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Learning objectives
General considerations on GBCA
Approval
EU, USA, Jap EU, USA, Jap EU EU, USA, Jap EU EU, USA
Gadoversetamide (OptiMARK)
Gadoxetic acid disodium (Primovist) Gadofosveset (Vasovist)
CNS, liver
Liver Vessels (abd., limbs)
EU, USA
EU, USA EU
MR contrast agents
Generally most MR contrast agents are safe
but
they are not a 100% safe
Side effects
Nephrogenic systemic fibrosis (NSF)
Nephrotoxicity
Symmetric distribution
Peau dorange Thickening of cutis woody texture
Pains
Pruritus
NSF
Dendritic cells
CD68, F XIIIa positive Thickened, chaotic collagen bundles Mucin deposits in the skin
Prognosis of NSF
Natural history - not well understood
Pathophysiology of NSF
Circulating fibrocytes
Mostly affected patients with severe renal insufficiency (grade 4 and 5) i.e. eGFR < 30 mL/min per 1.73 m2 or ARF
Higher cumulative doses Proinflammatory or profibrotic conditions Linear GBCA risk compared to macrocyclic agents
Stability of GBCA
In vitro and in vivo studies
GBCA - Transmetallation
Leads to release of free Gd3+ which is extremely toxic. Gd replaced by endogenous metals such as zinc or copper Transmetallation is more likely with linear chelates and when GBCA remains in the body for a long period Transmetallation is more likely in acidotic condition
GBCA - Stability
Thermodynamic stability (Ktherm) describes affinity of Gd for the ligand at pH 14 Conditional stability (Kcon) describes equilibrium considering all protonated forms of the ligand at pH 7.4 Variable amounts of free ligands or calcium complexes in some agents to ensure chelation of any free Gd3+
GBCA Stability
Kinetic stability describes speed of dissociation
GBCA - Transmetallation
More likely to occur with unstable molecules as indicated by:
GBCA - Stability
Molecular structure
Non-ionic molecules are thermodynamically less stable in comparison to ionic chelates [Kcon] Gadoversetamide (Optimark) Gadodiamide (Omniscan) non-ionic (15.0) non-ionic (14.9)
Gadoteridol (ProHance)
Gadobutrol (Gadovist) Gd-DTPA (Magnevist) Gadobenate (MultiHance)
non-ionic (17.1)
non-ionic (15.5) ionic ionic (18.1) (18.4)
Gd-DOTA (Dotarem)
ionic
(18.8)
GBCA - Stability
[Ktherm]
Gadoversetamide (Optimark)
Gadodiamide (Omniscan) Gd-DTPA (Magnevist) Gadobutrol (Gadovist)
16.6
16.9 22.1 21.8
Gadobenate (MultiHance)
Gadoteridol (ProHance) Gd-DOTA (Dotarem)
22.6
23.8 25.8
GBCA - Stability
Excess chelates
Gadoversetamide (Optimark)
Gadodiamide (Omniscan) Gd-DTPA (Magnevist) Gadoteridol (ProHance)
28.40
12.00 00.40 00.23
Gadobutrol (Gadovist)
Gadobenate (MultiHance) Gd-DOTA (Dotarem)
00.00
00.00 00.00
GBCA - Stability
Molecular structure
Macrocyclic agents are kinetically much more stable than linear chelates
Gadoversetamide (Optimark)
Gadodiamide (Omniscan) Gd-DTPA (Magnevist) Gadobenate (MultiHance)
Linear
Linear Linear Linear
Gadobutrol (Gadovist)
Gadoteridol (ProHance) Gd-DOTA (Dotarem)
Cyclic
Cyclic Cyclic
Extracellular Gd-CM Gadoversetamide (OptiMark) Gadodiamide (Omniscan) Gadobutrol (Gadovist) Gadoteridol (ProHance) Gadopentetate (Magnevist) Gadobenate (MultiHance) Gadoterate (Dotarem)
Type
Condition stability
15
16.9
14.9
12
35 sec
21.8 23.8
15.5 17.1
18h* 4h*
Ionic linear
Ionic linear Ionic cyclic
22.1
22.6 25.8
18.1
18.4 18.8
0.4
None None
10 min
Not available 85h*
Differences within the group of non-ionic and the ionic linear class, but no differences within the macrocyclic class For the macrocyclic agents, Gadovist, Dotarem and Prohance, no (< 0.1%) release was observed within 15 days
Frenzel et al. Invest. Radiol. 2008
Addition of phosphate enhances release of Gd from linear agents, but class differences prevail For the macrocyclic agents, Gadovist, Dotarem and ProHance, no (< 0.1%) release was observed within 15 days. Phosphate had no effect on stability. No difference between Gadovist, Dotarem, and ProHance
Frenzel et al. Invest. Radiol. 2008
Omniscan
Magnevist OptiMark Unspecified Gd-CM
48 mio.
100 mio. 9 mio.
347 patients
89 patients 5 patients 151 patients
Gadovist
4 mio.
one patient
* Company data presented at FDA Advisory Board Dec. 09, Gadovist data from BSP
Current guidelines
FDA
EMA
ESUR
FDA
Package insert with black box warning on the risk of NSF
Risk groups for NSF: acute and chronic kidney disease grades 4 and 5 and every grade of ARF
Check for renal dysfunction before administration of GBCA (medical history, laboratory tests) No off-label use
FDA
It may be prudent to institute prompt dialysis in patients with advanced kidney dysfunction who receive GBCA. Although there are no data to determine the utility of dialysis to prevent or treat NSF in patients with decreased kidney function, average excretory rates of gadolinium are 78%, 96%, and 99% in the first to third haemodialysis sessions, respectively.
EMA
Package insert with black box warning on the risk of NSF
Check for renal dysfunction before administration of GBCA (medical history, laboratory tests)
Omniscan
Magnevist
OptiMark
Ethical issue
At the centre which reported the largest series of cases with NSF: Since they have stopped gadodiamide in March 06 and switched to a macrocyclic MRI-CM, they have not seen a single new case of NSF.
No cases of NSF were identified in dialysis patients who received ProHance Reilly RF, Clin J Am Soc Nephrol 2008
A recent study documented that no cases of NSF were seen in 135 patients with advanced renal impairment (GFR < 30 ml/min) who received the ionic macrocyclic agent Dotarem between July 05 to July 06
Thank you!