1. Name Of The Medicinal Product
NIOPAM 340, solution for injection
2. Qualitative And Quantitative Composition
69.4% w/v Iopamidol equivalent to 340mg iodine/ml.
Each ml contains 694 mg Iopamidol.
For excipients, see 6.1.
3. Pharmaceutical Form
Solution for injection.
Clear aqueous solution filled into colourless glass bottles.
4. Clinical Particulars
4.1 Therapeutic Indications
X-ray contrast medium for use in peripheral arteriography, angiocardiography and left ventriculography, coronary arteriography, aortography - retrograde, selective renal arteriography, selective visceral angiography, digital subtraction angiography, computer tomography enhancement, urography and arthrography.
4.2 Posology And Method Of Administration
Route of administration
Intra-ventricular
Intra-arterial
Intravenous
Intra-articular
Dosage
NIOPAM 340 : DOSAGE SCHEDULE
Procedure
|
Dosage
|
Peripheral arteriography and venography
|
Adults 10 - 50 ml
Children: **
|
Angiocardiography and left ventriculography
|
Adults 30 - 80 ml
Children **
|
Coronary arteriography
|
Adults: 4 - 8 ml * per artery
|
Aortography - retrograde
|
Adults: 30 - 80 ml *
|
Selective renal arteriography
|
Adults: 5 - 10ml
Children: **
|
Selective visceral angiography
Hepatic
Coeliac
Superior Mesenteric
Inferior Mesenteric
|
Adults: 30 - 70 ml
Adults: 40 - 70ml
Adults: 25 - 70ml
Adults: 5 - 30ml
|
Digital subtraction angiography (DSA)
Intravenous injection
Coronary arteriography - by intra-arterial DSA,
Ventriculography
|
Adults 30 - 50 ml
Children: **
Adults: 2-5ml
Adults: 25ml*
Children: 1.0-1.5ml/kg
|
Computer tomography enhancement
|
Adults: 50 - 100ml
|
Intravenous urography
|
Adults: up to 1.5ml/kg
Children: 1-2.5ml/kg or **
|
Arthrography
|
Adults: 1 - 10ml according to the joint being examined
|
* repeat as necessary; ** according to body size and age;
Do not exceed 250 ml. Single injection volume depends on the vascular area to be examined.
Elderly: dosage as for adults. The lowest effective dose should be used.
Method of administration
No other drugs should be mixed with the contrast medium.
Peripheral arteriography and phlebography (venography)
Percutaneous injection into the appropriate blood vessel is used for visualisation of peripheral arteries and veins.
Angiocardiography, left ventriculography, selective coronary arteriography
Niopam may be administered by rapid injection through a catheter into a suitable peripheral artery or vein. It can also be introduced under pressure through a cardiac catheter into any of the heart chambers, or injected into large vessels for immediate visualisation. The contrast medium may also be administered during selective catheterisation of the coronary arteries.
Aortography
The contrast medium may be introduced directly by intra-arterial injection (retro-grade method) for visualisation of the aorta and its main branches.
Arthrography
Visualisation of joint cavities and articular surfaces can be achieved by either single or double contrast examination.
Selective visceral angiography
Visualisation can be achieved by selective catheterisation and injection into the hepatic, coeliac or mesenteric arteries.
Digital subtraction angiography
For cardiac imaging the contrast medium may be administered intra-arterially by selective catheterisation to provide subtracted images. Niopam 340 and 370 injected intravenously either centrally or peripherally is also recommended for use in this modality.
Urography
The contrast medium is injected intravenously and rapidly eliminated through the kidneys. In patients with severe renal failure, high dose urography should be used.
Computer tomography enhancement
Contrast enhancement for brain scans can be achieved between one and three minutes after i.v. injection. Niopam 200 and 300 are also used for total body scanning examinations after i.v. administration as a bolus, as a drip infusion or by a combination of the two methods.
4.3 Contraindications
Use in patients with proven or suspected hypersensitivity to iodine containing preparations of this type.
4.4 Special Warnings And Precautions For Use
A positive history of allergy, asthma or untoward reaction during previous similar investigations indicates a need for extra caution; the benefit should clearly outweigh the risk in such patients. Appropriate resuscitative measures should be immediately available.
X-ray examination of women should if possible be conducted during the pre-ovulation phase of the menstrual cycle and should be avoided during pregnancy.
When examining small children or babies, do not limit fluid intake before administering a hypertonic contrast solution. Also, correct any existing water and electrolyte imbalance.
Care should be exercised in carrying out radiographic procedures with contrast media in patients with severe functional impairment of the liver or myocardium, severe systemic disease and in myelomatosis (including Waldenströms macroglobulinemia, multiple myeloma).
In the latter condition patients should not be exposed to dehydration; similarly abnormalities of fluid or electrolyte balance should be corrected prior to use.
Particular care should also be exercised in patients with moderate to severe impairment of renal function (as reflected by a raised blood urea) or in diabetes. Substantial deterioration in renal function is minimised if the patient is well hydrated. Renal function parameters should be monitored after the procedure in these patients.
Patients with severe hepato-renal insufficiency should not be examined unless absolutely indicated. Re-examination should be delayed for 5-7 days.
Special care should be exercised when this product is injected into the right heart or pulmonary artery in patients with pulmonary hypertension. Right heart angiography should be carried out only when absolutely indicated.
Niopam should be administered with caution in elderly patients and patients with increased intracranial pressure or suspicion of intracranial tumour, abscess or haematoma, and in those with a history of a previous reaction to contrast media, asthma, allergy, epilepsy, severe cardiovascular disease, renal impairment, chronic alcoholism or multiple sclerosis.
Patients with these conditions have an increased risk of neurological complications.
General anaesthesia may be indicated in selected patients. However, a higher incidence of adverse reactions has been reported in these patients, probably due to the hypotensive effect of the anaesthetic.
Contrast media may promote sickling in individuals who are homozygous for sickle cell disease when injected intravenously and intra-arterially.
Patients with phaeochromocytoma may develop severe hypertensive crisis following intravascular Iopamidol. Pre-medication with α-receptor blockers is recommended.
The administration of iodinated contrast media may aggravate the symptoms of myasthenia gravis.
Patients with congestive heart failure should be observed for several hours following the procedure to detect delayed haemodynamic disturbances, which may be associated with a transitory increase in the circulating osmotic load. All other patients should be observed for at least one hour after the procedure, as most of the adverse events occur in this period. The patient should also be informed that allergic reactions may develop up to several days after the procedure; in such case, a physician should be consulted immediately.
In neonates, and particularly in premature neonates, it is recommended that tests of thyroid function (typically TSH and T4), should be checked 7-10 days and 1 month after the administration of iodinated contrast media because of the risk of hypothyroidism due to iodine overload.
In patients scheduled for thyroid examination with a radioactive iodine tracer, one must take into consideration that iodine uptake in the thyroid gland will be reduced for several days (up to two weeks) after dosing with an iodinized contrast medium that is eliminated through the kidneys.
Local tissue irritation can occur as an event of perivascular infiltration.
Neuroradiology
In patients who are known epileptics or have a history of epilepsy, anticonvulsant therapy should be maintained before and following myelographic procedures. In some instances, anticonvulsant therapy may be increased for 48 hours before the examination.
Neuroleptics must be absolutely avoided because they lower the seizure threshold. The same applies to analgesics, anti-emetics, antihistamines and sedatives of the phenothiazine group. Whenever possible, treatment with such drugs should be discontinued at least 48 hours before administration of the contrast medium and not be resumed less than 12 hours after completion of the procedure.
Angiography
In patients undergoing angiocardiographic procedures special attention should be paid to the status of the right heart and pulmonary circulation. Right heart insufficiency and pulmonary hypertension may precipitate bradycardia and systemic hypotension, when the organic iodine solution is injected. Right heart angiography should be carried out only when absolutely indicated.
In angiographic procedures, the possibility of dislodging plaque or damaging or perforating the vessel wall should be considered during catheter manipulation and contrast medium injection. Test injections to ensure proper catheter placements are recommended.
Angiography should be avoided whenever possible in patients with homocystinuria due to an increased risk of thrombosis and embolism.
In patients undergoing peripheral angiography, there should be pulsation in the artery into which the X-ray contrast medium will be injected. In patients with thromboangiitis obliterans or ascending infections in combination with serious ischemia the angiography should be performed, if at all, with special caution.
In patients undergoing venography, special caution should be exercised in patients with suspected phlebitis, serious ischaemia, local infections, or a complete venous occlusion.
Serious neurological events have been observed following direct injection of contrast media into cerebral arteries or vessels supplying the spinal cord or in angiocardiography due to inadvertent filling of the carotids.
In paediatric roentgenology, one should proceed with great caution when injecting the contrast medium into the right heart chambers of cyanotic neonates with pulmonary hypertension and impaired cardiac function.
In examinations of the aortic arch the tip of the catheter should be positioned carefully to avoid hypotension, bradycardia and CNS injury due to excess pressure transmitted from the injector pump to the brachiocephalic branches of the aorta.
Urography
Care should be exercised in patients with moderate to severe impairment of renal function (as reflected by a raised blood urea). Substantial deterioration in renal function is minimized if the patient is well hydrated. Renal function parameters, especially urinary output should be monitored after the examination in these patients.
Re-examination should be delayed 5-7 days.
Non-ionic contrast media have less anti-coagulant activity in-vitro than ionic media. Meticulous attention should therefore be paid to angiographic technique. Non-ionic media should not be allowed to remain in contact with blood in the syringe and intravascular catheters should be flushed frequently, to minimise the risk of clotting, which rarely has led to serious thromboembolic complications after procedures.
Niopam should be used with caution in patients with hyperthyroidism. It is possible that hyperthyroidism may recur in patients previously treated for Graves' disease.
The presence of renal damage in diabetic patients is one of the factors predisposing to renal impairment following contrast media administration. This may precipitate lactic acidosis in patients who are taking metformin. As a precaution, metformin should be discontinued at the time of, or prior to, the procedure and withheld for 48 hours subsequent to the procedure and re-instituted only after renal function has been re-evaluated and found to be normal.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Thyroid function tests: use of iodinated contrast media may interfere with tests for thyroid function which depend on iodine estimations, such as Protein Binding Iodine and radioactive iodine uptake. As a consequence they will not accurately reflect thyroid function for up to 16 days following administration of iodinated contrast media. Thyroid function tests not depending on iodine estimations, e.g. T3 resin uptake and total or free thyroxine (T4) assays are not affected.
No other specific interference with physiological functions has been noted.
The administration of an X-ray contrast medium in diabetic patients with nephropathy who are taking biguanides may precipitate lactic acidosis.
Arterial thrombosis has been reported when Iopamidol was given following papaverine.
The administration of vasopressors strongly potentiates the neurological effect of the intra-arterial contrast media.
Contrast media may interfere with laboratory tests for bilirubin, proteins or inorganic substances (eg iron, copper, calcium, phosphate). These substances should not be assayed during the same day following the administration of contrast media.
4.6 Pregnancy And Lactation
X-ray examination of women should if possible be conducted during the pre-ovulation phase of the menstrual cycle and should be avoided during pregnancy; also, since it has not been demonstrated that Niopam is safe for use in pregnant women, it should be administered only if the procedure is considered essential by the physician.
Niopam is poorly excreted in human milk. From animal experience, Niopam is non toxic in animals after oral administration. Although, no serious adverse reactions have been reported in nursing infants, Niopam should be administered to lactating women only if considered essential by the physician.
4.7 Effects On Ability To Drive And Use Machines
There is no known effect on the ability to drive and operate machines. However, because of the risk of early reactions, driving or operating machinery is not advisable for one hour following the last injection.
4.8 Undesirable Effects
The use of iodinated contrast media may cause untoward side effects. They are usually mild to moderate and transient in nature. However , severe and life threatening reactions sometimes leading to death have been reported.
Anaphylaxis (anaphylactoid reactions/hypersensitivity) may manifest with: mild localized or more diffuse angioneurotic oedema, tongue oedema, laryngospasm or laryngeal oedema, dysphagia, pharyngitis and throat tightness, pharyngolaryngeal pain, cough, conjunctivitis, rhinitis, sneezing, feeling hot, sweating increased, asthenia, dizziness, pallor, dyspnoea, wheezing, bronchospasm, and moderate hypotension. Skin reactions may occur in the form of various types of rash, diffuse erythema, diffuse blisters, urticaria, and pruritus. These reactions, which occur irrespective of the dose administered and the route of administration, may represent the first signs of incipient state of shock. Administration of the contrast medium must be discontinued immediately and – if necessary – specific treatment initiated via a venous access.
More severe reactions involving the cardiovascular system such as vasodilatation with pronounced hypotension, tachycardia, dyspnoea, agitation, cyanosis and loss of consciousness (syncope) may require emergency treatment.
Intravascular administration –Adults
The safety of Iopamidol injection through intravascular administration was evaluated in 2,548 adult patients involved in clinical trials.
The adverse reactions are classified by System Organ Class and frequency, using the following convention: Very common (
System Organ Class
|
Adverse Reactions
|
|
|
|
Clinical Trials
|
Post-marketing Surveillance
|
|
|
|
Common
(
|
Uncommon
(
|
Rare
(
|
Frequency unknown
|
|
Blood and lymphatic system disorders
|
|
|
|
Thrombocytopenia
|
Immune system disorders
|
|
|
|
Anaphylaxis, Anaphylactoid reaction
|
Psychiatric disorders
|
|
|
Confusional state
|
|
Nervous system disorders
|
Headache
|
Dizziness, Taste alteration
|
Paraesthesia
|
Coma, Transient ischaemic attack, Syncope, Depressed level of consciousness or loss of consciousness, Convulsion,
|
Eye disorders
|
|
|
|
Transient blindness, Visual disturbance, Conjunctivitis, Photophobia
|
Cardiac disorders
|
|
Cardiac dysrhythmias such as extrasystoles, atrial fibrillation, ventricular tachycardia and ventricular fibrillation*
|
Bradycardia
|
Myocardial ischaemia or infarction, Cardiac failure, Cardio-respiratory arrest, Tachycardia
|
Vascular disorders
|
|
Hypotension, Hypertension, Flushing
|
|
Circulatory collapse or shock
|
Respiratory, thoracic and mediastinal disorders
|
|
|
Pulmonary oedema, Asthma, Bronchospasm
|
Respiratory arrest, Respiratory failure, Acute respiratory distress syndrome, Respiratory distress, Apnoea, Laryngeal oedema, Dyspnoea
|
Gastrointestinal disorders
|
Nausea
|
Vomiting, Diarrhea, Abdominal pain, Dry mouth
|
|
Salivary hypersecretion, Salivary gland enlargement
|
Skin and subcutaneous tissue disorders
|
|
Rash, Urticaria, Pruritus, Erythema, Sweating increased
|
|
Face oedema, muco-cutaneous syndromes **
|
Musculoskeletal and connective tissue disorders
|
|
Back pain
|
Muscle spasms
|
Musculoskeletal pain, Muscular weakness
|
Renal and urinary disorders
|
|
Acute renal failure
|
|
|
General disorders and administration site conditions
|
Feeling hot
|
Chest pain, Injection site pain***, Pyrexia, Feeling cold
|
|
Rigors, Pain, Malaise
|
Investigations
|
|
Blood creatinine increased
|
|
Electrocardiogram change including ST segment depression
|
|
|
*
|
Cardiac reactions may occur as consequences of the coronary catheterization procedural hazard: these complications include coronary artery thrombosis and coronary artery embolism.
|
**
|
As with other iodinated contrast media, very rare cases of muco-cutaneous syndromes, including Stevens-Johnson syndrome, toxic epidermal necrolysis (Lyell syndrome) and erythema multiforme, have been reported following the administration of Iopamidol
|
***
|
Injection site pain and swelling may occur. In the majority of cases it is due to extravasation of contrast medium. These reactions are usually transient and result in recovery without sequelae. However, inflammation and even skin necrosis have been seen on very rare occasions. In isolated reports extravasation led to the development of compartment syndrome
|
Intravascular administration – Pediatric Population
Frequency type and severity of adverse reactions in children are similar to those in adults.
Body cavity administration
The majority of the reactions occur some hours after the contrast administration due to the slow absorption from the area of administration and distribution in the whole organism.
The reactions reported in cases of arthrography usually represent irritative manifestations superimposed on existing tissue inflammation.
Systemic hypersensitivity is rare, generally mild and in the form of skin reactions. However, the possibility of severe anaphylactoid reactions cannot be excluded.
4.9 Overdose
Treatment of overdosage is directed toward the support of all vital functions and the elimination of the contrast medium while maintaining the patient well hydrated.
If needed, hemodyalisis can be used to eliminate Iopamidol from the body.
5. Pharmacological Properties
Pharmacotherapeutic group; ATC code: V08A B04
5.1 Pharmacodynamic Properties
Iopamidol is contrast medium belonging to the new generation of non-ionic compound whose solubility is due to the presence of hydrophilic substitutes in the molecule. This results in a solution of low osmolality when compared with ionic media.
Iopamidol has been shown to be effective as an X-ray contrast medium in neuroradiology, angiography, venography, arthrography, urography, cerebral angiography and left ventriculography and coronary arteriography. Its toxicity particularly cardiac and CNS toxicity are less than those of ionic contrast media.
5.2 Pharmacokinetic Properties
The pharmacokinetics of Iopamidol conform to an open two compartment pharmacokinetic model with first order elimination.
Distribution volume is equivalent to extracellular fluid.
Elimination is almost completely through the kidneys. Less that 1% of the administered dose has been recovered in the faeces up to 72 hours after dosing. Elimination is rapid; up to half the administered dose may be recovered in the urine in the first two hours of dosing.
There is no evidence of biotransformation.
Serum protein binding is negligible.
5.3 Preclinical Safety Data
No adverse effects can be predicted from animal toxicology studies other than those documented from human use of Iopamidol.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Excipients are: trometamol, hydrochloric acid and edetate calcium disodium.
6.2 Incompatibilities
No other drug should be mixed with the contrast medium.
6.3 Shelf Life
5 years.
6.4 Special Precautions For Storage
Protect from light.
6.5 Nature And Contents Of Container
50, 70, 100 and 200ml clear, colourless Type I or Type II glass bottles with rubber closures and aluminium caps.
6.6 Special Precautions For Disposal And Other Handling
Discard if the solution is not clear of particulate matter.
Exceptionally, the event of crystallisation of Niopam could occur. It has been shown that such a phenomenon is caused by a damaged or defective container and therefore the product should not be used in this case.
The bottle, once opened, must be used immediately.
Any residue of contrast medium must be discarded.
Niopam, as other iodinated contrast media, can react with metallic surfaces containing copper (e.g. brass), therefore the use of equipment, in which the product comes into direct contact with such surfaces, should be avoided.
7. Marketing Authorisation Holder
Bracco U.K. Ltd,
Bracco House, Mercury Park,
Wycombe Lane, Wooburn Green,
Buckinghamshire HP10 OHH
8. Marketing Authorisation Number(S)
PL 18920/0010
9. Date Of First Authorisation/Renewal Of The Authorisation
13th January 1989 / 9th January 2002
10. Date Of Revision Of The Text
15 November 2011
