Medication Guide App

Technetium Tc 99m Succimer (Systemic)


VA CLASSIFICATION
Primary: DX201

Commonly used brand name(s): MPI DMSA Kidney Reagent.

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

Not commercially available in Canada.



Category:


Diagnostic aid, radioactive (renal disorders)—

Indications

Accepted

Renal imaging, radionuclide—Technetium Tc 99m succimer is indicated as a renal imaging agent to evaluate renal parenchymal disorders. {01} {12}


Physical Properties

Nuclear data:



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 h -1
Isomeric
transition to
Tc 99
Gamma
(18)
0.062
Gamma
(140.5)
0.891


Pharmacology/Pharmacokinetics

Mechanism of action/Effect:

Based on its clearance through the urinary tract. A significant amount is retained in the proximal tubular cells of the renal cortex long enough to allow external detection by means of a scintillation camera. {09} {13}

Distribution:

Distributed in the plasma, loosely bound to proteins. Cleared from the plasma with a half-time of about 60 minutes, then concentrating in the tubular cells of the renal cortex. After one hour, about 25% of the administered activity is concentrated in the kidneys, increasing to 40% after six hours. {01} {02} {13} {15}

Radiation dosimetry:


Estimated absorbed radiation dose*
Organ
mGy/MBq
rad/mCi
Kidneys
0.17
0.63
Bladder wall
0.019
0.070
Adrenals
0.013
0.048
Spleen
0.013
0.048
Liver
0.0097
0.036
Pancreas
0.0090
0.033
Red marrow
0.0063
0.023
Stomach wall
0.0055
0.020
Small intestine
0.0052
0.019
Large intestine
wall (upper)

0.0051

0.019
Uterus
0.0046
0.017
Ovaries
0.0037
0.014
Bone surfaces
0.0035
0.013
Large intestine
wall (lower)

0.0032

0.012
Lungs
0.0025
0.0093
Breast
0.0018
0.0067
Testes
0.0018
0.0067
Thyroid
0.0011
0.0041
Other tissue
0.0030
0.011
Effective dose: 0.016 mSv/MBq (0.059 rem/mCi)
* For adults; intravenous injection.
 Data based on the International Commission on Radiological Protection (ICRP) Publication 53—Radiation dose to patients from radiopharmaceuticals. {08}

Elimination:
    Renal (about 16% of the administered activity in 2 hours). {01} {12} {15}


Precautions to Consider

Pregnancy/Reproduction

Pregnancy—
Tc 99m (as free pertechnetate) crosses the placenta. However, studies have not been done with technetium Tc 99m succimer in humans.

The possibility of pregnancy should be assessed in women of child-bearing potential. Clinical situations exist where the benefit to the patient and fetus, based on information derived 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. {10}

Studies have not been done in animals.

FDA Pregnancy Category C. {01} {12}

Breast-feeding

Although it is not known whether technetium Tc 99m succimer is distributed into breast milk, it is known that Tc 99m as free pertechnetate is distributed into breast milk. Based on the assumption that the Tc 99m in breast milk is in the form of pertechnetate and based on the effective half-life of the radionuclide in breast milk, the daily volume of milk, a dose factor relating the radionuclide to its critical organ (thyroid) in the nursing infant, and the maximum permissible dose to that organ, a guideline has been proposed. According to this guideline, it has been calculated that nursing can be safely resumed when the concentration in breast milk reaches 30.3 × 10 -4 megabecquerels (8.2 × 10 -2 microcuries) per mL. This level of activity is probably reached, in the majority of patients, within 12 to 24 hours after administration of technetium Tc 99m–labeled radiopharmaceuticals. {07}

Pediatrics

Studies performed in children have not demonstrated pediatrics-specific problems that would limit the usefulness of technetium Tc 99m succimer in children. However, because of the potential risk of radiation exposure, risk-benefit must be considered. {04} {13}


Geriatrics


Appropriate studies on the relationship of age to the effects of technetium Tc 99m succimer have not been performed in the geriatric population. However, no geriatrics-specific problems have been documented to date.

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 this test

Due to other medications
Captopril or
Enalapril or
Lisinopril    (in patients with unilateral renal artery stenosis, use of angiotensin-converting enzyme inhibitors may result in decreased uptake of technetium Tc 99m succimer by the affected kidney because of a loss of effective trans-membrane filtration pressure {03} {06} {09})


Due to medical problems or conditions
Dehydration    (decreased urinary flow may result in poor renal images {18})


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. {01}

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


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 only if they continue or are bothersome
Incidence rare {12}
    
Fever
    
flushing or redness of skin
    
nausea
    
skin rash
    
stomach pain
    
syncope (fainting)





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
Action in the body: Concentration of radioactive succimer in kidneys

Retention of radioactivity in kidneys allows visualization

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

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

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





Breast-feeding—Not known if technetium Tc 99m succimer is distributed into breast milk, but Tc 99m as free pertechnetate is distributed into breast milk; temporary discontinuation of nursing may be recommended because of risk to infant from radiation exposure





Use in children—Risk from 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

Precautions after having this test
Adequate intake of fluids and voiding as often as possible for 4 to 6 hours after examination to minimize radiation dose to bladder


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.

Adequate hydration of the patient is recommended before and after examination to promote urinary flow. Also, urination is recommended as often as possible for 4 to 6 hours after the examination to reduce radiation exposure to the bladder. {09} {18}

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

Safety considerations for handling this radiopharmaceutical
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. {17}


Parenteral Dosage Forms

TECHNETIUM Tc 99m SUCCIMER INJECTION USP

Usual adult and adolescent administered activity
Renal imaging
Intravenous, 74 to 222 megabecquerels (2 to 6 millicuries), administered slowly. {12}


Usual pediatric administered activity
Renal imaging
Dosage must be individualized by physician. The minimum recommended total dosage is 55 megabecquerels (1.5 millicuries), with a maximum total dosage of 185 megabecquerels (5 millicuries), intravenously. {14} {15}


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

Strength(s) usually available
U.S.—


1.2 mg succimer and 0.42 mg anhydrous stannous chloride, per 2.2-mL reagent ampule (Rx) [MPI DMSA Kidney Reagent]

Canada—
Not commercially available.

Packaging and storage:
Store between 15 and 30 °C (59 and 86 °F), in a light-resistant container. Protect from freezing. {16}

Preparation of dosage form:
To prepare injection, an oxidant-free sodium pertechnetate Tc 99m solution is used. After reconstitution with sodium pertechnetate Tc 99m, the newly formed complex should be allowed to incubate for 10 minutes, at room temperature, to permit the formation of a more desirable succimer complex. See manufacturer's package insert for complete instructions. {09} {12}

Stability:
Injection should be administered within 30 minutes after preparation. {12} {15}

Incompatibilities:
If oxidants such as peroxides and hypochlorites are present in the sodium pertechnetate Tc 99m used for labeling, the final preparation may be adversely affected and should be discarded.

Note: Caution—Radioactive material.




Revised: 08/02/1994



References

Note: All references used in the development and earlier revisions of this monograph have not yet been incorporated into the computer database and, therefore, are not listed below. Citations for information not yet referenced in the monograph will be provided upon request.

  1. MPI DMSA package insert (Medi-Physics—US), Rev 3/89.
  1. Chilton HM, Witcofski RL: Nuclear pharmacy—an introduction to the clinical application of radiopharmaceuticals. Philadelphia: Lea & Febiger, 1986: 127.
  1. Hladik WB, Saha GB, Study KT. Essentials of nuclear medicine science. Baltimore: Williams & Wilkins, 1987: 196.
  1. Handmaker H, Young BW, Lowenstein JM. Clinical experience with Tc 99m-DMSA (dimercaptosuccinic acid), a new renal-imaging agent. J Nucl Med 1975; 16(1): 28-32.
  1. Watkinson JC, Lazarus CR, Maisey MN. 99Tcm(v)-DMSA planar scintigraphy: does it have a role in the management of patients with head and neck squamous carcinoma. Nucl Med Commun 1989; 10(12): 859-70.
  1. Arch Intern Med 1986; 146: 1705-8.
  1. USP Radiopharmaceuticals Advisory Panel (per 1/88 meeting).
  1. 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: 186.
  1. Swanson DP, Chilton HM, Thrall JH, editors. Pharmaceuticals in medical imaging. New York: Macmillan Publishing Company, 1990: 521-6.
  1. USP Radiopharmaceuticals Panel meeting on 05/08/91.
  1. USP Radiopharmaceuticals Panel meeting on 08/04/92.
  1. MPI DMSA package insert (Medi-Physics—US), Rev 2/91.
  1. Williams GD, Rossleigh M, Rosenberg AR, et al. Abnormal cortical appearances in pediatric renal allografts. J Nucl Med 1991; 32: 1542-4.
  1. Pediatric dosages as recommended by USP Radiopharmaceuticals Advisory panelists, 08/92.
  1. Reviewers' responses to monograph revision of 11/20/92.
  1. The United States pharmacopeia. The national formulary. USP 22nd revision (January 1, 1990). NF 17th ed (January 1, 1990). Rockville, MD: The United States Pharmacopeial Convention, Inc., 1990: 1319.
  1. Reviewers' responses to Ballot of 5/11/94.
  1. Reviewers' comments per monograph revision of 07/84.
  1. Blaufox MD. Procedures of choice in renal nuclear medicine. J Nucl Med 1991; 32: 1301-9.
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