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Sodium Pertechnetate Tc 99m (Systemic)

VA CLASSIFICATION
Primary: DX201


Note: For information on sodium pertechnetate Tc 99m injection for intraurethral administration, see Sodium Pertechnetate Tc 99m (Mucosal-Local) .
For information on sodium pertechnetate Tc 99m injection for ophthalmic administration, see Sodium Pertechnetate Tc 99m (Ophthalmic) .



Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).



Category:


Diagnostic aid, radioactive (vascular disorders; brain disorders; thyroid disorders; salivary gland disorders; cardiac disorders; gastrointestinal disorders)—

Indications

Note: Bracketed information in the Indications section refers to uses that are not included in U.S. product labeling.

Accepted

Blood pool imaging, radionuclide—Sodium pertechnetate Tc 99m is indicated for blood pool imaging, especially radionuclide angiography. ^{{01} {02} {04} {05} {06} {37}}

Brain imaging, radionuclide and
Angiography, cerebral, radionuclide—Sodium pertechnetate Tc 99m is indicated for brain imaging, including cerebral radionuclide angiography. It is used to screen patients for primary brain tumors, to detect cerebral metastases, to evaluate patients with cerebrovascular disease, to localize arteriovenous malformations, to detect intracranial injury due to trauma, to localize intracranial abscesses, and to monitor patients with intracranial diseases. ^{{01} {02} {04} {05} {06} {36}} However, this procedure has been almost entirely replaced by other imaging procedures, including computed tomography (CT) and magnetic resonance imaging (MRI). ^{37}

Thyroid imaging, radionuclide—Sodium pertechnetate Tc 99m is indicated for thyroid imaging in the evaluation of thyroid nodules; carcinoma; and masses in the lingual region, neck, and mediastinum; and to study thyroid size, position, and function. Sodium pertechnetate Tc 99m may be preferred over the radioiodine study in thyroid scanning in cases in which the radioiodine is unsuccessful because of poor uptake, in children to reduce radiation exposure, and when results of the procedure are needed as soon as possible. ^{36} However, sodium iodide I 131 or I 123 may be preferred over sodium pertechnetate Tc 99m for characterizing the function of thyroid nodules or for detecting substernal or lingual thyroids. ^{{01} {02} {04} {05} {06} {07} {37}}

Salivary gland imaging, radionuclide—Sodium pertechnetate Tc 99m is indicated in adult patients for salivary gland imaging as an adjunct in the evaluation of space-occupying lesions and in the evaluation of the size, position, and function of the gland. ^{{02} {04} {05} {06}}

Placenta localization—Sodium pertechnetate Tc 99m is indicated for placenta localization. However, this procedure has generally been replaced by ultrasound procedures. ^{{05} {37}}

[Gastric mucosa imaging, radionuclide]¹—Sodium pertechnetate Tc 99m is used to localize Meckel's diverticula. ^{{08} {25} {27}}

[Red blood cells, labeling of]¹—Sodium pertechnetate Tc 99m is used for in vitro or in vivo labeling of red blood cells (which have been pretreated with stannous ion). Red blood cells labeled with sodium pertechnetate Tc 99m are used for the following diagnostic studies:^{30}
Cardiac blood pool imaging, radionuclide—To evaluate cardiac function, including measurement of cardiac output, ejection fraction, and wall motion. ^{{08} {25}}

Bleeding, gastrointestinal (diagnosis)—To evaluate patients suspected of having gastrointestinal bleeding, to detect the site of bleeding and help establish the amount of bleeding. ^{{12} {13} {21} {25} {34}}

¹ Not included in Canadian product labeling.

Physical Properties

Nuclear data: ^{{05} {06} {18}}

Radionuclide (half-life)	Decay constant	Mode of decay	Principal photon emissions (keV)	Mean number of emissions/ disintegration (³0.01)
Tc 99m (6.0 hr)	0.1151 hr -1	Isomeric transition to Tc 99	Gamma (18)	0.062
			Gamma (140.5)	0.891

Pharmacology/Pharmacokinetics

Mechanism of action/Effect:

Vascular disorders—Pertechnetate Tc 99m remains in the intravascular space long enough to allow external detection for the evaluation of blood flow patterns in brain or in other regions of the body, or to allow the depiction of the large blood pool in the heart or major vessels. ^{{19} {37}}

Brain disorders—The mechanism by which pertechnetate Tc 99m accumulates in the abnormal areas of the brain is not precisely known but is most likely related to a change in the blood-brain barrier permeability. ^{{05} {19} {33} {37}}

Thyroid disorders—Pertechnetate Tc 99m is handled by the body in a way similar to the iodide ion. Pertechnetate Tc 99m is trapped by the thyroid (but not organified) and remains in the gland long enough for images to be obtained. ^{{05} {19} {37}}

Salivary gland disorders—Exact mechanism of action is unknown. However, pertechnetate Tc 99m is handled by the body in a way similar to the iodide ion and, since radioiodine is known to concentrate in the duct cells of the salivary glands, this is also probably true for pertechnetate Tc 99m. The accumulation in the glands is sufficient to allow images to be obtained. ^{{14} {19} {37}}

Gastrointestinal disorders—Meckel's diverticula: Following intravenous injection, sodium pertechnetate Tc 99m binds to albumin in the serum. It is then handled by the body in a way similar to that for chloride ions by the gastric mucosa, which concentrates and secretes sodium pertechnetate Tc 99m.

Red blood cells, labeling of—When used for cardiac blood pool imaging or detection of gastrointestinal bleeding, pretreatment of red blood cells with stannous ions causes Tc 99m (as sodium pertechnetate Tc 99m) to bind to the red blood cells in vivo with about 70 to 80% of the injected radioactivity remaining in the blood pool long enough to provide images of the cardiac chambers or sites of active (rapid) or cumulative (intermittent) gastrointestinal bleeding. ^{36} A modified in vivo/in vitro ^{{08} {25}} method of labeling red blood cells usually results in a greater percentage of the injected radioactivity remaining in the blood pool.

Placenta localization—The large pool of maternal blood in the placenta accumulates more radionuclide than the surrounding less vascular structures (i.e., fetus and uterus). The accumulation is sufficient to allow images to be obtained. ^{19}

Absorption:

Oral—Usually well absorbed from gastrointestinal tract; may be incomplete in some patients. ^{{06} {15}}

Distribution:

Intravenous or oral—Selectively concentrated in intracranial lesions with altered blood-brain barrier, thyroid gland, salivary glands, stomach and intestines, and choroid plexus; remainder distributed within circulatory system and extracellular spaces. ^{{05} {06} {14} {15} {37}}

Protein binding:

High (75% of plasma radioactivity is loosely bound). ^{{06} {15}}

Half-life:
^{06}{15}

Elimination ₁:

Blood: 10 minutes.

Cerebrospinal fluid (CSF): < 1 hour.



Elimination ₂:

Blood: 6 hours.

CSF: 11 to 12 hours.


Time to peak concentration:


Oral:

Blood: 1 to 3 hours.



Intravenous:

CSF: 31/2 hours.

Thyroid (euthyroid patients): 15 minutes to 2 hours.


Radiation dosimetry:
^{31}

Organ	Estimated absorbed radiation dose*
	Without blocking agent		With blocking agent
	mGy/ MBq	rad/ mCi	mGy/ MBq	rad/ mCi
Large intestine wall (upper)	0.062	0.23	0.0032	0.012
Thyroid	0.023	0.085	0.021	0.078
Stomach wall	0.029	0.11	0.0032	0.012
Large intestine wall (lower)	0.022	0.08	0.0045	0.017
Bladder wall	0.019	0.07	0.032	0.12
Small intestine	0.018	0.067	0.0041	0.015
Ovaries	0.01	0.037	0.0047	0.017
Salivary glands	0.0093	0.034
Uterus	0.0081	0.03	0.0066	0.024
Red marrow	0.0061	0.023	0.0045	0.017
Pancreas	0.0059	0.022	0.0035	0.013
Kidneys	0.005	0.019	0.0047	0.017
Spleen	0.0044	0.016	0.0032	0.012
Liver	0.0039	0.014	0.0031	0.011
Bone surfaces	0.0039	0.014	0.0038	0.014
Adrenals	0.0036	0.013	0.0033	0.012
Lungs	0.0027	0.01	0.0028	0.01
Testes	0.0027	0.01	0.0032	0.012
Breast	0.0023	0.0085	0.0025	0.0093
Other tissue	0.0034	0.013	0.0029	0.011

Radionuclide	Effective dose*
	Without blocking agent		With blocking agent
	mSv/ MBq	rem/ mCi	mSv/ MBq	rem/ mCi
Tc 99m	0.013	0.048	0.0053	0.020

^* For adults; intravenous injection of sodium pertechnetate Tc 99m. Data based on the International Commission on Radiological Protection (ICRP) Publication 53—Radiation dose to patients from radiopharmaceuticals. ^{31}

Elimination:


Oral or intravenous ^{{06} {15}}—
        Renal: Primary, 15 to 50% of administered Tc 99m is eliminated within 24 hours. ^{{36} {37}}
        Fecal: Secondary, 10 to 55% of administered Tc 99m is eliminated in the feces within 3 days. ^{{06} {37} {38}}



Precautions to Consider

Pregnancy/Reproduction

Pregnancy—
Tc 99m as sodium pertechnetate crosses the placenta. The possibility of pregnancy should be assessed in women of child-bearing potential. Clinical situations exist in which the benefit to the patient and fetus derived from information from radiopharmaceutical use outweighs the risks from fetal exposure to radiation. In these situations, the physician should use discretion and reduce the radiopharmaceutical dose to the lowest possible amount. ^{23}

Studies have not been done in animals.

FDA Pregnancy Category C. ^{{05} {33}}

Breast-feeding

Tc 99m as sodium pertechnetate is distributed into breast milk. It has been estimated that after a 24-hour discontinuation of breast-feeding, the breast-fed infant's exposure to radiation will be less than 20 mrems after a 20-millicurie dose of sodium pertechnetate Tc 99m. Accordingly, discontinuation of breast-feeding for 24 hours is generally recommended for this radiopharmaceutical. If the patient wishes further guidance concerning her individual circumstances, the activity in breast milk can be measured and the radiation dose to the infant estimated to determine how long discontinuation of breast-feeding is appropriate. ^{{20} {25} {26}}

Pediatrics

Diagnostic studies performed to date using sodium pertechnetate Tc 99m have not demonstrated pediatrics-specific problems that would limit its usefulness in children. When this radiopharmaceutical is used in children, as with other groups of patients, the diagnostic benefit should be judged to outweigh the potential risk of radiation. ^{37}

For brain or blood pool imaging, potassium perchlorate should be administered prior to sodium pertechnetate Tc 99m, in order to minimize thyroidal uptake. ^{{02} {04} {06}}


Geriatrics


Appropriate studies on the relationship of age to the effects of sodium pertechnetate Tc 99m have not been performed in the geriatric population. However, no geriatrics-specific problems have been documented to date. ^{21}

Drug interactions and/or related problems
See Diagnostic interference .

Diagnostic interference
The following have been selected on the basis of their potential clinical significance (possible effect in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):

With results of brain imaging

Due to other medications
Antacids, aluminum-containing    (prior administration of aluminum-containing antacids may decrease uptake of sodium pertechnetate Tc 99m in brain lesions ^{14})


Antineoplastics, especially intrathecally-administered    (chemotherapeutic neurotoxicity may result in patchy increased brain uptake or localization in ventricles or meninges ^{{14} {37}})


Corticosteroids, glucocorticoid    (concurrent use may decrease brain tumor or abscess uptake of sodium pertechnetate Tc 99m because of reduced peritumor edema caused by large doses of the steroid ^{14})


Technetium Tc 99m pyrophosphate    (brain scan may give either false-positive or false-negative results when performed after a bone scan using technetium Tc 99m pyrophosphate that contains stannous ions; to avoid false results, brain scan may be performed prior to bone scan or with a brain imaging agent other than sodium pertechnetate Tc 99m ^{03})

With results of thyroid uptake tests and thyroid imaging

Due to other medications
Antacids, aluminum-containing or^{14}
Amiodarone or^{37}
Antithyroid agents—thioamide derivatives or aromatic preparations or^{08}{14}{30}
Contrast media, iodinated or^{30}
Corticosteroids or^{08}{14}
Goitrogenic foods (e.g., cabbage, turnips) or^{30}
Iodine-containing foods or^{08}{14}
Iodine-containing preparations or^{08}{14}{30}
Iodine-contaminated bromides or
Iodine, stable or^{08}
Monovalent anions (e.g., perchlorate, thiocyanate) or^{30}
Pyrazolone derivatives, such as oxyphenbutazone and phenylbutazone or^{14}
Salicylates, chronic administration of, or^{08}{14}
Salt, iodized, excessive intake of or^{14}
Thiopental or^{14}
Thyroid blocking agents, such as strong iodine solution, potassium iodide, or potassium perchlorate or^{08}{30}
Thyroid preparations, natural or synthetic^{08}{14}{30}    (may decrease thyroidal uptake of pertechnetate ion)

    (a rebound effect may occur following the sudden withdrawal of antithyroid preparations, resulting in a period of up to 5 days of very high thyroidal uptake ^{14})

    (a rebound effect may also occur when discontinuing salicylate therapy, resulting in a period of 3 to 10 days of increased thyroidal uptake)

With results of salivary gland imaging

Due to other medications
Perchlorate or^{14}
Sodium iodide I 131, therapeutic^{14}    (may decrease salivary uptake of pertechnetate ion)

With results of gastric mucosa imaging

Due to other medications
Antacids, aluminum-containing    (prior administration of aluminum-containing antacids may decrease stomach uptake and urinary excretion of sodium pertechnetate Tc 99m and thus interfere with Meckel's diverticula evaluation ^{{14} {37}})


Perchlorate    (may decrease gastric uptake of sodium pertechnetate Tc 99m if given prior to imaging of Meckel's diverticulum ^{14})

With results of cardiac blood pool imaging and diagnosis of gastrointestinal bleeding using Tc 99m-labeled red blood cells

Due to other medications
Digoxin or
Doxorubicin or
Heparin sodium or
Hydralazine or
Methyldopa or
Prazosin or
Propranolol or
Quinidine or
Radiopaque agents, water-soluble organic iodides, with intravascular administration    (these medications may impair blood pool imaging by decreasing the labeling efficiency of red blood cells ^{{14} {16} {17} {30} {32} {35}})


Due to medical problems or conditions
Goiter, toxic diffuse or
Hyperthyroidism    (thyroid uptake may be increased ^{29})


Lupus erythematosus    (labeling of red blood cells may be decreased ^{29})


Transfusion-induced reaction    (labeling efficiency may be decreased because of red blood cell antibody formation ^{29})


Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).

See also Diagnostic interference .

Risk-benefit should be considered when the following medical problem exists
Sensitivity to the radiopharmaceutical preparation^{03}


Side/Adverse Effects
The following side/adverse effects have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses where appropriate)—not necessarily inclusive:

Those indicating need for medical attention
Incidence less frequent or rare
    
Allergic reaction (skin rash, hives, or itching^{05}{10})





Patient Consultation
As an aid to patient consultation, refer to Advice for the Patient, Radiopharmaceuticals (Diagnostic).

In providing consultation, consider emphasizing the following selected information (» = major clinical significance):

Description of use

Actions in the body
Concentration of pertechnetate Tc 99m in intravascular spaces, in abnormal areas of brain, in thyroid, salivary glands, and stomach tissue allows visualization of these areas

Distribution in body of injected radioactive red blood cells same as normal red blood cells

Small amounts of radioactivity used in diagnosis; radiation exposure is low and considered safe

Before having this test
»   Conditions affecting use, especially:
Sensitivity to the radiopharmaceutical preparation

Pregnancy—Sodium pertechnetate Tc 99m crosses placenta; risk to fetus from radiation exposure as opposed to benefit derived from use should be considered





Breast-feeding—Tc 99m as sodium pertechnetate distributed into breast milk; discontinuation of nursing for 24 hours recommended to decrease possibility of risk to infant from radiation exposure





Use in children—Possible risk of radiation exposure as opposed to benefit derived from use should be considered


Preparation for this test
Special preparatory instructions may be given; patient should inquire in advance

Fasting for 6 hours before administration (oral only)

Fasting for 8 to 12 hours before Meckel's diverticulum imaging

Precautions after having this test
Fasting for 2 hours after administration (oral only)


Side/adverse effects
Signs of potential side effects, especially allergic reaction


General Dosing Information
Radiopharmaceuticals are to be administered only by or under the supervision of physicians who have had extensive training in the safe use and handling of radioactive materials and who are authorized by the Nuclear Regulatory Commission (NRC) or the appropriate Agreement State agency, if required, or, outside the U.S., the appropriate authority. ^{{24} {37}}

Sodium pertechnetate Tc 99m is usually administered intravenously but may be given orally, except for cystography in which it is instilled into the bladder (see Sodium Pertechnetate Tc 99m, Mucosal-Local ) and for lacrimal drainage studies in which it is placed on the eye (see Sodium Pertechnetate Tc 99m, Ophthalmic ). ^{{06} {15} {37}}

When sodium pertechnetate Tc 99m is given orally, fasting is recommended for at least 6 hours before and 2 hours after administration. ^{05}

Prior to the administration of sodium pertechnetate Tc 99m for brain or blood pool imaging, up to 1 gram of pharmaceutical grade potassium perchlorate may be given orally to help block the uptake of Tc 99m into the thyroid gland, salivary glands, choroid plexus, and gastric mucosa. This is especially important in children receiving sodium pertechnetate Tc 99m for brain or blood pool imaging in order to reduce the absorbed radiation dose to the thyroid gland. ^{05}

Manufacturer's package insert or other appropriate literature should be consulted for optimal times when imaging should be performed.

Safety considerations for handling this medication
Improper handling of this radiopharmaceutical may cause radioactive contamination. Guidelines for handling radioactive material have been prepared by scientific, professional, state, federal, and international bodies and are available to the specially qualified and authorized users who have access to radiopharmaceuticals.


Oral or Parenteral Dosage Forms

Note: Bracketed uses in the Dosage Forms section refer to categories of use and/or indications that are not included in U.S. product labeling.

SODIUM PERTECHNETATE Tc 99m INJECTION USP

Usual adult and adolescent administered activity
Vascular disorders or
Intravenous, 370 to 1110 megabecquerels (10 to 30 millicuries).

Brain disorders
Intravenous or oral, 370 to 740 megabecquerels (10 to 20 millicuries).

Thyroid disorders
Intravenous or oral, 37 to 370 megabecquerels (1 to 10 millicuries).

Salivary gland disorders
Intravenous, 37 to 185 megabecquerels (1 to 5 millicuries).

Placenta localization
Intravenous, 37 to 111 megabecquerels (1 to 3 millicuries). ^{05}

[Gastrointestinal disorders (Meckel's diverticula)]¹
Intravenous, 185 to 555 megabecquerels (5 to 15 millicuries).

Note: Some investigators have used cimetidine prior to Meckel's imaging to produce a more intense and prolonged uptake of sodium pertechnetate Tc 99m by the gastric mucosa in both the stomach and in Meckel's diverticulum. Cimetidine is thought to work by blocking acid secretion from the mucosa, leading to an increased accumulation of sodium pertechnetate Tc 99m. ^{{09} {22} {28}}
Also, some investigators have used glucagon, with or without pentagastrin, to inhibit intestinal peristalsis and allow pooling of secreted sodium pertechnetate Tc 99m. ^{{14} {37}}


[Cardiac disorders]¹
Intravenous, 555 to 1295 megabecquerels (15 to 35 millicuries) of Tc 99m-labeled red blood cells. ^{25}

Note: For cardiac blood pool imaging, the injection of 0.5 to 2.1 mg of stannous ion 15 to 60 minutes before the administration of sodium pertechnetate Tc 99m injection is necessary to promote the labeling of Tc 99m to red blood cells. ^{{01} {08} {25} {30} {37}}


[Gastrointestinal bleeding]¹
Intravenous, 740 to 1110 megabecquerels (20 to 30 millicuries) of Tc 99m-labeled red blood cells. ^{{21} {37}}


Usual pediatric administered activity
Vascular disorders or
Brain disorders
Intravenous or oral, 5 to 10 megabecquerels (140 to 280 microcuries) per kg of body weight.

Note: For radionuclide angiography performed as part of the brain imaging or blood pool procedures, a minimum of 111 to 185 megabecquerels (3 to 5 millicuries) should be used.


Thyroid disorders
Intravenous or oral, 2 to 3 megabecquerels (60 to 80 microcuries) per kg of body weight.

[Gastrointestinal disorders (Meckel's diverticula)]¹
Intravenous, 1.85 to 3.7 megabecquerels (50 to 100 microcuries) per kg of body weight ^{25} .


Usual geriatric administered activity
See Usual adult and adolescent administered activity .

Strength(s) usually available
U.S.—
740 megabecquerels to 3.7 gigabecquerels (20 to 100 millicuries) per mL at time of calibration.

Note: Sodium pertechnetate Tc 99m injection is supplied as a molybdenum Mo 99/technetium Tc 99m generator in sizes of Mo 99 ranging from 30.7 to 614.2 gigabecquerels (830 to 16,600 millicuries); 9.25 to 111 gigabecquerels (250 to 3000 millicuries) [ Ultra-TechneKow FM]; or 8.3 to 100 gigabecquerels (225 to 2700 millicuries) [ TechneLite]. Each eluate of the generator should not contain more than the USP limit of 0.15 kilobecquerel of molybdenum Mo 99 per megabecquerel of technetium Tc 99m (0.15 microcurie Mo 99 per millicurie Tc 99m) per administered dose at the time of administration. ^{{33} {36}}


Canada—
Sodium pertechnetate Tc 99m injection is supplied as a molybdenum Mo 99/technetium Tc 99m generator in sizes of Mo 99 ranging from 8.3 to 100 gigabecquerels (225 to 2700 millicuries). Each eluate of the generator should not contain more than the Canadian Regulatory limit of 1.1 kilobecquerels of molybdenum Mo 99 per 37 megabecquerels of technetium Tc 99m (0.03 microcurie Mo 99 per millicurie Tc 99m) per administered dose at the time of administration. ^{05}

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Protect from freezing. ^{33}

Stability:
Generator eluate does not contain an antimicrobial agent, and thus, should be used within 12 hours from the time of generator elution. ^{33}

Note: Caution—Radioactive material.

Revised: 08/19/1994

References

1. Minitec package insert (Squibb—US), Rev 1/79.
   

2. Minitec package insert (Squibb—US), Rev 9/88.
   

3. Osteoscan-HDP package insert (Mallinckrodt—US), Rev 6/89.
   

4. Sodium Pertechnetate Tc 99m package insert (Medi-Physics—US), Rev 3/88.
   

5. Sodium Pertechnetate Tc 99m package insert (Medi-Physics—US), Rev 4/91.
   

6. Ultra-TechneKow package insert (Mallinckrodt—US), Rev 4/85.
   

7. Campbell CM, Khafagi FA. Insensitivity of Tc 99m pertechnetate for detecting metastases of differentiated thyroid carcinoma. Clin Nucl Med 1990; 15(1): 1–4.
   

8. Chilton HM, Witcofski RL. Nuclear pharmacy—an introduction to the clinical application of radiopharmaceuticals. Philadelphia: Lea & Febiger, 1986: 91-6, 136.
   

9. Diamond RH, Rothstein RD, Alavi A. The role of cimetidine-enhanced technetium-99m-pertechnetate imaging for visualizing Meckel's diverticulum. J Nucl Med 1991; 32: 1422-4.
   

10. European system for reporting of adverse reactions and drug effects—ninth report, 1991. Per: personal communication, Knud Kristensen, Denmark National Board of Health, 6/8/92.
    

11. Fed Regist 2/25/85; 50(37): 7663.
    

12. Gupta SM. Scintigraphic detection of and localization of GI bleeding. Resid Staff Physician 1982; 28; 42-52.
    

13. Gupta SM, Luna E, Kingsley S, et al. Detection of gastrointestinal bleeding by radionuclide scintigraphy. Am J Gastroenterol 1984; 79: 26-31.
    

14. Hladik WB, Saha GB, Study KT. Essentials of nuclear medicine science. Baltimore: Williams & Wilkins, 1987: 169, 183-4, 199-202, 217, 225.
    

15. Lathrop KA, Harper PV. Biologic behavior of Tc 99m for Tc 99m pertechnetate ion. Progr Nucl Med 1972; 1: 145-62.
    

16. Laven DL, Clanton JA, Hladik WB, et al. Pharmacologic alterations in the biorouting/performance of select radiopharmaceuticals used in cardiac imaging. Monograph presented at SNM Annual Meeting 6/90.
    

17. Leitl GP, Drew HMN, Kelly ME, et al. Interference with tc-99m labeling of red blood cells (RBCs) by RBC antibodies. J Nucl Med 1980; 21: 44.
    

18. Loevinger R, Budinger TF, Watson EE, editors. MIRD primer for absorbed dose calculations. New York: Society of Nuclear Medicine, 1988: 65-8.
    

19. Maynard CD. Clinical nuclear medicine. Philadelphia: Lea & Febiger, 1971: 32-4, 139-41, 145-52, 158-63, 177-81, 246-8.
    

20. Mountford PJ, Coakley AJ. A review of the secretion of radioactivity in human breast milk: data, quantitative analysis and recommendations. Nucl Med Commun 1989; 10: 15-27.
    

21. Orecchia PM, Hensley EK, McDonald PT, et al. Localization of lower gastrointestinal hemorrhage. Arch Surg 1985; 120: 621-4.
    

22. Petrokubi RJ, Baum S, Rohrer GV. Cimetidine administration resulting in improved pertechnetate imaging of Meckel's diverticulum. Clin Nucl Med 1978; 3: 385-8.
    

23. Radiopharmaceuticals Advisory Panel Meeting, 5/91.
    

24. Radiopharmaceuticals Advisory Panel meeting, 8/4/92.
    

25. Reviewers' responses to monograph revision.
    

26. Romney BM, Nickoloff EL, Esser PD, et al. Radionuclide administration to nursing mothers: Mathematically derived guidelines. Radiology 1986; 160: 549-54.
    

27. Sfakianakis GN, Conway JJ. Detection of ectopic gastric mucosa in Meckel's diverticulum and in other aberrations by scintigraphy. J Nucl Med 1981; 22: 647-54, 732-8.
    

28. Sfakianakis GN, Anderson GF, King DR, et al. The effect of gastrointestinal hormones on the pertechnetate imaging of ectopic gastric mucosa in experimental Meckel's diverticulum. J Nucl Med 1981; 22: 678-83.
    

29. Shaw SM. Drugs and diseases that may alter the biodistribution or pharmacokinetics of radiopharmaceuticals. Pharmacy Int'l 1985 Dec: 293-8.
    

30. Swanson DP, Chilton HM, Threll JH, editors. Pharmaceuticals in medical imaging. New York: MacMillan Publishing Company, 1990: 343-57, 445-6; 449-50.
    

31. Task Group of Committee 2 of the International Commission on Radiological Protection. Annals of the ICRP. ICRP Publication 53—Radiation dose to patients from radiopharmaceuticals. New York: Pergamon Press, 1988: 197.
    

32. Tatum JL, Burke TS, Hirsch JI, et al. Pitfall to modified in vivo method of technetium-99m red blood cell labeling-iodinated contrast media. Clin Nucl Med 1983; 8: 585-7.
    

33. Ultra-TechneKow FM package insert (Mallinckrodt—US), Rev 8/90.
    

34. Winzelgberg GG, McKusick KA, Froelich JW, et al. Detection of gastrointestinal bleeding with Tc-99m-labeled red blood cells. Semin Nucl Med 1982; 12: 139-46.
    

35. Zimmer AM, Spies SM, Majewski W. Effect of drugs on in vivo RBC labeling: a proposed mechanism of inhibition. Presented at Second International Symposium on Radiopharmacology, Chicago 9/81.
    

36. TechneLite package insert (Du Pont—US), Rev 11/92.
    

37. Reviewers' comments per 3/14/94 monograph revision.
    

38. McAfee JG. Tc 99m pertechnetate for brain scanning. J Nucl Med 1964; 5: 811-27.
    

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