In adults

In pediatric patients

In adults

In pediatric patients

Directions for Proper Use of OPTIRAY Pharmacy Bulk Package

Use OPTIRAY 300 or OPTIRAY 320. The recommended dose for visualization of cerebral arteries is shown below (may repeat as necessary):

<div class="scrollingtable"><table width="80%"> <col class="Lrule Rrule" width="34%"/> <col class="Lrule Rrule" width="33%"/> <col class="Lrule Rrule" width="33%"/> <tbody class="Headless"> <tr class="Botrule First Toprule"> <td class="Lrule Rrule"> Diagnostic area</td><td class="Lrule Rrule"> Dose</td><td class="Lrule Rrule"> Maximum Cumulative Dose</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> carotid or vertebral arteries</td><td class="Lrule Rrule"> 2 to 12 mL</td><td class="Lrule Rrule"> 200 mL</td> </tr> <tr class="Botrule Last Toprule"> <td class="Lrule Rrule"> <p class="First"> aortic arch injection</p> <p> (four vessel study)</p> </td><td class="Lrule Rrule"> 20 to 50 mL</td><td class="Lrule Rrule"> 200 mL</td> </tr> </tbody> </table></div>

Use OPTIRAY 300, OPTIRAY 320 or OPTIRAY 350. The recommended dose for visualization of peripheral arteries is shown below (may repeat as necessary):

<div class="scrollingtable"><table width="80%"> <col class="Lrule Rrule" width="34%"/> <col class="Lrule Rrule" width="33%"/> <col class="Lrule Rrule" width="33%"/> <tbody class="Headless"> <tr class="Botrule First Toprule"> <td class="Lrule Rrule"> Diagnostic area</td><td class="Lrule Rrule"> Dose</td><td class="Lrule Rrule"> Maximum Cumulative Dose</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> aorta-iliac runoff</td><td class="Lrule Rrule"> 60 mL (range 20 to 90 mL)</td><td class="Lrule Rrule"> 250 mL</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> common iliac, femoral</td><td class="Lrule Rrule"> 40 mL (range 10 to 50 mL)</td><td class="Lrule Rrule"> 250 mL</td> </tr> <tr class="Botrule Last Toprule"> <td class="Lrule Rrule"> subclavian, brachial</td><td class="Lrule Rrule"> 20 mL (range 15 to 30 mL)</td><td class="Lrule Rrule"> 250 mL</td> </tr> </tbody> </table></div>

Use OPTIRAY 320. The recommended dose for visualization for the aorta and visceral arteries is shown below (may repeat as necessary):

<div class="scrollingtable"><table width="80%"> <col class="Lrule Rrule" width="34%"/> <col class="Lrule Rrule" width="33%"/> <col class="Lrule Rrule" width="33%"/> <tbody class="Headless"> <tr class="Botrule First Toprule"> <td class="Lrule Rrule"> Diagnostic area</td><td class="Lrule Rrule"> Dose</td><td class="Lrule Rrule"> Maximum Cumulative Dose</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> aorta</td><td class="Lrule Rrule"> 45 mL (range 10 to 80 mL)</td><td class="Lrule Rrule"> 250 mL</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> celiac</td><td class="Lrule Rrule"> 45 mL (range 12 to 60 mL)</td><td class="Lrule Rrule"> 250 mL</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> superior mesenteric</td><td class="Lrule Rrule"> 45 mL (range 15 to 60 mL)</td><td class="Lrule Rrule"> 250 mL</td> </tr> <tr class="Botrule Last Toprule"> <td class="Lrule Rrule"> renal or inferior mesenteric</td><td class="Lrule Rrule"> 9 mL (range 6 to 15 mL)</td><td class="Lrule Rrule"> 250 mL</td> </tr> </tbody> </table></div>

Use OPTIRAY 320 or OPTIRAY 350. The recommended dose for visualization of the coronary arteries and left ventricle is shown below (may repeat as necessary):

<div class="scrollingtable"><table width="80%"> <col class="Lrule Rrule" width="34%"/> <col class="Lrule Rrule" width="33%"/> <col class="Lrule Rrule" width="33%"/> <tbody class="Headless"> <tr class="Botrule First Toprule"> <td class="Lrule Rrule"> Diagnostic area</td><td class="Lrule Rrule"> Dose</td><td class="Lrule Rrule"> Maximum Cumulative Dose</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> left coronary</td><td class="Lrule Rrule"> 8 mL (range 2 to 10 mL)</td><td class="Lrule Rrule"> 250 mL</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> right coronary</td><td class="Lrule Rrule"> 6 mL (range 1 to 10 mL)</td><td class="Lrule Rrule"> 250 mL</td> </tr> <tr class="Botrule Last Toprule"> <td class="Lrule Rrule"> left ventricle</td><td class="Lrule Rrule"> 40 mL (range 30 to 50 mL)</td><td class="Lrule Rrule"> 250 mL</td> </tr> </tbody> </table></div>

Use OPTIRAY 300, OPTIRAY 320 or OPTIRAY 350 for head and body imaging.

Head Imaging The recommended dosing is shown below:

<div class="scrollingtable"><table width="50%"> <col class="Lrule Rrule" width="50%"/> <col class="Lrule Rrule" width="50%"/> <tbody class="Headless"> <tr class="Botrule First Toprule"> <td class="Lrule Rrule"></td><td class="Lrule Rrule"> <p class="First"> <span class="Bold"> Infusion</span> </p> </td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> OPTIRAY 300</td><td class="Lrule Rrule"> 50 to 150 mL</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> OPTIRAY 320</td><td class="Lrule Rrule"> 50 to 150 mL</td> </tr> <tr class="Botrule Last Toprule"> <td class="Lrule Rrule"> OPTIRAY 350</td><td class="Lrule Rrule"> 50 to 150 mL</td> </tr> </tbody> </table></div>

Body Imaging OPTIRAY may be administered by bolus injection, by rapid infusion, or by a combination of both. The recommended dosing is shown below:

<div class="scrollingtable"><table width="80%"> <col class="Lrule Rrule" width="34%"/> <col class="Lrule Rrule" width="33%"/> <col class="Lrule Rrule" width="33%"/> <tbody class="Headless"> <tr class="Botrule First Toprule"> <td class="Lrule Rrule"></td><td class="Lrule Rrule"> <p class="First"> <span class="Bold"> Bolus Injection</span> </p> </td><td class="Lrule Rrule"> <p class="First"> <span class="Bold"> Infusion</span> </p> </td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> OPTIRAY 300</td><td class="Lrule Rrule"> 25 to 75mL</td><td class="Lrule Rrule"> 50 to 150 mL</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> OPTIRAY 320</td><td class="Lrule Rrule"> 25 to 75mL</td><td class="Lrule Rrule"> 50 to 150 mL</td> </tr> <tr class="Botrule Last Toprule"> <td class="Lrule Rrule"> OPTIRAY 350</td><td class="Lrule Rrule"> 25 to 75mL</td><td class="Lrule Rrule"> 50 to 150 mL</td> </tr> </tbody> </table></div>

Use OPTIRAY 300, OPTIRAY 320 or OPTIRAY 350. The recommended dose is 50 to 100 mL per extremity; with a maximum cumulative dose of 250 mL.

Use OPTIRAY 350, OPTIRAY 320, or OPTIRAY 300. The recommended dose is shown below:

<div class="scrollingtable"><table width="80%"> <col class="Lrule Rrule" width="25%"/> <col class="Lrule Rrule" width="25%"/> <col class="Lrule Rrule" width="25%"/> <col class="Lrule Rrule" width="25%"/> <tbody class="Headless"> <tr class="Botrule First Toprule"> <td class="Lrule Rrule"></td><td class="Lrule Rrule"> <p class="First"> <span class="Bold"> Usual Dose</span> </p> </td><td class="Lrule Rrule"> <p class="First"> <span class="Bold"> High Dose Urography</span> </p> </td><td class="Lrule Rrule"> <p class="First"> <span class="Bold"> Maximum Dose</span> </p> </td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> OPTIRAY 300</td><td class="Lrule Rrule"> 50 to 75mL</td><td class="Lrule Rrule"> 1.6 mL/kg</td><td class="Lrule Rrule"> 150 mL</td> </tr> <tr class="Botrule Toprule"> <td class="Lrule Rrule"> OPTIRAY 320</td><td class="Lrule Rrule"> 50 to 75mL</td><td class="Lrule Rrule"> 1.5 to 2 mL/kg</td><td class="Lrule Rrule"> 150 mL</td> </tr> <tr class="Botrule Last Toprule"> <td class="Lrule Rrule"> OPTIRAY 350</td><td class="Lrule Rrule"> 50 to 75mL</td><td class="Lrule Rrule"> 1.4 mL/kg</td><td class="Lrule Rrule"> 150 mL</td> </tr> </tbody> </table></div>

Use OPTIRAY 350. The recommended dose range per injection is 30 to 50 mL; may repeat as necessary with a maximum cumulative dose of 250mL.

Injection rates will vary depending on the site of catheter placement and vessel size.

Intra-arterial Procedures

Use OPTIRAY 350 or OPTIRAY 320. The recommended single ventricular dose is 1.25 mL/kg (range 1 mL/kg to 1.5 mL/kg). The maximum cumulative dose is 5 mL/kg up to a maximum total volume of 250 mL.

Intravenous Procedures

Use OPTIRAY 320.

Head and Body Imaging The recommended dose in pediatric patients is 1.5 mL/kg to 2 mL/kg (range 1 mL/kg to 3 mL/kg).

Use OPTIRAY 320. The recommended dose for pediatric patients is 1 mL/kg to 1.5 mL/kg (range 0.5 mL/kg to 3 mL/kg); with a maximum cumulative dose not exceeding 3 mL/kg.

Injection: clear, colorless to pale yellow solutions containing no undissolved solids, available in the following strengths and multiple-dose containers:

{ "type": "p", "children": [], "text": "Injection: clear, colorless to pale yellow solutions containing no undissolved solids, available in the following strengths and multiple-dose containers:" }

<div class="scrollingtable"><table width="80%"> <col align="center" class="Lrule Rrule" width="30%"/> <col align="center" class="Lrule Rrule" width="13%"/> <col align="center" class="Lrule Rrule" width="22%"/> <col align="center" class="Lrule Rrule" width="35%"/> <tbody class="Headless"> <tr class="Botrule First Toprule"> <td align="center" class="Lrule Rrule"> Imaging Product </td><td align="center" class="Lrule Rrule"> mg of<br/>ioversol<br/>per mL </td><td align="center" class="Lrule Rrule"> mg of organically<br/>bound iodine<br/>per mL </td><td align="center" class="Lrule Rrule"> Pharmacy Bulk Pack Presentation </td> </tr> <tr class="Botrule Toprule"> <td align="center" class="Lrule Rrule">OPTIRAY 300<br/>(Ioversol 64%)</td><td align="center" class="Lrule Rrule">636</td><td align="center" class="Lrule Rrule">300</td><td align="center" class="Lrule Rrule">Yes</td> </tr> <tr class="Botrule Toprule"> <td align="center" class="Lrule Rrule">OPTIRAY 320<br/>(Ioversol 68%)</td><td align="center" class="Lrule Rrule">678</td><td align="center" class="Lrule Rrule">320</td><td align="center" class="Lrule Rrule">Yes</td> </tr> <tr class="Botrule Last Toprule"> <td align="center" class="Lrule Rrule">OPTIRAY 350<br/>(Ioversol 74%)</td><td align="center" class="Lrule Rrule">741</td><td align="center" class="Lrule Rrule">350</td><td align="center" class="Lrule Rrule">Yes</td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table width=\"80%\">\n<col align=\"center\" class=\"Lrule Rrule\" width=\"30%\"/>\n<col align=\"center\" class=\"Lrule Rrule\" width=\"13%\"/>\n<col align=\"center\" class=\"Lrule Rrule\" width=\"22%\"/>\n<col align=\"center\" class=\"Lrule Rrule\" width=\"35%\"/>\n<tbody class=\"Headless\">\n<tr class=\"Botrule First Toprule\">\n<td align=\"center\" class=\"Lrule Rrule\">\n Imaging Product\n </td><td align=\"center\" class=\"Lrule Rrule\">\n mg of<br/>ioversol<br/>per mL\n </td><td align=\"center\" class=\"Lrule Rrule\">\n mg of organically<br/>bound iodine<br/>per mL\n </td><td align=\"center\" class=\"Lrule Rrule\">\n Pharmacy Bulk Pack Presentation\n </td>\n</tr>\n<tr class=\"Botrule Toprule\">\n<td align=\"center\" class=\"Lrule Rrule\">OPTIRAY 300<br/>(Ioversol 64%)</td><td align=\"center\" class=\"Lrule Rrule\">636</td><td align=\"center\" class=\"Lrule Rrule\">300</td><td align=\"center\" class=\"Lrule Rrule\">Yes</td>\n</tr>\n<tr class=\"Botrule Toprule\">\n<td align=\"center\" class=\"Lrule Rrule\">OPTIRAY 320<br/>(Ioversol 68%)</td><td align=\"center\" class=\"Lrule Rrule\">678</td><td align=\"center\" class=\"Lrule Rrule\">320</td><td align=\"center\" class=\"Lrule Rrule\">Yes</td>\n</tr>\n<tr class=\"Botrule Last Toprule\">\n<td align=\"center\" class=\"Lrule Rrule\">OPTIRAY 350<br/>(Ioversol 74%)</td><td align=\"center\" class=\"Lrule Rrule\">741</td><td align=\"center\" class=\"Lrule Rrule\">350</td><td align=\"center\" class=\"Lrule Rrule\">Yes</td>\n</tr>\n</tbody>\n</table></div>" }

Symptomatic hyperthyroidism.

{ "type": "p", "children": [], "text": "Symptomatic hyperthyroidism." }

OPTIRAY is indicated for intravascular use only [see Dosage and Administration (2.1)]. Inadvertent intrathecal administration can cause death, convulsions, cerebral hemorrhage, coma, paralysis, arachnoiditis, acute renal failure, cardiac arrest, seizures, rhabdomyolysis, hyperthermia, and brain edema.

OPTIRAY can cause life-threatening or fatal hypersensitivity reactions including anaphylaxis and anaphylactic shock. Manifestations include respiratory arrest, laryngospasm, bronchospasm, angioedema, and shock. Most severe reactions develop shortly after the start of the injection (e.g. within 1 to 3 minutes), but delayed reactions may occur. There is an increased risk in patients with a history of a previous reaction to contrast agent, and known allergies (i.e., bronchial asthma, drug, or food allergies), and other hypersensitivities. Premedication with antihistamines or corticosteroids to avoid or minimize possible allergic reactions does not prevent serious life-threatening reactions, but may reduce both their incidence and severity.

Obtain a history of allergy, hypersensitivity, or prior hypersensitivity reactions to iodinated contrast agents. Always have emergency resuscitation equipment and trained personnel available and monitor all patients for hypersensitivity reactions.

Acute kidney injury, including renal failure, may occur after OPTIRAY administration. Risk factors include: pre-existing renal impairment, dehydration, diabetes mellitus, congestive heart failure, advanced vascular disease, elderly age, concomitant use of nephrotoxic or diuretic medications, multiple myeloma / paraproteinaceous diseases, repetitive and/or large doses of an iodinated contrast agent.

Use the lowest necessary dose of OPTIRAY in patients with renal impairment. Adequately hydrate patients prior to and following OPTIRAY administration. Do not use laxatives, diuretics, or preparatory dehydration prior to OPTIRAY administration.

OPTIRAY increases the circulatory osmotic load and may induce acute or delayed hemodynamic disturbances in patients with congestive heart failure, severely impaired renal function, combined renal and hepatic disease, combined renal and cardiac disease, particularly when repetitive or large doses are administered.

Life-threatening or fatal cardiovascular reactions have occurred with the use of OPTIRAY, including cardiac arrest, hypotensive collapse, and shock. Most deaths occur within 10 minutes of injection; with cardiovascular disease as the main underlying factor. Cardiac decompensation, serious arrhythmias, and myocardial ischemia or infarction can occur during coronary arteriography and ventriculography.

Based upon literature reports, deaths from the administration of iodinated contrast agents range from 6.6 per 1 million (0.00066 percent) to 1 in 10,000 patients (0.01 percent). Use the lowest necessary dose of OPTIRAY in patients with congestive heart failure and always have emergency resuscitation equipment and trained personnel available. Monitor all patients for severe cardiovascular reactions.

Angiocardiography Serious, fatal, thromboembolic events causing myocardial infarction and stroke can occur during angiographic procedures with OPTIRAY. During these procedures, increased thrombosis and activation of the complement system occurs. Risk factors for thromboembolic events include: length of procedure, catheter and syringe material, underlying disease state, and concomitant medications.

To minimize thromboembolic events use meticulous angiographic technique. Avoid blood remaining in contact with syringes containing OPTIRAY, which increases the risk of clotting. Avoid angiocardiography in patients with homocystinuria because of the risk of inducing thrombosis and embolism [see Clinical Pharmacology (12.2)].

Extravasation can occur with OPTIRAY administration, particularly in patients with severe arterial or venous disease and can be associated with pain, hemorrhage and necrosis. Ensure intravascular placement of catheters prior to injection. Monitor patients for extravasation and advise patients to seek medical care for progression of symptoms.

OPTIRAY is contraindicated in patients with symptomatic hyperthyroidism [see Contraindications (4)]. Thyroid storm has occurred following the intravascular use of iodinated radiopaque agents in patients with hyperthyroidism or with an autonomously functioning thyroid nodule. Evaluate the risk in such patients before use of OPTIRAY.

Thyroid dysfunction characterized by hypothyroidism or transient thyroid suppression has been reported after both single exposure and multiple exposures to iodinated contrast media (ICM) in pediatric patients 0 to 3 years of age.

Younger age, very low birth weight, prematurity, underlying medical conditions affecting thyroid function, admission to neonatal or pediatric intensive care units, and congenital cardiac conditions are associated with an increased risk of hypothyroidism after ICM exposure. Pediatric patients with congenital cardiac conditions may be at the greatest risk given that they often require high doses of contrast during invasive cardiac procedures.

An underactive thyroid during early life may be harmful for cognitive and neurological development and may require thyroid hormone replacement therapy. After exposure to ICM, individualize thyroid function monitoring based on underlying risk factors, especially in term and preterm neonates.

Hypertensive crisis has occurred after the use of iodinated radiopaque contrast agents in patient with pheochromocytoma. Closely monitor patients when administering OPTIRAY if pheochromocytoma or catecholamine-secreting paraganglioma is suspected. Inject the minimum amount of OPTIRAY necessary and have measures for treatment of hypertensive crisis readily available.

Iodinated contrast agents may promote sickling in individuals who are homozygous for sickle cell disease. Hydrate patients prior to and following OPTIRAY administration, use OPTIRAY only if the necessary imaging information cannot be obtained with alternative imaging modalities, and inject the minimum amount necessary.

Severe cutaneous adverse reactions (SCAR) may develop from 1 hour to several weeks after intravascular contrast agent administration. These reactions include Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN), acute generalized exanthematous pustulosis (AGEP) and drug reaction with eosinophilia and systemic symptoms (DRESS). Reaction severity may increase and time to onset may decrease with repeat administration of a contrast agent; prophylactic medications may not prevent or mitigate severe cutaneous adverse reactions. Avoid administering OPTIRAY to patients with a history of a severe cutaneous adverse reaction to OPTIRAY.

Adult Patients Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The following table shows reactions based upon clinical trials with OPTIRAY (ioversol) in 4,187 patients. Adverse reactions are listed by organ system according to clinical importance. More severe reactions are listed before others in a system regardless of incidence. The most common reaction is nausea, occurring at a rate of 1 percent.

Cardiac disorders Cardiac arrest, myocardial infarction, arrhythmia, atrioventricular block complete, atrioventricular block, nodal rhythm, bradycardia, angina pectoris, palpitations

Ear and labyrinth disorders Vertigo, tinnitus

Eye disorders Vision blurred, periorbital edema, conjunctivitis

Gastrointestinal disorders Vomiting, abdominal pain, dysphagia, dry mouth

General disorders and administration site conditions Chest pain, pain, injection site pain, injection site hematoma, extravasation, pyrexia, swelling, asthenia, malaise, fatigue, chills

Infections and infestations Rhinitis

Injury, poisoning, and procedural complications Heart injury, vascular pseudoaneurysm

Investigations Electrocardiogram ST segment depression, blood pressure decreased

Metabolism and nutrition disorders Acidosis

Musculoskeletal and connective tissue disorders Muscular weakness, muscle spasms, back pain

Nervous system disorders Cerebral infarction, aphasia, tremor, dizziness, presyncope, headache, paraesthesia, dysgeusia

Psychiatric disorders Hallucination, visual hallucination, disorientation, anxiety

Renal and urinary disorders Urinary retention, renal pain, polyuria

Respiratory, thoracic, and mediastinal disorders Laryngeal edema, hypoxia, pulmonary edema, dyspnea, hyperventilation, cough, sneezing,nasal congestion

Skin and subcutaneous tissue disorders Urticaria, rash, pruritus, swelling face, hyperhidrosis, erythema

Vascular disorders Hypertension, hypotension, arterial spasm, vasospasm, vasodilation, flushing

Pediatric Patients In clinical trials involving 311 patients for pediatric angiocardiography, contrast enhanced computed tomographic imaging of the head and body, and intravenous excretory urography; 6% of patients reported an adverse reactions, with the most common adverse reactions being nausea and fever. Adverse reactions reported were similar in quality and frequency to the adverse events reported by adults.

The following adverse drug reactions have been reported during post-approval use of OPTIRAY. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate frequency or establish a casual relationship to drug exposure.

Cardiac disorders: coronary artery spasm, cyanosis, arrhythmia (ventricular fibrillation, tachycardia, extrasystole), ECG abnormal.

Endocrine disorders: Hyperthyroidism, hypothyroidism.

Eye disorders: temporary blindness, conjunctivitis (including eye irritation, ocular hyperemia, watery eyes).

Gastrointestinal disorders: tongue edema, salivary hypersecretion.

General disorders and administration site conditions: injection site reactions including pain, hemorrhage, and necrosis especially after extravasation [see Warnings and Precautions (5.6)], face edema, feeling hot.

Immune system disorders: hypersensitivity reactions including fatal anaphylactic shock.

Nervous system disorders: seizure, loss of consciousness, somnolence, hypoesthesia, dyskinesia, amnesia.

Respiratory disorders: respiratory arrest, asthma, bronchospasm, laryngeal spasm and obstruction, throat irritation, dysphonia.

Skin and subcutaneous tissue disorders: Reactions range from mild (e.g. rash, erythema, pruritus, urticaria, and skin discoloration) to severe: [e.g. Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN)], acute generalized exanthematous pustulosis (AGEP) and drug reaction with eosinophilia and systemic symptoms (DRESS).

Vascular Disorders: phlebitis, thrombosis.

Metformin

In patients with renal impairment, metformin can cause lactic acidosis. Iodinated contrast agents appear to increase the risk of metformin induced lactic acidosis, possibly as a result of worsening renal function. Stop metformin at the time of, or prior to, OPTIRAY administration in patients with an eGFR between 30 and 60 mL/min/1.73 m2; in patients with a history of hepatic impairment, alcoholism or heart failure; or in patients who will be administered intra-arterial iodinated contrast agents. Re-evaluate eGFR 48 hours after the imaging procedure, and reinstitute only after renal function is stable.

Radioactive Iodine

Administration of iodinated contrast agents may interfere with thyroid uptake of radioactive iodine (I 131) and decrease therapeutic efficacy in patients with carcinoma of the thyroid. The decrease in efficacy lasts for 6-8 weeks.

Oral Cholecystographic Contrast Agents

Renal toxicity has been reported in patients with liver impairment who were given oral cholecystographic agents followed by intravascular contrast agents. Administration of OPTIRAY should be postponed in patients who have recently received a cholecystographic contrast agent.

Protein-Bound Iodine, Radioactive Iodine Determinations

The results of protein bound iodine and radioactive iodine uptake studies, which depend on iodine estimation, will not accurately reflect thyroid function for up to 16 days following administration of iodinated contrast agent. However, thyroid function tests that do not depend on iodine estimations, e.g., T3 resin uptake and total or free thyroxine (T4) assays are not affected.

Risk SummaryPostmarketing data with OPTIRAY use in pregnant women are insufficient to determine if there is a risk of drug-associated adverse developmental outcomes. Ioversol crosses the placenta and reaches fetal tissues in small amounts [see Data]. In animal reproduction studies, no adverse developmental effects were observed following daily intravenous administrations of ioversol to pregnant rats (from Gestation Day 7 to 17) and rabbits (Gestation Day 6 to 18) at doses 0.35 and 0.71 times, respectively, the maximum recommended human dose.

The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of major birth defects, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriages in clinically recognized pregnancies is 2-4% and 15-20%, respectively.

Data

Human Data Literature reports show that ioversol crosses the placenta and is visualized in the digestive tract of exposed infants after birth.

Animal Data Developmental toxicity studies were conducted with ioversol given intravenously at doses of 0, 0.2, 0.8, and 3.2 g iodine/kg/day from Gestation Day7 to 17 and 6 to 18, in rats and rabbits, respectively. No adverse effects on embryo-fetal development were observed in either species at the maximum dose tested (3.2 g iodine/kg/day). Maternal toxicity was observed in rabbits at 0.8 and 3.2 g iodine/kg/day.

Risk SummaryThere is no information about the presence of ioversol in human or animal milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production. However, iodinated contrast agents are excreted unchanged in human milk in very low amounts with poor absorption from the gastrointestinal tract of the breastfed infant. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for OPTIRAY and any potential adverse effects on the breastfed infant from OPTIRAY or from the underlying maternal condition.

Clinical Considerations Interruption of breastfeeding after exposure to iodinated contrast agents is not necessary because the potential exposure of the breastfed infant to iodine is small. However, a lactating woman may consider interrupting breastfeeding and pumping and discarding breast milk for 8 hours (approximately 5 elimination half-lives) after OPTIRAY administration in order to minimize drug exposure to a breast fed infant.

Safety and effectiveness in pediatric patients have been established for the use of OPTIRAY 350 and OPTIRAY 320 in angiocardiography; and for OPTIRAY 320 in contrast enhanced computed tomographic imaging of the head and body, and intravenous excretory urography. Use of OPTIRAY 350 and OPTIRAY 320 in these age groups is based on controlled clinical trials involving 159 patients for pediatric angiocardiography; contrast enhanced computed tomographic imaging of the head and body, and intravenous excretory urography. In general, the types of adverse reactions reported are similar to those of adults [see Adverse Reactions (6.1)].

Safety and effectiveness of OPTIRAY 350 and OPTIRAY 320 have not been established in pediatric patients less than 1 month of age. Safety and effectiveness of OPTIRAY 300 has not been established in pediatric patients.

Pediatric patients at higher risk of experiencing adverse reactions to OPTIRAY include patients with: asthma, sensitivity to medication and/or allergens, congestive heart failure, serum creatinine greater than 1.5 mg/dL, or age less than 12 months. Thyroid function tests indicative of hypothyroidism or transient thyroid suppression have been uncommonly reported following iodinated contrast media administration in pediatric patients, including infants. Some patients were treated for hypothyroidism [See Adverse Reactions (6.2)].

Thyroid function tests indicative of thyroid dysfunction, characterized by hypothyroidism or transient thyroid suppression have been uncommonly reported following iodinated contrast media administration in pediatric patients, including term and preterm neonates;some patients were treated for hypothyroidism. After exposure to iodinated contrast media, individualize thyroid function monitoring in pediatric patients 0 to 3 years of age based on underlying risk factors, especially in term and preterm neonates [see Warnings and Precautions (5.8) and Adverse Reactions (6.2)].

OPTIRAY is substantially excreted by the kidney, and the risk of adverse reactions to OPTIRAY may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, dose selection 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.

In patients with impaired renal function, the elimination half-life is prolonged. Ioversol can be removed by dialysis.

The adverse effects of overdosage are life-threatening and affect mainly the pulmonary and cardiovascular system. Treatment of an overdosage is directed toward the support of all vital functions and prompt institution of symptomatic therapy.

{ "type": "p", "children": [], "text": "The adverse effects of overdosage are life-threatening and affect mainly the pulmonary and cardiovascular system. Treatment of an overdosage is directed toward the support of all vital functions and prompt institution of symptomatic therapy." }

Ioversol does not bind to plasma or serum protein and is, therefore, dialyzable.

{ "type": "p", "children": [], "text": "Ioversol does not bind to plasma or serum protein and is, therefore, dialyzable." }

OPTIRAY (ioversol injection) is a non-ionic radiographic contrast agent. OPTIRAY formulations are sterile, nonpyrogenic, aqueous solutions intended for intravascular use. Each bottle is to be used as a Pharmacy Bulk Package for dispensing multiple single dose preparations utilizing a suitable transfer device. Ioversol is designated chemically as N,N'-Bis (2,3-dihydroxypropyl)-5-[N-(2-hydroxyethyl) -glycolamido] -2,4,6-triiodoisophthalamide. The molecular weight of ioversol is 807.11 and the organically bound iodine content is 47.2%.The structural formula of ioversol is as follows:

OPTIRAY Pharmacy Bulk Package is available in three strengths:

The pH of the OPTIRAY formulations has been adjusted to 6.0 to 7.4 with hydrochloric acid or sodium hydroxide. All solutions are sterilized by autoclaving and contain no preservatives. Ioversol does not dissociate in solution.

Some physical and chemical properties of these formulations are listed below:

<div class="scrollingtable"><table width="80%"> <col width="34%"/> <col align="center" width="22%"/> <col align="center" width="22%"/> <col align="center" width="22%"/> <tbody class="Headless"> <tr class="Bold First"> <td></td><td align="center" class="Botrule"> OPTIRAY 300</td><td align="center" class="Botrule"> OPTIRAY 320</td><td align="center" class="Botrule"> OPTIRAY 350</td> </tr> <tr> <td> Ioversol content (mg/mL)</td><td align="center">636</td><td align="center">678</td><td align="center">741</td> </tr> <tr> <td>   Iodine content (mg l/mL)</td><td align="center">300</td><td align="center">320</td><td align="center">350</td> </tr> <tr> <td> Osmolality (mOsm/kg water)</td><td align="center">651</td><td align="center">702</td><td align="center">792</td> </tr> <tr> <td> Viscosity (cps)</td><td align="center"></td><td align="center"></td><td align="center"></td> </tr> <tr> <td>      at 25°C</td><td align="center">8.2</td><td align="center">9.9</td><td align="center">14.3</td> </tr> <tr> <td>      at 37°C</td><td align="center">5.5</td><td align="center">5.8</td><td align="center">9.0</td> </tr> <tr class="Last"> <td> Specific Gravity at 37°C</td><td align="center">1.352</td><td align="center">1.371</td><td align="center">1.405</td> </tr> </tbody> </table></div>

The OPTIRAY formulations are clear, colorless to pale yellow solutions containing no undissolved solids. Crystallization does not occur at room temperature. OPTIRAY solutions have osmolalities 2.3 to 2.8 times that of plasma (285 mOsm/kg water) as shown in the above table and are hypertonic under conditions of use.

Intravascular injection of ioversol opacifies those vessels in the path of the flow of the contrast medium, permitting radiographic visualization of the internal structures until significant hemodilution occurs.

Ioversol may be visualized in the renal parenchyma within 30 to 60 seconds following rapid intravenous injection. Opacification of the calyces and pelves in patients with normal renal function becomes apparent within 1 to 3 minutes, with optimum contrast occurring within 5 to 15 minutes.

OPTIRAY enhances computed tomographic imaging through augmentation of radiographic efficiency. The degree of density enhancement is directly related to the iodine content in an administered dose; peak iodine blood levels occur immediately following rapid intravenous injection. Blood levels fall rapidly within 5 to 10 minutes and the vascular compartment half-life is approximately 20 minutes. This can be accounted for by the dilution in the vascular and extravascular fluid compartments which causes an initial sharp fall in plasma concentration. Equilibration with the extracellular compartments is reached in about 10 minutes; thereafter, the fall becomes exponential.

Following administration of OPTIRAY, the degree of enhancement is directly related to the iodine content in an administered dose. Peak iodine plasma levels occur immediately following rapid injection. The time to maximum contrast enhancement can vary, depending on the organ, from the time that peak blood iodine concentrations are reached to one hour after intravenous bolus administration. When a delay between peak blood iodine concentrations and peak contrast is present, it suggests that radiographic contrast enhancement is at least in part dependent on the accumulation of iodine-containing medium within the lesion and outside the blood pool.For angiography, contrast enhancement is greatest immediately (15 seconds to 120 seconds) after rapid injection. Iodinated contrast agents may be visualized in the renal parenchyma within 30-60 seconds following rapid intravenous injection. Opacification of the calyces and pelves in patients with normal renal function becomes apparent within 1-3 minutes, with optimum contrast occurring within 5-15 minutes.

Based on the blood clearance curves for 12 healthy volunteers (6 receiving 50 mL and 6 receiving 150 mL of OPTIRAY 320), the biological half-life was 1.5 hours for both doses.

Distribution In an in vitro human plasma study, ioversol did not bind to protein. The volume of distribution in adults was 0.26 L/kg body weight, consistent with distribution to the extracellular space.

Elimination Metabolism Ioversol does not undergo significant metabolism, deiodination or biotransformation.

Excretion Greater than 95% of the administered dose was excreted in urine within the first 24 hours, with the peak urine concentration occurring in the first two hours after administration.

No long term animal studies have been performed to evaluate carcinogenic potential. Nonclinical studies show that this drug is not mutagenic and does not affect fertility.

Animal studies indicate that ioversol does not cross the blood-brain barrier.

OPTIRAY is a clear, colorless to pale yellow, sterile, pyrogen-free, aqueous solution available in three strengths. The products are supplied in containers from which the air has been displaced by nitrogen. OPTIRAY is supplied in the following configurations:

                                                                      NDC Number

OPTIRAY Pharmacy Bulk Package - 350

6x500 mL Pharmacy Bulk Packages              0019-1333-61

OPTIRAY Pharmacy Bulk Package - 320

6x500 mL Pharmacy Bulk Packages              0019-1323-61

OPTIRAY Pharmacy Bulk Package - 300

6x500 mL Pharmacy Bulk Packages              0019-1332-61

Manufactured by:Liebel-Flarsheim Company LLCRaleigh, NC 27616

Made in USA

GBT 13PB223

For Intravascular Use Sterile Solution Optiray™ Pharmacy Bulk Package - 350 500 mL NDC 0019-1333-61 IOVERSOL INJECTION 74% 350 mg/mL Organically Bound Iodine NOT FOR INTRATHECAL USE Rx only Pharmacy Bulk Package - Not for Direct Infusion Protect from light • Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Discard contents if product is frozen or if crystallization occurs. Each mL contains 741 mg ioversol, 3.6 mg tromethamine as a buffer and 0.2 mg edetate calcium disodium as a stabilizer. The pH is adjusted with hydrochloric acid or sodium hydroxide. Usual Dosage: See Package Insert for indications, dosage and dispensing information. Once bottle has been penetrated, withdrawal of contents should be completed without delay. Discard the container no later than 4 hours after initial entry.        12880419

{ "type": "p", "children": [], "text": "\nFor Intravascular Use Sterile Solution\n Optiray™ Pharmacy Bulk Package - 350 \n500 mL NDC 0019-1333-61\n IOVERSOL INJECTION 74%\n 350 mg/mL Organically Bound Iodine \n NOT FOR INTRATHECAL USE\n\nRx only\n\n Pharmacy Bulk Package - Not for Direct Infusion\n\n Protect from light • Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Discard contents if product is frozen or if crystallization occurs. Each mL contains 741 mg ioversol, 3.6 mg tromethamine as a buffer and 0.2 mg edetate calcium disodium as a stabilizer. The pH is adjusted with hydrochloric acid or sodium hydroxide.\nUsual Dosage: See Package Insert for indications, dosage and dispensing information. Once bottle has been penetrated, withdrawal of contents should be completed without delay. Discard the container no later than 4 hours after initial entry.        \n12880419" }

Manufactured by:Liebel-Flarsheim Company LLCRaleigh, NC 27616Made in USA

{ "type": "p", "children": [], "text": "Manufactured by:Liebel-Flarsheim Company LLCRaleigh, NC 27616Made in USA" }

For Intravascular Use Sterile Solution Optiray™ Pharmacy Bulk Package - 320 500 mL NDC 0019-1323-61 IOVERSOL INJECTION 68% 320 mg/mL Organically Bound Iodine NOT FOR INTRATHECAL USE Rx only Pharmacy Bulk Package - Not for Direct Infusion Protect from light • Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Discard contents if product is frozen or if crystallization occurs. Each mL contains 678 mg ioversol, 3.6 mg tromethamine as a buffer and 0.2 mg edetate calcium disodium as a stabilizer. The pH is adjusted with hydrochloric acid or sodium hydroxide. Usual Dosage: See Package Insert for indications, dosage and dispensing information. Once bottle has been penetrated, withdrawal of contents should be completed without delay. Discard the container no later than 4 hours after initial entry. 12840419

{ "type": "p", "children": [], "text": "\nFor Intravascular Use Sterile Solution\n\n\nOptiray™ Pharmacy Bulk Package - 320 \n500 mL NDC 0019-1323-61\nIOVERSOL INJECTION 68%\n 320 mg/mL Organically Bound Iodine \n NOT FOR INTRATHECAL USE\n\nRx only\n\n Pharmacy Bulk Package - Not for Direct Infusion\n\n Protect from light • Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Discard contents if product is frozen or if crystallization occurs. Each mL contains 678 mg ioversol, 3.6 mg tromethamine as a buffer and 0.2 mg edetate calcium disodium as a stabilizer. The pH is adjusted with hydrochloric acid or sodium hydroxide.\nUsual Dosage: See Package Insert for indications, dosage and dispensing information. Once bottle has been penetrated, withdrawal of contents should be completed without delay. Discard the container no later than 4 hours after initial entry. \n12840419" }

Manufactured by:Liebel-Flarsheim Company LLCRaleigh, NC 27616Made in USA

{ "type": "p", "children": [], "text": "Manufactured by:Liebel-Flarsheim Company LLCRaleigh, NC 27616Made in USA" }

For Intravascular UseSterile Solution Optiray™ Pharmacy Bulk Package - 300 500 mL NDC 0019-1332-61 IOVERSOL INJECTION 64% 300 mg/mL Organically Bound Iodine NOT FOR INTRATHECAL USE Rx only Pharmacy Bulk Package - Not for Direct Infusion Protect from light • Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Discard contents if product is frozen or if crystallization occurs. Each mL contains 636 mg ioversol, 3.6 mg tromethamine as a buffer and 0.2 mg edetate calcium disodium as a stabilizer. The pH is adjusted with hydrochloric acid or sodium hydroxide. Usual Dosage: See Package Insert for indications, dosage and dispensing information. Once bottle has been penetrated, withdrawal of contents should be completed without delay. Discard the container no later than 4 hours after initial entry. 12910419 Manufactured by:Liebel-Flarsheim Company LLCRaleigh, NC 27616Made in USA

{ "type": "p", "children": [], "text": "\nFor Intravascular UseSterile Solution\n Optiray™ Pharmacy Bulk Package - 300 \n500 mL NDC 0019-1332-61\n IOVERSOL INJECTION 64%\n 300 mg/mL Organically Bound Iodine \n NOT FOR INTRATHECAL USE\n\nRx only\n\n Pharmacy Bulk Package - Not for Direct Infusion\n\n Protect from light • Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Discard contents if product is frozen or if crystallization occurs. Each mL contains 636 mg ioversol, 3.6 mg tromethamine as a buffer and 0.2 mg edetate calcium disodium as a stabilizer. The pH is adjusted with hydrochloric acid or sodium hydroxide.\nUsual Dosage: See Package Insert for indications, dosage and dispensing information. Once bottle has been penetrated, withdrawal of contents should be completed without delay. Discard the container no later than 4 hours after initial entry. \n12910419\nManufactured by:Liebel-Flarsheim Company LLCRaleigh, NC 27616Made in USA" }