Label: LUMASON- sulfur hexafluoride
- NDC Code(s): 68155-099-16
- Packager: Bracco Suisse SA
- Category: HUMAN PRESCRIPTION DRUG LABEL
- DEA Schedule: None
- Marketing Status: New Drug Application
Updated December 10, 2018
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- BOXED WARNING(What is this?)
WARNING: SERIOUS CARDIOPULMONARY REACTIONS
Serious cardiopulmonary reactions, including fatalities, have occurred uncommonly during or following the injection of ultrasound contrast agents, including sulfur hexafluoride lipid microspheres [see Warnings and Precautions (5.1)]. Most serious reactions occur within 30 minutes of administration [see Warnings and Precautions (5.1)].
- Assess all patients for the presence of any condition that precludes administration [see Contraindications (4)].
- Always have resuscitation equipment and trained personnel readily available [see Warnings and Precautions (5.1)].
- HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use LUMASON ® safely and effectively. See full prescribing information for LUMASON.
LUMASON (sulfur hexafluoride lipid-type A microspheres) for injectable suspension, for intravenous use or intravesical use
Initial U.S. Approval: 2014
WARNING: SERIOUS CARDIOPULMONARY REACTIONS
See full prescribing information for complete boxed warning.
Serious cardiopulmonary reactions, including fatalities, have occurred uncommonly during or following the injection of ultrasound contrast agents, including sulfur hexafluoride lipid microspheres (5.1). Most serious reactions occur within 30 minutes of administration (5.1).
RECENT MAJOR CHANGES
INDICATIONS AND USAGE
Lumason is an ultrasound contrast agent indicated for use
- in echocardiography to opacify the left ventricular chamber and to improve the delineation of the left ventricular endocardial border in adult patients with suboptimal echocardiograms (1)
- in ultrasonography of the liver for characterization of focal liver lesions in adult and pediatric patients (1)
- in ultrasonography of the urinary tract for the evaluation of suspected or known vesicoureteral reflux in pediatric patients (1)
DOSAGE AND ADMINISTRATION
See Full Prescribing Information for reconstitution instructions (2.3)
For intravenous injection:
- Echocardiography: After reconstitution, administer 2 mL as an intravenous injection in adult patients (2.2, 2.4)
- Ultrasonography of the liver in adults: After reconstitution, administer 2.4 mL as an intravenous injection (2.2, 2.4)
- Ultrasonography of the liver in pediatric patients: After reconstitution, administer 0.03 mL per kg as an intravenous injection, up to a maximum of 2.4 mL per injection (2.2, 2.4)
- May repeat dose one time during a single examination (2.2, 2.4)
- Follow each injection with an intravenous flush of 0.9% Sodium Chloride Injection (2.2, 2.4)
For intravesical administration in pediatric patients:
- Ultrasonography of the urinary tract: After reconstitution, administer 1 mL via sterile 6-8F urinary catheter. Bladder should be first emptied and then partially filled with saline before injection of Lumason (2.2, 2.4)
- After Lumason administration, continue filling the bladder with saline until the patient has the urge to micturate or at the first sign of back pressure to the infusion (2.4)
DOSAGE FORMS AND STRENGTHS
- For injectable suspension: 25 mg of lipid-type A lyophilized powder with headspace fill of 60.7 mg sulfur hexafluoride in a single-patient use vial for reconstitution (3)
- History of hypersensitivity reactions to sulfur hexafluoride lipid microsphere components or to any of the inactive ingredients in Lumason (4)
WARNINGS AND PRECAUTIONS
Most common adverse reactions (incidence ≥ 0.5%) are headache and nausea (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
See 17 for PATIENT COUNSELING INFORMATION.
- FULL PRESCRIBING INFORMATION: CONTENTS*
- Sections or subsections omitted from the full prescribing information are not listed.
- 1 INDICATIONS AND USAGE
- 2 DOSAGE AND ADMINISTRATION
2.1 Important Administration Instructions
Do not administer by intra-arterial injection [see Warnings and Precautions (5.3)].
2.2 Recommended Dosage
The recommended dose of Lumason after reconstitution is 2 mL administered as an intravenous bolus injection during echocardiography. During a single examination, a second injection of 2 mL may be administered to prolong contrast enhancement. Follow each Lumason injection with an intravenous flush using 5 mL of 0.9% Sodium Chloride Injection.
2.3 Reconstitution Instructions
- Inspect the Lumason kit and its components for signs of damage. Do not use the kit if the protective caps on the Lumason vial and prefilled syringe with 5 mL Sodium Chloride 0.9% Injection are not intact or if the kit shows other signs of damage.
- Under aseptic conditions, reconstitute Lumason by injecting the prefilled syringe with 5 mL Sodium Chloride 0.9% Injection into the Lumason vial using the following illustrated steps:
4. Remove the flip cap plastic protective cap from the vial, remove the Mini-Spike spike protection and position the spike in the center of the rubber stopper of the vial. Press firmly inward until the spike is fully inserted in the stopper (see Figure 4).
- Following reconstitution, Lumason suspension contains 1.5 to 5.6 x108 microspheres/mL with 45 mcg/mL of sulfur hexafluoride.
- Use immediately after reconstitution. If the suspension is not used immediately after reconstitution, resuspend the microspheres for a few seconds by hand agitation before the suspension is drawn into the syringe. Reconstituted suspension within a vial may be used for up to 3 hours from the time of its reconstitution. Maintain the vial containing the reconstituted suspension at room temperature.
2.4 Administration Instructions
Inspect visually for particulate matter and discoloration prior to administration, whenever solution and container permit. The reconstituted suspension is milky-white, and does not contain visible particulate matter. Do not use the single-patient use vial for more than one patient.
2.5 Imaging Guidelines
- 3 DOSAGE FORMS AND STRENGTHS
- one Lumason clear vial containing 25 mg of lipid-type A sterile white lyophilized powder with headspace filled with 60.7 mg of sulfur hexafluoride gas
- one prefilled syringe containing 5 mL Sodium Chloride 0.9% Injection, USP (Diluent)
- one Mini-Spike
- 4 CONTRAINDICATIONS
- 5 WARNINGS AND PRECAUTIONS
5.1 Serious Cardiopulmonary Reactions
Serious cardiopulmonary reactions, including fatalities have occurred uncommonly during or shortly following administration of ultrasound contrast agents, including Lumason. These reactions typically occurred within 30 minutes of administration. The risk for these reactions may be increased among patients with unstable cardiopulmonary conditions (acute myocardial infarction, acute coronary artery syndromes, worsening or unstable congestive heart failure, or serious ventricular arrhythmias). Always have cardiopulmonary resuscitation personnel and equipment readily available prior to Lumason administration and monitor all patients for acute reactions.
The reported reactions that may follow the administration of ultrasound contrast agents include: fatal cardiac or respiratory arrest, shock, syncope, symptomatic arrhythmias (atrial fibrillation, tachycardia, bradycardia, supraventricular tachycardia, ventricular fibrillation, and ventricular tachycardia), hypertension, hypotension, dyspnea, hypoxia, chest pain, respiratory distress, stridor, wheezing, loss of consciousness, and convulsions.
5.2 Hypersensitivity Reactions
Hypersensitivity reactions such as skin erythema, rash, urticaria, flushing, throat tightness, dyspnea, or anaphylactic shock have uncommonly been observed following the injection of Lumason. These reactions may occur in patients with no history of prior exposure to sulfur hexafluoride lipid containing microspheres. Always have cardiopulmonary resuscitation personnel and equipment readily available prior to Lumason administration and monitor all patients for hypersensitivity reactions.
5.3 Systemic Embolization
When administering Lumason to patients with cardiac shunt, microspheres can bypass filtering by the lung and enter the arterial circulation. Assess patients with shunts for embolic phenomena following Lumason administration. Lumason is only for intravenous and/or intravesical administration; do not administer Lumason by intra-arterial injection [see Dosage and Administration (2.1)].
5.4 Ventricular Arrhythmia Related to High Mechanical Index
High ultrasound mechanical index values may cause microsphere cavitation or rupture and lead to ventricular arrhythmias. Additionally, end-systolic triggering with high mechanical indices has been reported to cause ventricular arrhythmias.
- 6 ADVERSE REACTIONS
- Severe cardiopulmonary reactions [see Warnings and Precautions (5.1)]
- Hypersensitivity reactions [see Warnings and Precautions (5.2)]
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.
In completed clinical trials, a total of 6984 adult subjects (128 healthy volunteers and 6856 patients) received Lumason at cumulative doses ranging from 0.2 to 161 mL (mean 9.8 mL). Lumason was administered mainly as single or multiple injections; however, some subjects received infusion dosing. The majority (75%) of subjects received Lumason at cumulative doses of 10 mL or less. There were 64% men and 36% women, with an average age of 59 years (range 17 to 99 years). A total of 79% subjects were Caucasian; 4% were Black; 16% were Asian; <1% were Hispanic; and <1% were in other racial groups or race was not reported.
In the clinical trials, serious adverse reactions were observed in 2 subjects; one who experienced a hypersensitivity-type rash and presyncope and another who experienced anaphylactic shock shortly following Lumason administration.
*occurring in at least 0.2% of patients Table 1. Adverse Reactions in Patients*
n = 6856
Number (%) of Patients with Adverse Reactions 340 (5%) Headache 65 (1%) Nausea 37 (0.5%) Dysgeusia 29 (0.4%) Injection site pain 23 (0.3%) Feeling Hot 18 (0.3%) Chest discomfort 17 (0.2%) Chest pain 12 (0.2%) Dizziness 11 (0.2%) Injection Site Warmth 11 (0.2%)
6.2 Postmarketing Experience
In the international postmarketing clinical experience and on-going clinical trials, serious adverse reactions have uncommonly been reported following administration of Lumason. 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. The serious adverse reactions include fatalities, especially in a pattern of symptoms suggestive of anaphylactoid/hypersensitivity reactions. Other serious reactions included arrhythmias and hypertensive episodes. These reactions typically occurred within 30 minutes of Lumason administration.
The risk for serious cardiopulmonary reactions may be increased among patients with unstable cardiopulmonary conditions (acute myocardial infarction, acute coronary artery syndromes, worsening or unstable congestive heart failure, or serious ventricular arrhythmias [see Warnings and Precautions (5.1]).
- 8 USE IN SPECIFIC POPULATIONS
There are no data with Lumason use in pregnant women to inform any drug-associated risks. No adverse developmental outcomes were observed in animal reproduction studies with administration of sulfur hexafluoride lipid-type A microspheres in pregnant rats and rabbits during organogenesis at doses up to at least 10 and 20 times, respectively, the maximum human dose of 4.8 mL based on body surface area (see Data).
Lumason was administered intravenously to rats at doses of 0.2, 1, and 5 mL/kg (approximately 0.4, 2, and 10 times the recommended maximum human dose of 4.8 mL, respectively, based on body surface area); Lumason doses were administered daily for about 30 consecutive days, from two weeks before pairing until the end of organogenesis. Lumason was administered intravenously to rabbits at doses of 0.2, 1, and 5 mL/kg (approximately 0.8, 4, and 20 times the recommended maximum human dose, respectively, based on body surface area); Lumason doses were administered daily from gestation day 6 to day 19 inclusive. No significant findings on the fetus were observed.
There are no data on the presence of Lumason in human milk, the effects on the breastfed infant, or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Lumason and any potential adverse effects on the breastfed infant from Lumason or from the underlying maternal condition.
8.4 Pediatric Use
8.5 Geriatric Use
Of the total number of 6179 6856 adult patients in clinical studies of Lumason, 39% were 65 and over, while 11% were 75 and older. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly or younger patients, but greater sensitivity of some older individuals cannot be ruled out.
- 11 DESCRIPTION
Lumason (sulfur hexafluoride lipid-type A microspheres) for injectable suspension, for intravenous or intravesical use is used to prepare the ultrasound contrast agent. The single-patient use kit contains the following three items:
- one clear glass 10 mL vial containing 25 mg of lyophilized powder lipid-type A, 60.7 mg of sulfur hexafluoride gas and capped with a blue flip-cap
- one prefilled syringe containing 5 mL Sodium Chloride 0.9% Injection, USP (Diluent)
- one Mini-Spike
Each vial is formulated as a 25 mg sterile, pyrogen-free lyophilized powder containing 24.56 mg of polyethylene glycol 4000, 0.19 mg of distearoylphosphatidyl-choline (DSPC), 0.19 mg of dipalmitoylphosphatidylglycerol sodium (DPPG-Na) and 0.04 mg of palmitic acid. The headspace of each vial contains 6.07 mg/mL (± 2 %) sulfur hexafluoride, SF6, or 60.7 mg per vial.
Each milliliter of reconstituted Lumason suspension contains 1.5 to 5.6 x108 microspheres, 68 mcg SF6 (12 mcL), 0.038 mg DSPC, 0.038 mg DPPG-Na, 4.91 mg polyethylene glycol 4000 and 0.008 mg palmitic acid. The sulphur hexafluoride associated with the microspheres suspension is 45 mcg/mL. Fifteen to twenty three percent of the total lipids in the suspension are associated with the microspheres.
Table 2. Microsphere Characteristics Mean diameter range 1.5 – 2.5 µm Percent of microspheres ≤ 10 µm ≥ 99% Upper size limit 100.0% ≤ 20 µm
- 12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Within the blood, the acoustic impedance of Lumason microspheres is lower than that of the surrounding non-aqueous tissue. Therefore, an ultrasound beam is reflected from the interface between the microspheres and the surrounding tissue. The reflected ultrasound signal provides a visual image that shows a contrast between the blood and the surrounding tissues.
Lumason provides useful echocardiographic signal intensity for two minutes after the injection. Lumason microspheres are destroyed and contrast enhancement decreases as the mechanical index increases (values of 0.8 or less are recommended).
The pharmacokinetic of the SF6 gas component of Lumason was evaluated in 12 healthy adult subjects. After intravenous bolus injections of 0.03 mL/kg and 0.3 mL/kg of Lumason, corresponding to approximately 1 and 10 times the recommended doses, concentrations of SF6 in blood peaked within 1 to 2 minutes for both doses. The terminal half-life of SF6 in blood was approximately 10 minutes for the 0.3 mL/kg dose. The area-under-the-curve of SF6 was dose-proportional over the dose range studied.
In a study of healthy subjects, the mean values for the apparent steady-state volume of distribution of SF6 following intravenous administration, were 341 mcL and 710 mcL for Lumason doses of 0.03 mL/kg and 0.3 mL/kg, respectively. Preferential distribution to the lung is likely responsible for these values.
Following intravenous administration, the SF6 component of Lumason is eliminated via the lungs. In a clinical study that examined SF6 elimination twenty minutes following Lumason injection, the mean cumulative recovery of SF6 in expired air was 82 ± 20% (SD) at the 0.03 mL/kg dose and 88 ± 26% (SD) at the 0.3 mL/kg dose.
SF6 undergoes first pass elimination within the pulmonary circulation; approximately 40% to 50% of the SF6 content was eliminated in the expired air during the first minute following Lumason injection.
In a study of patients with pulmonary impairment, blood concentrations of SF6 peaked at 1 to 4 minutes following Lumason administration. The cumulative recovery of SF6 in expired air was 102 ± 18% (mean ± standard deviation), and the terminal half-life of SF6 in blood was similar to that measured in healthy subjects.
- 13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
No long-term animal studies were performed to evaluate the carcinogenic potential of Lumason. No evidence of genotoxicity was found in the following studies conducted with Lumason: 1) a bacterial mutagenesis (Ames) assay, 2) an in vitro human lymphocyte chromosome aberration assay, and 3) an in vivo mouse micronucleus assay.
- 14 CLINICAL STUDIES
A total of 191 patients with suspected cardiac disease and suboptimal non-contrast echocardiography received Lumason in three multi-center controlled clinical trials (76 patients in Study A, 62 patients in Study B, and 53 patients in Study C). Among these patients, there were 127 men and 64 women. The mean age was 59 years (range 22 to 96 years). The racial and ethnic representations were 79% Caucasian, 16% Black, 4% Hispanic, < 1% Asian, and < 1% other racial or ethnic groups. The mean weight was 204 lbs (range 92 to 405 lbs). Approximately 20% of the patients had a chronic pulmonary disorder and 30% had a history of heart failure. Of the 106 patients for whom a New York Heart Association (NYHA) classification of heart failure was assigned, 49% were Class I, 33% were Class II, and 18% were Class III. Patients with NYHA Class IV heart failure were not included in these studies.
In Studies A and B, each patient received four intravenous bolus injections of Lumason (0.5, 1, 2, and 4 mL), in randomized order. In Study C, each patient received two doses of Lumason (1 mL and 2 mL) in randomized order. All three studies assessed endocardial border delineation and left ventricular opacification. For each patient in each study, echocardiography with Lumason was compared to non-contrast (baseline) echocardiography. A recording of 2D echocardiography was obtained from 30 seconds prior to each injection to at least 15 minutes after dosing or until the disappearance of the contrast effect, whichever was longer. Contrast and non-contrast echocardiographic images for each patient were evaluated by two independent reviewers, who were blinded to clinical information and the Lumason dose. Evaluation of left ventricular endocardial border consisted of segment based assessment involving six endocardial segments and using two apical views (2- and 4chamber views).
In all three studies, administration of Lumason improved left ventricular endocardial border delineation. The majority of the patients who received a 2.0 mL dose of Lumason had improvement in endocardial border delineation manifested as visualization of at least two additional endocardial border segments. Table 3 demonstrates the improvement in endocardial border delineation following Lumason administration as a reduction in percentage of patients with inadequate border delineation in at least one pair of adjacent segments (combined 2-chamber and 4-chamber view). The results are shown by reader.
Table 3. Reduction in Percentage of Patients with Inadequate Border Delineation Reader Study A
N = 76
N = 62
N = 53
Non-contrast Lumason Non-contrast Lumason Non-contrast Lumason A 60 (79%) 22 (33%) 31 (50%) 12 (19%) 12 (23%) 10 (19%) B 62 (82%) 29 (37%) 54 (87%) 6 (10%) 45 (85%) 20 (38%)
In all three studies, complete left ventricular opacification was observed in 52% to 80% of the patients following administration of a 2.0-mL dose of Lumason. The studies did not sufficiently assess the effect of Lumason upon measures of left ventricular ejection fraction and wall motion.
14.2 Ultrasonography of the Liver
Table 4. Diagnostic Performance of Lumason Ultrasound for Characterization of Focal Liver Lesions Study A: Sensitivity (patients with malignant lesions)
Specificity (patients with benign lesions)
Reader 1 87* 49 38 (30, 54) 71 63 8 (-4, 21) Reader 2 76* 35 41 (29, 52) 83* 54 29 (21, 44) Reader 3 92* 16 76 (67, 84) 73* 22 51 (40, 61) Study B: Sensitivity (patients with malignant lesions)
Specificity (patients with benign lesions)
Reader 4 65 53 12 (-1, 23) 72* 24 48 (35, 58) Reader 5 61* 41 20 (7, 32) 67* 7 60 (50, 70) Reader 6 47 66 -19 (-31, -7) 88* 59 29 (18, 40) * Statistically significant improvement from non-contrast (p<0.05 based on McNemar’s test)
- 16 HOW SUPPLIED/STORAGE AND HANDLING
- One Lumason vial of 25 mg lipid-type A white lyophilized powder with headspace fill of 60.7 mg of sulfur hexafluoride
- One prefilled syringe containing 5mL of Sodium Chloride 0.9% Injection, USP (Diluent)
- One Mini-Spike
- 17 PATIENT COUNSELING INFORMATION
- PRINCIPAL DISPLAY PANEL
- PRINCIPAL DISPLAY PANEL
- PRINCIPAL DISPLAY PANEL
- INGREDIENTS AND APPEARANCE
sulfur hexafluoride kit
Product Information Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:68155-099 Packaging # Item Code Package Description Marketing Start Date Marketing End Date 1 NDC:68155-099-16 5 in 1 BOX 01/15/2015 1 1 in 1 KIT; Type 1: Convenience Kit of Co-Package Quantity of Parts Part # Package Quantity Total Product Quantity Part 1 1 VIAL 25 mg Part 2 1 SYRINGE 5 mL Part 1 of 2 LUMASON
sulfur hexafluoride injection, powder, lyophilized, for suspension
Product Information Route of Administration INTRAVENOUS, INTRAVESICAL Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength SULFUR HEXAFLUORIDE (UNII: WS7LR3I1D6) (SULFUR HEXAFLUORIDE - UNII:WS7LR3I1D6) SULFUR HEXAFLUORIDE 60.7 mg in 1 mg DISTEAROYLPHOSPHATIDYLCHOLINE, DL- (UNII: EAG959U971) (DISTEAROYLPHOSPHATIDYLCHOLINE, DL- - UNII:EAG959U971) DISTEAROYLPHOSPHATIDYLCHOLINE, DL- .19 mg in 1 mg SODIUM 1,2-DIPALMITOYL-SN-GLYCERO-3-PHOSPHO-(1'-RAC-GLYCEROL) (UNII: 841B886EJ7) (SODIUM 1,2-DIPALMITOYL-SN-GLYCERO-3-PHOSPHO-(1'-RAC-GLYCEROL) - UNII:841B886EJ7) SODIUM 1,2-DIPALMITOYL-SN-GLYCERO-3-PHOSPHO-(1'-RAC-GLYCEROL) .19 mg in 1 mg Inactive Ingredients Ingredient Name Strength POLYETHYLENE GLYCOL 4000 (UNII: 4R4HFI6D95) 24.56 mg in 1 mg PALMITIC ACID (UNII: 2V16EO95H1) .04 mg in 1 mg Packaging # Item Code Package Description Marketing Start Date Marketing End Date 1 25 mg in 1 VIAL; Type 1: Convenience Kit of Co-Package Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date NDA NDA203684 01/15/2015 Part 2 of 2 DILUENT
sodium chloride 0.9% injection,usp injection
Product Information Route of Administration INTRAVENOUS, INTRAVESICAL Inactive Ingredients Ingredient Name Strength SODIUM CHLORIDE (UNII: 451W47IQ8X) .9 mg in 1 mL Packaging # Item Code Package Description Marketing Start Date Marketing End Date 1 5 mL in 1 SYRINGE; Type 1: Convenience Kit of Co-Package Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date NDA NDA203684 01/15/2015 Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date NDA NDA203684 01/15/2015 Labeler - Bracco Suisse SA (485635705) Registrant - Bracco Suisse SA (485635705) Establishment Name Address ID/FEI Business Operations Vetter Pharma-Fertigung GmbH & Co. KG 316126754 MANUFACTURE(68155-099) Establishment Name Address ID/FEI Business Operations Bracco Suisse SA 485635705 MANUFACTURE(68155-099) , ANALYSIS(68155-099)