IOMERVU

1 INDICATIONS AND USAGE IOMERVU is a radiographic contrast agent indicated for: Intra-arterial Procedures † ( 1.1 ) Cerebral arteriography, includingintra-arterial digital subtraction angiography (IA-DSA), in adults and pediatric patients Visceral and peripheral arteriography and aortography, including IA-DSA, in adults and pediatric patients Coronary arteriography and cardiac ventriculography in adults Radiographic evaluation of cardiac chambers and related arteries in pediatric patients Intravenous Procedures † ( 1.2 ) Computed tomography (CT) of the head and body in adults and pediatric patients CT angiography of intracranial, visceral, and lower extremity arteries in adults and pediatric patients Coronary CT angiography in adults and pediatric patients CT urography in adults and pediatric patients † Specific concentrations are recommended for each type of imaging procedure. ( 2.2 , 2.3 , 2.4 , 2.5 ) 1.1 Intra-arterial Procedures † IOMERVU is indicated for: Cerebral arteriography, including intra-arterial digital subtraction angiography (IA-DSA), in adults and pediatric patients Visceral and peripheral arteriography and aortography, including IA-DSA, in adults and pediatric patients Coronary arteriography and cardiac ventriculography in adults Radiographic evaluation of cardiac chambers and related arteries in pediatric patients 1.2 Intravenous Procedures † IOMERVU is indicated for: Computed tomography (CT) of the head and body in adults and pediatric patients CT angiography of intracranial, visceral, and lower extremity arteries in adults and pediatric patients Coronary CT angiography in adults and pediatric patients CT urography in adults and pediatric patients † Specific concentrations of IOMERVU are recommended for each type of imaging procedure [see Dosage and Administration ( 2.2 , 2.3 , 2.4 , 2.5 )] .

2 DOSAGE AND ADMINISTRATION Individualize the volume and concentration according to the specific dosing tables accounting for factors such as age, body weight, vessel size, rate of blood flow within the vessel, and structures or areas to be examined. ( 2.2 , 2.3 , 2.4 , 2.5 ) See full prescribing information for complete dosage and administration information. ( 2 ) 2.1 Important Dosing and Administration Information IOMERVU is for intra-arterial or intravenous use only and must not be administered intrathecally [see Warnings and Precautions ( 5.1 )] . Specific concentrations of IOMERVU are recommended for each type of imaging procedure [see Dosage and Administration ( 2.2 , 2.3 , 2.4 , 2.5 )]. Individualize the volume, concentration, and injection rate of IOMERVU within the specified ranges [see Dosage and Administration ( 2.2 , 2.3 , 2.4 , 2.5 )]. Consider factors such as age, body weight, vessel size, rate of blood flow within the vessel, anticipated pathology, degree and extent of opacification required, structures or area to be examined, disease processes affecting the patient, and equipment and technique to be employed. Hydrate patients before and after IOMERVU administration [see Warnings and Precautions ( 5.3 )] . Use aseptic technique for all handling and administration of IOMERVU. IOMERVU may be administered at either body temperature (37°C, 98.6°F) or room temperature (20°C to 25°C, 68°F to 77°F). Visually inspect IOMERVU for particulate matter or discoloration before administration, whenever the solution and container permit. Do not administer IOMERVU if particulate matter or discoloration is observed. Do not mix IOMERVU with, or inject in intravenous lines containing, other drugs or total nutritional admixtures. Each single-dose container of IOMERVU injection is intended for one procedure only. Discard any unused portion. 2.2 Recommended Dosage for Intra-arterial Procedures in Adults Recommended doses of IOMERVU in adults for intra-arterial procedures are shown in Table 1. Inject at rates approximately equal to the flow rate in the vessel being injected. Table 1. Recommended Concentrations and Volumes of IOMERVU to Administer per Single Injection into Selected Arteries for Intra-arterial Procedures in Adults Imaging Procedure Concentration (mg Iodine/mL) Volume (mL) Maximum Total Dose (mL) Cerebral arteriography 300 Carotid, subclavian, and vertebral arteries: 6 mL to 12 mL Aortic arch: 30 mL to 50 mL 200 mL Visceral and peripheral arteriography; aortography 300 Aortography: 30 mL to 70 mL Renal arteries: 10 mL to 12 mL Other major branches of aorta: 20 mL to 60 mL 200 mL Intra-arterial digital subtraction angiography 300 Carotid, subclavian, and vertebral arteries: 4 mL to 12 mL Aortic arch: 20 mL to 25 mL Aortography: 15 mL to 40 mL Renal arteries: 6 mL to 16 mL Other major branches of aorta: 10 mL to 40 mL Ilio-femoral runoff: 8 mL to 40 mL 200 mL Coronary arteriography and cardiac ventriculography 300 Coronary arteries: 3 mL to 7 mL Cardiac ventriculography: 30 mL to 45 mL 286 mL 350 245 mL 400 215 mL 2.3 Recommended Dosage for Intra-arterial Procedures in Pediatric Patients Recommended doses of IOMERVU in pediatric patients for intra-arterial procedures are shown in Table 2. Inject at rates approximately equal to the flow rate in the vessel being injected. Table 2. Recommended Concentrations and Volumes per Body Weight of IOMERVU to Administer per Single Injection for Intra-arterial Procedures in Pediatric Patients Imaging Procedure Concentration (mg Iodine/mL) Volume (mL/kg body weight) Maximum Total Dose (mL/kg) Cerebral arteriography 300 0.5 mL/kg to 2 mL/kg 5 mL/kg Do not exceed adult maximum dose (see Table 1) Visceral and peripheral arteriography; aortography 300 0.5 mL/kg to 2 mL/kg Intra-arterial digital subtraction angiography 300 0.3 mL/kg to 1 mL/kg Radiographic evaluation of cardiac chambers and related arteries 300, 350, or 400 0.5 mL/kg to 2 mL/kg 2.4 Recommended Dosage for Intravenous Procedures in Adults Recommended doses of IOMERVU in adults for intravenous procedures are shown in Table 3. Table 3. Recommended Concentrations, Volumes, and Injection Rates of IOMERVU for Intravenous Procedures in Adults Imaging Procedure Concentration (mg Iodine/mL) Volume (mL) Injection Rate 3 (mL/s) CT of Head and Body 250 or 300 100 mL to 190 mL 2 mL/s to 4 mL/s 350 or 400 75 mL to 150 mL CT Angiography 1 300, 350, or 400 80 mL to 130 mL 4 mL/s to 6 mL/s Coronary CT Angiography 1 400 50 mL to 90 mL 4 mL/s to 6 mL/s CT Urography 2 350 90 mL to 120 mL 2.5 mL/s 1 The IOMERVU volume may be immediately followed by a 40 mL to 50 mL 0.9% sodium chloride injection flush at the same flow rate as the contrast volume. 2 The IOMERVU volume may be administered either as a single bolus, or for dual-phase protocols as divided doses. 3 The injection rate of IOMERVU should be determined according to the clinical indication and the location, size, and type of the intravenous access. 2.5 Recommended Dosage for Intravenous Procedures in Pediatric Patients Recommended doses of IOMERVU in pediatric patients for intravenous procedures are shown in Table 4. Table 4. Recommended Concentrations, Volumes per Body Weight, and Injection Rates of IOMERVU for Intravenous Procedures in Pediatric Patients Imaging Procedure Concentration (mg Iodine/mL) Volume (mL/kg body weight) Injection Rate (mL/s)* CT of Head and Body 250 or 300 1.5 mL/kg to 2.5 mL/kg 1 mL/s to 2 mL/s 350 or 400 1 mL/kg to 2 mL/kg CT Angiography 300, 350, or 400 1 mL/kg to 2 mL/kg 2 mL/s to 3 mL/s Coronary CT Angiography 300 or 400 1 mL/kg to 2 mL/kg 2 mL/s to 3 mL/s CT Urography 300 1 mL/kg to 2 mL/kg 1 mL/s to 2 mL/s * The injection rate of IOMERVU should be determined according to the clinical indication and the location, size, and type of the intravenous access. In neonates and patients <15 kg in whom a 24-gauge angiocatheter is the only option, an injection rate of 1 mL/s is recommended.

4 CONTRAINDICATIONS None. None ( 4 )

5 WARNINGS AND PRECAUTIONS Hypersensitivity Reactions: Life-threatening or fatal reactions can occur. Always have emergency resuscitation equipment and trained personnel available. ( 5.2 ) Acute Kidney Injury: Acute injury including renal failure can occur. Minimize dose and maintain adequate hydration to minimize risk. ( 5.3 ) Cardiovascular Adverse Reactions: Hemodynamic disturbances including shock and cardiac arrest may occur during or after administration. ( 5.4 ) Thyroid Dysfunction in Pediatric Patients 0 Years to 3 Years of Age: Individualize thyroid function monitoring based on risk factors such as prematurity. ( 5.8 ) 5.1 Risks Associated with Inadvertent Intrathecal Administration IOMERVU is for intra-arterial or intravenous use only and must not be administered intrathecally [see Dosage and Administration ( 2.1 )]. Intrathecal administration, even if inadvertent, can cause death, convulsions, cerebral hemorrhage, coma, paralysis, arachnoiditis, acute renal failure, cardiac arrest, seizures, rhabdomyolysis, hyperthermia, and brain edema. 5.2 Hypersensitivity Reactions IOMERVU can cause life-threatening or fatal hypersensitivity reactions including anaphylaxis. Manifestations include respiratory arrest, laryngospasm, bronchospasm, angioedema, and shock [see Adverse Reactions ( 6.2 )]. Most severe reactions develop shortly after the start of injection (e.g., within 1 to 3 minutes), but delayed reactions can occur. There is an increased risk in patients with a history of a previous reaction to contrast agents, and known allergic disorders (i.e., bronchial asthma, drug, or food allergies) or other hypersensitivities. Premedication with antihistamines or corticosteroids to minimize possible allergic reactions does not prevent serious life-threatening reactions, but may reduce their incidence and severity. Obtain a history of allergy, hypersensitivity, and hypersensitivity reactions to iodinated contrast agents. Always have emergency resuscitation equipment and trained personnel available before use of IOMERVU. Monitor all patients for hypersensitivity reactions. 5.3 Acute Kidney Injury Acute kidney injury, including renal failure, may occur after IOMERVU administration. Risk factors include pre-existing renal impairment, dehydration, diabetes mellitus, heart failure, advanced vascular disease, advanced age, concomitant use of nephrotoxic or diuretic medications, multiple myeloma or other paraproteinemia, and repetitive or large doses of IOMERVU. Use the lowest necessary dose of IOMERVU in patients with renal impairment. Adequately hydrate patients prior to and following IOMERVU administration. Do not use laxatives, diuretics, or preparatory dehydration prior to IOMERVU administration. 5.4 Cardiovascular Adverse Reactions IOMERVU increases the circulatory osmotic load and may induce acute or delayed hemodynamic disturbances in patients with heart failure, severely impaired renal function, combined renal and hepatic disease, or combined renal and cardiac disease, particularly when repetitive or large doses are administered. Life-threatening or fatal cardiovascular reactions including hypotension, shock, and cardiac arrest have occurred with the use of IOMERVU. 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 IOMERVU in patients with heart failure and always have emergency resuscitation equipment and trained personnel available. Monitor all patients for severe cardiovascular reactions. 5.5 Thromboembolic Events Serious, in some cases fatal, thromboembolic events including myocardial infarction and stroke can occur during angiographic procedures with iodinated contrast agents including IOMERVU. During these procedures, increased thrombosis and activation of the complement system can occur. Risk factors for developing thromboembolic events include length of procedure, catheter and syringe material, underlying disease state, and concomitant medications. To reduce risk of thromboembolic events, use meticulous angiographic techniques and minimize the length of the procedure. Avoid blood remaining in contact with syringes containing IOMERVU, which increases the risk of clotting. Avoid angiocardiography in patients with homocystinuria because of the risk of inducing thrombosis and embolism. 5.6 Extravasation and Injection Site Reactions Extravasation can occur with IOMERVU administration, particularly in patients with severe arterial or venous disease. Inflammation, blistering, skin necrosis, and compartment syndrome have been reported following extravasation. In addition, injection site reactions such as pain and swelling at the injection site can also occur [see Adverse Reactions ( 6.1 , 6.2 )] . Ensure intravascular placement of catheters prior to injection. Monitor patients for extravasation and advise patients to seek medical care for progression of symptoms. 5.7 Thyroid Storm in Patients with Hyperthyroidism Thyroid storm has occurred after the intravascular use of iodinated contrast agents in patients with hyperthyroidism or with an autonomously functioning thyroid nodule. Evaluate the risk in such patients before use of IOMERVU. 5.8 Thyroid Dysfunction in Pediatric Patients 0 Years to 3 Years of Age Thyroid dysfunction characterized by hypothyroidism or transient thyroid suppression has been reported after both single exposure and multiple exposures to iodinated contrast agents in pediatric patients 0 years 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 iodinated contrast agent exposure. Pediatric patients with congenital cardiac conditions may be at 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 IOMERVU, individualize thyroid function monitoring based on underlying risk factors, especially in term and preterm neonates. 5.9 Hypertensive Crisis in Patients with Pheochromocytoma Hypertensive crisis has occurred after the use of iodinated contrast agents in patients with pheochromocytoma. Closely monitor patients when administering IOMERVU if pheochromocytoma or catecholamine-secreting paragangliomas are suspected. Inject the minimum amount of IOMERVU necessary, assess blood pressure throughout the procedure, and have measures for treatment of a hypertensive crisis readily available. 5.10 Sickle Cell Crisis in Patients with Sickle Cell Disease Iodinated contrast agents when administered intravascularly may promote sickling in individuals who are homozygous for sickle cell disease. Hydrate patients prior to and following IOMERVU administration and use IOMERVU only if the necessary imaging information cannot be obtained with alternative imaging modalities. 5.11 Severe Cutaneous Adverse Reactions 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 IOMERVU to patients with a history of a severe cutaneous adverse reaction to IOMERVU. 5.12 Interference with Laboratory Tests IOMERVU can interfere with protein-bound iodine tests [see Drug Interactions ( 7.2 )].

7 DRUG INTERACTIONS 7.1 Drug-Drug Interactions Metformin Stop metformin at the time of, or prior to, IOMERVU administration in patients with an eGFR between 30 and 60 mL/min/1.73 m 2 ; 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 metformin only after renal function is stable. Metformin can cause lactic acidosis in patients with renal impairment. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function. Radioactive Iodine Avoid thyroid therapy or testing using radioactive iodine for up to 6 weeks post IOMERVU. Administration of IOMERVU may interfere with thyroid uptake of radioactive iodine (I-131 and I-123) and decrease therapeutic and diagnostic efficacy. 7.2 Drug-Laboratory Test Interactions Protein-Bound Iodine Test Do not perform a protein-bound iodine test for at least 16 days following administration of IOMERVU. Iodinated contrast agents, including IOMERVU, will temporarily increase protein-bound iodine in blood. However, thyroid function tests that do not depend on iodine estimations, e.g., triiodothyronine (T 3 ) resin uptake and total or free thyroxine (T 4 ) assays, are not affected.

6 ADVERSE REACTIONS The following clinically significant adverse reactions are described elsewhere in the labeling: Risks Associated with Intrathecal Administration [see Warnings and Precautions ( 5.1 )] Hypersensitivity Reactions [see Warnings and Precautions ( 5.2 )] Acute Kidney Injury [see Warnings and Precautions ( 5.3 )] Cardiovascular Adverse Reactions [see Warnings and Precautions ( 5.4 )] Thromboembolic Events [see Warnings and Precautions ( 5.5 )] Extravasation and Injection Site Reactions [see Warnings and Precautions ( 5.6 )] Thyroid Dysfunction in Pediatric Patients 0 Years to 3 Years of Age [see Warnings and Precautions ( 5.8 )] Severe Cutaneous Adverse Reactions [see Warnings and Precautions ( 5.11 )] Most common adverse reactions (incidence ≥0.5%) are feeling hot, headache, nausea, chest pain, back pain, and vomiting. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Bracco Diagnostics Inc. at 1-800-257-5181 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1 Clinical Trials Experience 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. Adverse Reactions in Adult Patients The safety of IOMERVU was evaluated in 4,621 adult patients who received 1,500 mg to 86,000 mg iodine doses of IOMERVU intra-arterially or intravenously in clinical trials. The average age was 60 years (range 18 years to 99 years), and 34% were female. The racial and ethnic distribution was 83% White, 10% Asian, 1% Black, 1% Hispanic, and 5% patients of other or unspecified groups. Table 5 provides a summary of the adverse reactions reported in ≥0.5% of adult patients. Table 5: Adverse Reactions Reported in ≥0.5% of 4,621 Adult Patients Receiving Intra-arterial or Intravenous Administration of IOMERVU in Clinical Trials Adverse Reaction Incidence (%) Feeling hot 2 Headache 1.2 Nausea 1 Chest pain 0.6 Back pain 0.5 Vomiting 0.5 The following adverse reactions were observed in <0.5% of the adult patients receiving IOMERVU: Blood and lymphatic system disorders: activated partial thromboplastin time prolonged, prothrombin time prolonged Cardiovascular disorders: ventricular fibrillation, hypertensive crisis, coronary arteriospasm, congestive cardiac failure, cardiac flutter, atrioventricular block, right bundle branch block, hypotension, arrhythmia, bradycardia, supraventricular extrasystoles, ventricular extrasystoles, increased blood pressure, flushing Ear and labyrinth disorders : vertigo, ear discomfort Eye disorder: vision blurred, periorbital edema, photopsia Gastrointestinal : esophageal varices hemorrhage, abdominal pain, abdominal distension, alanine aminotransferase (ALT) increased, constipation, diarrhea, dry mouth, salivary hypersecretion, oral paresthesia General disorders: pain, injection site reactions (pain, discomfort, or warmth), peripheral edema, chills, asthenia, malaise Musculoskeletal and connective tissue disorders: arthralgia, pain in jaw Nervous system disorders: cerebrovascular disorder, dysarthria, visual field defect, burning sensation, presyncope, dizziness, dysgeusia, paresthesia Psychiatric disorders : delirium, anxiety, insomnia Renal and urinary disorders: acute kidney injury, increased blood creatinine, urinary urgency Respiratory, thoracic, and mediastinal disorders: respiratory arrest, pulmonary edema, bronchospasm, dyspnea, cough, rhinitis, throat irritation or tightness, sneezing Skin and subcutaneous tissue disorders: urticaria, blister, purpura, ecchymosis, rash, pruritus, erythema Adverse Reactions in Pediatric Patients The safety of IOMERVU was evaluated in 184 pediatric patients who received 1,800 mg to 76,000 mg iodine doses of IOMERVU intra-arterially or intravenously in clinical trials. The average age was 6 years (range 11 days to 17 years), and 47% were female. The racial distribution was 98% White, 1% Black, and 1% patients of other or unspecified groups. The overall character, quality, and severity of adverse reactions reported in pediatric patients were similar to those reported in adult patients. 6.2 Post Marketing Experience The following adverse reactions have been identified during post-approval use of IOMERVU outside the United States. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Blood and lymphatic system disorders: thrombocytopenia, leukopenia, leukocytosis Cardiovascular disorders: cardio-respiratory arrest, circulatory collapse or shock, myocardial infarction, atrial fibrillation, cyanosis, pallor Endocrine disorders: hyperthyroidism, hypothyroidism Eye disorders: transient blindness, conjunctivitis, increased lacrimation Gastrointestinal disorders: salivary gland enlargement, increased aspartate aminotransferase (AST), dysphagia General disorders and administration site conditions: injection site swelling (usually due to extravasation) Immune system disorders: hypersensitivity reactions including fatal anaphylaxis Nervous system disorders: coma, loss of consciousness, encephalopathy, transient ischemic attack, paralysis, convulsion, syncope, amnesia, somnolence Psychiatric disorders : confusional state Respiratory, thoracic, and mediastinal disorders: acute respiratory distress syndrome (ARDS), laryngeal edema, pharyngeal edema, dysphonia Skin and subcutaneous tissue disorders : severe reactions (Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN), acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS)) and mild reactions (rash, erythema, pruritus, urticaria, and skin discoloration)

8.1 Pregnancy Risk Summary Available data from literature and postmarketing reports on iomeprol use in pregnant women over decades have not identified a drug-associated risk of major birth defects, miscarriage, or other adverse maternal or fetal outcomes. In animal reproduction studies, no adverse developmental outcomes were observed with intravenous administration of iomeprol to pregnant rats and rabbits at doses up to 0.45-times the maximum recommended human dose of 86,000 mg iodine. Animal studies show that iomeprol crosses the placenta ( see Data ). The background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defects, loss or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data Animal Data Embryo-fetal developmental toxicity studies were performed with intravenous administration of iomeprol in rats at daily doses of 600 mg, 1,500 mg, or 4,000 mg iodine/kg (0.07-, 0.17- or 0.45-fold the human equivalent dose (HED, mg/m 2 ) using the maximum human dose of 86,000 mg iodine per administration) from gestation days (GD) 6 to 15 and in rabbits at daily doses of 300 mg, 800 mg, or 2,000 mg iodine/kg (0.07-, 0.18- or 0.45-fold the HED using the maximum human dose of 86,000 mg iodine per administration) from GD 6 to 18. Iomeprol did not result in fetal harm at the highest doses evaluated, 0.45-times the maximum recommended human dose of 86,000 mg iodine. A biodistribution study with a single intravenous administration of 1,000 mg iodine/kg (0.11-fold the HED using the maximum human dose of 86,000 mg iodine per administration) of radiolabeled iomeprol to pregnant rats showed that iomeprol crosses the placenta. No accumulation of radioactivity in fetal tissues was observed.