Flutemetamol

12.1 Mechanism of Action Flutemetamol F 18 binds to amyloid beta plaques in the brain and the F 18 isotope produces a positron signal that is detected by a PET scanner. In in vitro binding studies using postmortem human brain homogenates containing fibrillar amyloid beta, the dissociation constant (Kd) for flutemetamol was 6.7 nM. Selectivity of 3 H-flutemetamol binding in postmortem human brain sections was demonstrated using autoradiography, silver-stained protein, and immunohistochemistry (monoclonal antibody to amyloid beta) correlation studies.

1 INDICATIONS AND USAGE VIZAMYL is indicated for positron emission tomography (PET) of the brain to estimate amyloid beta neuritic plaque density in adults with cognitive impairment for: Evaluation of Alzheimer's disease (AD) and other causes of cognitive decline Selection of patients who are indicated for amyloid beta-directed therapy as described in the prescribing information of the therapeutic products VIZAMYL is a radioactive diagnostic drug indicated for positron emission tomography (PET) of the brain to estimate amyloid beta neuritic plaque density in adults with cognitive impairment for: Evaluation of Alzheimer's disease (AD) and other causes of cognitive decline Selection of patients who are indicated for amyloid beta-directed therapy as described in the prescribing information of the therapeutic products ( 1 )

2 DOSAGE AND ADMINISTRATION The recommended amount of radioactivity is 185 MBq (5 mCi) administered as a single intravenous bolus within 40 seconds in a total volume of up to 10 mL. ( 2.2 ) Follow injection with an intravenous flush of 5 mL to 15 mL of 0.9% sodium chloride injection. ( 2.2 ) Obtain 10-minute to 20-minute PET images starting approximately 60 minutes to 120 minutes after drug administration. ( 2.3 ) See full prescribing information for image interpretation and radiation dosimetry. ( 2.4 , 2.5 , 2.6 ) 2.1 Radiation Safety - Drug Handling Handle VIZAMYL with appropriate safety measures to minimize radiation exposure during administration [see Warnings and Precautions (5.3) ] . Use waterproof gloves and effective radiation shielding, including lead-glass syringe shields when handling and administering VIZAMYL. Radiopharmaceuticals, including VIZAMYL, should be used by or under the control of healthcare providers who are qualified by specific training and experience in the safe use and handling of radionuclides, and whose experience and training have been approved by the appropriate governmental agency authorized to license the use of radionuclides. 2.2 Recommended Dosage and Administration Instructions Recommended Dosage The recommended amount of activity of VIZAMYL is 185 MBq (5 mCi) in a total volume of up to 10 mL, administered as a single intravenous bolus within 40 seconds. The maximum mass dose is 20 mcg. Follow the injection with an intravenous flush of 5 mL to 15 mL of 0.9% sodium chloride injection. Patient Preparation Instruct patients to hydrate before and after VIZAMYL administration and to void frequently following VIZAMYL administration to reduce radiation exposure [see Warnings and Precautions (5.3) ] . Administration Use aseptic technique and radiation shielding to withdraw and administer VIZAMYL. Visually inspect VIZAMYL for particulate matter and discoloration prior to administration. Do not use VIZAMYL if it contains particulate matter or if it is discolored. Do not dilute VIZAMYL. Calculate the necessary volume to administer based on calibration time and required dose. Measure the activity of VIZAMYL with a dose calibrator immediately prior to administration to the patient. Dispose of unused product in a safe manner in compliance with applicable regulations. 2.3 Image Acquisition Instructions Position the patient supine with the head positioned to center the brain, including the cerebellum, within a single field of view. The patient's head should be tilted so that the anterior commissure-posterior commissure (AC-PC) plane is at right angles to the bore-axis of the PET scanner, with the head positioned in a suitable head support. Tape or other flexible head restraints may be employed to reduce head movement. Acquire 10-minute to 20-minute PET images starting 60 minutes to 120 minutes after VIZAMYL administration using a PET scanner in 3-D mode with appropriate data corrections. Iterative or filtered back-projection reconstruction is recommended with a slice thickness of 2 mm to 4 mm, and matrix size of 128 × 128 with pixel sizes of approximately 2 mm. Where a post-smoothing filter is applied, full width at half maximum (FWHM) of not more than 5 mm is recommended; filter FWHM should be chosen to optimize the signal-to-noise ratio while preserving the sharpness of the reconstructed image. 2.4 Image Orientation and Display Image Orientation Orient axial and coronal images to show symmetry of brain structures, with equal heights of structures bilaterally. Orient sagittal images so that the head and neck are neither flexed nor extended; the anterior and posterior aspects of the corpus callosum should be parallel to the AC-PC line as shown in Figure 2. Image Display Display images with all planes (axial, sagittal, and coronal planes) linked by crosshairs. Select a color scale that provides a progression of low through high intensity (e.g., rainbow or Sokoloff). The selected color scale should: (1) provide colors that allow the reader to discriminate signal intensity above and below the signal intensity of the pons; (2) provide a color for regions with little or no amyloid binding such as the cerebellar cortex; and (3) provide a range of at least five distinct colors above 50% to 60% of the peak signal intensity. Display the reference scale. Adjust the color scale to set the pons to approximately 90% maximum signal intensity. The cerebellar cortex should represent approximately 20% to 30% of peak signal intensity on both negative and positive VIZAMYL scans. Display axial brain slices sequentially from the bottom of the brain to the top and look for signs of atrophy. Systematically review signal intensity in the following brain regions (recommended plane) for image interpretation [see Dosage and Administration (2.5) ] : Frontal lobes (axial, with optional sagittal plane view) Posterior cingulate and precuneus (sagittal, with optional coronal plane view) Lateral temporal lobes (axial,

6 ADVERSE REACTIONS The following clinically significant adverse reaction is described elsewhere in the labeling: Hypersensitivity Reactions [see Warnings and Precautions (5.1) ] Most common adverse reactions (incidence ≥ 1%) were flushing, increased blood pressure, headache, nausea, and dizziness. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact GE HealthCare at 1-800-654-0118 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 clinical practice. The safety of VIZAMYL was evaluated in 761 adult subjects who received VIZAMYL by intravenous injection in clinical trials. Most subjects (70%) received a dose of 185 MBq (5 mCi). The subjects had a mean age of 62 years (range 18 years to 93 years); 45% of the subjects were male and 91% were White. A serious hypersensitivity reaction characterized by flushing, dyspnea, and chest pressure was reported within minutes following VIZAMYL administration in one subject who recovered with treatment. Adverse reactions reported in ≥ 1% of subjects from the clinical trials are shown in Table 2. Table 2: Adverse Reactions Reported in ≥ 1% of Adult Subjects Who Received VIZAMYL in Clinical Trials Adverse Reaction VIZAMYL N=761 % Flushing 2 Increased blood pressure 2 Headache 1 Nausea 1 Dizziness 1 6.2 Postmarketing Experience The following adverse reactions have been identified during postapproval use of VIZAMYL. 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. Immune system disorders : anaphylactic reactions