is necessary to use Dotagita, the dose should not exceed 0.1 mmol/kg body weight. More than one dose should not be used during a scan. Because of the lack of information on repeated administration, Dotagita injections should not be repeated unless the interval between injections is at least 7 days.
Elderly (aged 65 years and above)
No dose adjustment is considered necessary. Caution should be exercised in elderly patients (see section 4.4).
Impaired hepatic junction
The adult dose applies to these patients. Caution is recommended, especially in the case of perioperative liver transplantation period (see above impaired renal function).
Paediatric population (0-18 years)
MRI of brain and spine / whole-body MRI:
The recommended and maximum dose of Gadoteric acid is 0.1 mmol/kg body weight. More than one dose should not be used during a scan.
Due to immature renal function in neonates up to 4 weeks of age and infants up to 1 year of age, Dotagita should only be used in these patients after careful consideration at a dose not exceeding 0.1 mmol/kg body weight. More than one dose should not be used during a scan. Because of the lack of information on repeated administration, Dotagita injections should not be repeated unless the interval between injections is at least 7 days.
Angiography:
Gadoteric acid is not recommended for angiography in children under 18 years of age due to insufficient data on efficacy and safety in this indication.
Method of administration
The product is indicated for intravenous administration only.
Infusion rate: 3-5 ml/min (higher infusion rates up to 120 ml/min, i.e. 2 ml/sec, may be used for angiographic procedures)
Optimal imaging: within 45 minutes after injection
Optimal image sequence: T1-weighted
Intravascular administration of contrast media should, if possible, be done with the patient lying down.
After the administration, the patient should be kept under observation for at least half an hour, since experience shows that the majority of undesirable effects occur within this time.
Prepare a syringe with a needle. Remove the plastic disk. After cleaning the stopper with a pad soaked in alcohol, puncture the stopper with the needle. Withdraw the quantity of product required for the examination and inject it intravenously.
Each vial is for single patient use only. Contents not used in a patient during one investigation must be discarded.
The solution for injection should be inspected visually prior to use. Only clear solutions free of visible particles should be used.
Paediatric population (0-18 years)
Depending on the amount of gadoteric acid to be given to the child, it is preferable to use gadoteric acid vials with a single use syringe of a volume adapted to this amount in order to have a better precision of the injected volume.
In neonates and infants the required dose should be administered by hand.
4.3 Contraindications
- Hypersensitivity to gadoteric acid, to meglumine or to any medicinal products containing gadolinium.
4.4 Special warnings and precautions for use
To be administered only by intravenous route.
Gadoteric acid must not be administered by subarachnoid (or epidural) injections.
The usual precaution measures for MRI examination should be taken, such as exclusion of patients with pacemakers, ferromagnetic vascular clips, infusion pumps, nerve stimulators, cochlear implants, or suspected intracorporal metallic foreign bodies, particularly in the eye.
Hypersensitivity
• As with other gadolinium containing contrast media hypersensitivity reactions can occur, including life-threatening (see section 4.8). Hypersensitivity reactions may be either allergic (described as anaphylactic reactions when serious) or non allergic. They can be either immediate (less than 60 minutes), or delayed (up to 7 days). Anaphylactic reactions occur immediately and can be fatal. They are independent of the dose, can occur after even the first dose of the product, and are often unpredictable.
• There is always a risk of hypersensitivity regardless of the dose injected.
• Patients who have already experienced a reaction during previous administration of a gadolinium-containing MRI contrast agent present an increased risk of experiencing another reaction on subsequent administration of the same product, or possibly other products, and are therefore considered to be at high risk.
• The injection of gadoteric acid may aggravate symptoms of an existing asthma. In patients with asthma uncontrolled with treatment, the decision to use gadoteric acid must be made after careful evaluation of the risk/benefit ratio.
• As known from the use of iodinated contrast media, hypersensitivity reactions can be aggravated in patients on beta-blockers, and particularly in the presence of bronchial asthma. These patients may be refractory to standard treatment of hypersensitivity reactions with beta-agonists.
• Before any contrast medium is injected, the patient should be questioned for a history of allergy (e.g. seafood allergy, hay fever, hives), sensitivity to contrast media and bronchial asthma as the reported incidence of adverse reactions to contrast media is higher in patients with these conditions and premedication with antihistamines and/or glucocorticoids may be considered.
• During the examination, supervision by a physician is necessary. If hypersensitivity reactions occur, administration of the contrast medium must be discontinued immediately and - if necessary - specific therapy instituted. A venous access should thus be kept during the entire examination. To permit immediate emergency countermeasures, appropriate medicinal products (e.g. epinephrine and antihistamines), an endotracheal tube and a respirator should be ready at hand.
Impaired renal function
Prior to administration of Dotagita, it is recommended that all patients are screened for renal dysfunction by obtaining laboratory tests.
There have been reports of nephrogenic systemic fibrosis (NSF) associated with use of some gadolinium-containing contrast agents in patients with acute or chronic severe renal impairment (GFR < 30 mL/min/1.73m2). Patients undergoing liver transplantation are at particular risk since the incidence of acute renal failure is high in this group. As there is a possibility that NSF may occur with Dotagita, it should therefore only be used in patients with severe renal impairment and in patients in the perioperative liver transplantation period after careful risk/benefit assessment and if the diagnostic information is essential and not available with non-contrast enhanced MRI.
Haemodialysis shortly after gadoteric acid administration may be useful to clear gadoteric acid from the body. There is no evidence to support the initiation of haemodialysis for prevention or treatment of NSF in patients not already undergoing haemodialysis.
Elderly
As the renal clearance of gadoteric acid may be impaired in the elderly, it is particularly important to screen patients aged 65 years and older for renal dysfunction.
Paediatric population
Neonates and infants
Due to immature renal function in neonates up to 4 weeks of age and infants up to 1 year of age, gadoteric acid should only be used in these patients after careful consideration.
In neonates and infants the required dose should be administered by hand.
According to the amount of gadoteric acid to be administered to infant, it would be better using gadoteric acid vials and single use small volume syringe to get a better accuracy of injected volume.
Cardiovascular disease
In patients with severe cardiovascular disease Dotagita should only be administrated after careful risk benefit assessment because only limited data are available so far.
CNS disorders
Like with other gadolinium containing contrast agents special precaution is necessary in patients with a low threshold for seizures. Precautionary measures should be taken, e.g. close monitoring. All equipment and medicinal products necessary to counter any convulsions which may occur must be made ready for use beforehand.
4.5 Interaction with other medicinal products and other forms of interaction
No interactions with other medicinal products have been observed. Formal medicinal product interaction studies have not been carried out.
Concomitant medications to be taken into account:
Beta-blockers, vasoactive substances, angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists: these medicinal products decrease the efficacy of the mechanisms of cardiovascular compensation for blood pressure disorders: the radiologist must be informed before injection of gadolinium complexes, and resuscitation equipment must be at hand.
4.6 Fertility, pregnancy and lactation
Pregnancy
There are no data from the use of gadoteric acid in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see section 5.3). Dotagita should not be used during pregnancy unless the clinical condition of the woman requires use of gadoteric acid.
Breast-feeding
Gadolinium containing contrast agents are excreted into breast milk in very small amounts (see section 5.3). At clinical doses, no effects on the infant are anticipated due to the small amount excreted in milk and poor absorption from the gut. Continuing or discontinuing breast feeding for a period of 24 hours after administration of Dotagita, should be at the discretion of the doctor and lactating mother.
4.7 Effects on ability to drive and use machines
No studies on the effects on the ability to drive and use machines have been performed. Ambulant patients while driving vehicles or operating machinery should take into account that nausea may incidentally occur.
4.8 Undesirable effects
Side effects in association with the use of gadoteric acid are usually mild to moderate in intensity and transient in nature. A sensation of heat, cold and/or pain at the injection site are the most frequently observed reactions.
During clinical trials, headache and paresthesia were very commonly observed (>1/10), and nausea, vomiting and skin reactions such as erythematous rash and pruritus were commonly observed (>1/100 - <1/10).
Since post-marketing, the most commonly reported adverse reactions following administration of gadoteric acid are nausea, vomiting, pruritus and hypersensitivity reactions.
In hypersensitivity reactions, the reactions most frequently observed are skin reactions, which can be localized, extended or generalized.
These reactions occur most often immediately (during the injection or within one hour after the start of injection) or sometimes delayed (one hour to several days after injection), presenting as skin reactions in this case.
Immediate reactions include one or more effects, which appear simultaneously or sequentially, which are most often cutaneous, respiratory and/or cardiovascular reactions. Each sign may be a warning sign of a starting shock and go very rarely to death.
Isolated cases of nephrogenic systemic fibrosis (NSF) have been reported with gadoteric acid, most of which were in patients co-administered other gadolinium-containing contrast agents (see section 4.4).
The adverse reactions are listed in the table below by SOC (System Organ Class) and by frequency with the following guidelines: very common (>1/10), common (>1/100 to <1/10),
uncommon (>1/1,000 to <1/100), rare (>1/10,000 to <1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data). The data presented are from clinical trials when available, or from an observational study involving 82,103 patients.
|
Organ Class System |
Frequency: adverse reaction |
|
Immune system disorders |
Uncommon: hypersensitivity, anaphylactic reaction, anaphylactoid reaction |
|
Psychiatric disorders |
Very rare: agitation, anxiety |
|
Nervous system disorders |
Very common: paraesthesia, headache Rare: dysgeusia Very rare: coma, convulsion, syncope, presyncope, dizziness, parosmia, tremor |
|
Eye disorders |
Very rare: conjunctivitis, ocular hyperaemia, vision blurred, lacrimation increased, eyelid edema |
|
Cardiac disorders |
Very rare: cardiac arrest, bradycardia, tachycardia, arrhythmia, palpitations |
|
Vascular disorders |
Very rare: hypotension, hypertension, vasodilatation, pallor |
|
Respiratory, thoracic and mediastal disorders |
Very rare: respiratory arrest, pulmonary oedema, bronchospasm, laryngospasm, pharyngeal oedema, dyspnoea, nasal congestion, sneezing, cough, dry throat |
|
Gastrointestinal disorders |
Common: nausea, vomiting Very rare: diarrhoea, abdominal pain, salivary hypersecretion |
|
Skin and subcutaneous tissue disorders |
Common: pruritus, erythema, rash Rare: urticaria, hyperhidrosis, Very rare: eczema, angioedema Not known: nephrogenic systemic fibrosis |
|
Musculoskeletal and connective tissue disorders |
Very rare: muscle contracture, muscular weakness, back pain |
|
Organ Class System |
Frequency: adverse reaction |
|
General Disorders and administration site conditions |
Common: feeling hot, feeling cold, injection site pain Very rare: malaise, thoracic pain, chest discomfort, fever, chills, face oedema, asthenia, injection site discomfort, injection site reaction, injection site oedema, injection site extravasation, injection site inflammation (in case of extravasation), injection site necrosis (in case of extravasation), superficial phlebitis |
|
Investigations |
Very rare: decreased oxygen saturation |
The following adverse reactions were reported with other intravenous contrast agents for MRI. It is therefore possible that they will also occur during treatment with Gadoteric Acid.
|
Organ Class System |
Adverse reaction |
|
Blood and lymphatic system system disorders |
Haemolysis |
|
Psychiatric disorders |
Confusion |
|
Eye disorders |
Blindness transient, eye pain |
|
Ear and labyrinth disorders |
Tinnitus, ear pain |
|
Respiratory, thoracic and mediastal disorders |
Asthma |
|
Gastrointestinal disorders |
Dry mouth |
|
Skin and subcutaneous tissue disorders |
Dermatitis bullous |
|
Investigations |
Electrocardiogram PR prolongation, blood iron increased, blood bilirubin increased, serum ferritin increased, liver function test abnormal |
|
Renal and urinary disorders |
Urinary incontinence, renal tubular necrosis, renal failure acute |
Adverse reactions in children
Adverse events related to gadoteric acid are uncommon in children. The expectedness of these events is identical to that of the events reported in adults (see section 4.2 and 4.4).
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme.
Website: www.mhra.gov.uk/yellowcard
4.9 Overdose
Gadoteric acid can be removed by haemodialysis. However there is no evidence that haemodialysis is suitable for prevention of nephrogenic systemic fibrosis (NSF).
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: paramagnetic contrast media
ATC code: V08CA02 (gadoteric acid)
Gadoteric acid is a paramagnetic contrast agent for magnetic resonance imaging. The contrast-enhancing effect is mediated by gadoteric acid which is a ionic gadolinium complex composed out of gadolinium oxide and 1,4,7,10 tetraazacyclododecane-N,N’,N”,N’” tetraacetic acid (Dota), and present as meglumine salt.
The paramagnetic effect (relaxivity) is determined from the effect on spin-lattice relaxation time (T1) about 3.4 mmol-1.L.sec-1 and on the spin-spin relaxation time (T2) about 4.27 mmol-1.L.sec-1.
Gadoteric acid does not pass the intact blood-brain barrier and therefore does not accumulate in healthy brain tissue or in lesions featuring an intact blood-brain barrier.
This product has no specific pharmacodynamic activity and is biologically inert
5.2 Pharmacokinetic properties
After intravenous administration gadoteric acid is quickly distributed in the extracellular fluids. The distribution volume was approx. 18 l which is approximately equal to the volume of extra-cellular fluid. Gadoteric acid does not bind to proteins like serum albumin and does not cross through the intact blood-brain barrier.
Gadoteric acid is eliminated rapidly (89% after 6 h, 95% after 24 h) in unchanged form through the kidneys by glomerular filtration. Excretion via the faeces is negligible. No hepatic metabolites were detected so hepatic insufficiency is not a limiting factor for elimination of gadoteric acid. The elimination half life amounts to about 1.6 hours in patients with a normal renal function. In renally impaired patients, the elimination half life was increased to approximately 5 hours for a creatinine clearance between 30 and 60 ml/min and approximately 14 hours for a creatinine clearance between 10 and 30 ml/min.
In animal experiments it has been demonstrated that gadoteric acid can be removed by dialysis.
In patient with normal renal function, the plasmatic half life is about 90 minutes. The elimination is by glomerular filtration unchanged.
The plasmatic clearance is reduced in case of renal impairment.
Gadoteric acid is poorly excreted in the milk and cross slowly through the placenta barrier.
5.3 Preclinical safety data
Pre-clinical data reveal no special hazards for humans based on conventional studies of safety pharmacology, repeated dose toxicity and genotoxicity. Animal studies have shown negligible (less than 1 % of the administered dose) secretion of gadoteric acid in maternal milk.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Meglumine
Water for injection
6.2 Incompatibilities
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
6.3 Shelf life
Unopened product: 2 years
Chemical and physical in-use stability has been demonstrated for 48 hours at 21°C to 23°C.
From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions are the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C, unless opening has taken place in controlled and validated aseptic conditions.
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
For storage conditions after first opening of the medicinal product, see section 6.
6.5 Nature and contents of container
1 and 10 Type I single-dose glass vials of 10 ml (filled with 5 ml or 10 ml)and 20 ml (filled with 15 ml or 20 ml) sealed with a stopper of bromobutyl rubber. The caps are made of aluminium with plastic overlay.
1 and 10 Type II single-dose glass vials of 60 ml sealed with a stopper of bromobutyl rubber. The caps are made of aluminium with plastic overlay.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
The peel-off tracking label on the vials should be stuck onto the patient record to enable accurate recording of the gadolinium contrast agent used. The dose used should also be recorded. If electronic patient records are used, the name of the product, the batch number and the dose should be entered into the patient record.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
7 MARKETING AUTHORISATION HOLDER
Agfa HealthCare Imaging Agents GmbH Am Coloneum 4 50829 Cologne Germany
8 MARKETING AUTHORISATION NUMBER(S)
PL 33127/0005
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
01/08/2014
10 DATE OF REVISION OF THE TEXT
23/07/2015