Gadolinium Toxicity

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European Medicines Agency takes action on Linear Gadolinium-based Contrast Agents

On July 21, 2017, the European Medicines Agency (EMA) confirmed previous recommendations to suspend the use of three linear gadolinium-based contrast agents (GBCAs) used for MRIs, citing potential risks from brain deposition of gadolinium.  The use of one other linear GBCA will be restricted to liver scans.

The 3 suspended agents are Magnevist (gadopentetic acid), Omniscan (gadodiamide), and OptiMark (gadoversetamide).  The agent restricted to liver scans is MultiHance (gadobenic acid).

Read the article on Aunt Minne about this action here:
http://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=117859

The official announcement from the EMA can be found here:
http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/gadolinium_contrast_agents_31/Opinion_provided_by_Committee_for_Medicinal_Products_for_Human_Use/WC500231824.pdf

Additional information on the EMA website can be found here:
http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/referrals/Gadolinium-containing_contrast_agents/human_referral_prac_000056.jsp&mid=WC0b01ac05805c516f

We are encouraged by the EMA’s action and believe that the FDA should take a similar stance.

Patients and their doctors should report all adverse events and clinical symptoms to the FDA or the appropriate governing authority in their country.  Chronic symptoms that develop soon after MRIs with contrast could be manifestations of the harm done by gadolinium deposition in the brain, bones, and elsewhere in the body.

European group recommends to stop using 4 linear GBCAs

March 10, 2017 – A committee of the European Medicines Agency (EMA) has recommended the suspension of the marketing authorizations for four linear gadolinium-based contrast agents (GBCAs) used for MRI scans because of  concerns about small amounts of gadolinium from administered GBCAs being deposited in the brain.

At the completion of its year-long review of GBCAs, the EMA’s Pharmacovigilance and Risk Assessment Committee (PRAC) “found convincing evidence of accumulation of gadolinium in the brain from studies directly measuring gadolinium in brain tissues and areas of increased signal intensity seen on MRI scan images many months after the last injection of a gadolinium contrast agent”.

Linear agents recommended for suspension by the PRAC are:
Gadobenic acid, marketed as MultiHance by Bracco Diagnostics Inc.
Gadodiamide, marketed as Omniscan by GE Healthcare
Gadopentetic acid, marketed as Magnevist by Bayer HealthCare Pharmaceuticals
Gadoversetamide, marketed as OptiMARK by Mallinckrodt Inc.

The PRAC’s final recommendations will be sent to the Committee for Medicinal Products for Human Use (CHMP) for its opinion.  Further details will be published when CHMP renders its opinion regarding the removal of the four linear agents from the market.

In its press release, the PRAC noted that deposition of gadolinium in other organs and tissues has been associated with rare side effects of skin plaques and Nephrogenic Systemic Fibrosis (NSF).  It also noted that “non-clinical laboratory studies have shown that gadolinium can be harmful to tissues”.

The PRAC said that two linear agents will remain available: gadoxetic acid (brand name Eovist), used at a low dose for liver scans, since it meets an important diagnostic need in patients with few alternatives, and a formulation of gadopentetic acid injected directly into joints because its gadolinium concentration is very low.  The PRAC indicated that both agents should be used at “the lowest dose that enhances images sufficiently to make diagnoses and only if unenhanced scans are not suitable”.

FDA actions 

On July 27, 2015, the FDA issued its first, and so far only, Safety Announcement regarding gadolinium retention in the brain following repeated use of a GBCA for MRIs.  It acknowledged that trace amounts of gadolinium may stay in the body long-term, and noted that “recent studies conducted in people and animals have confirmed that gadolinium can remain in the brain, even in individuals with normal kidney function”.

The 2015 announcement said that the FDA, including its National Center for Toxicological Research (NCTR), “will study this possible safety risk further”.  As of this writing, the FDA has made no further public safety announcements regarding the use of gadolinium-based contrast agents.

It remains to be seen if the FDA will follow the lead of the EMA and suspend the use of the linear GBCAs.  Three of the four suspended agents are linked to the most unconfounded cases of NSF, and they are among the most widely used GBCAs for magnetic resonance imaging (MRI) procedures.

Sharon Williams

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PRAC concludes assessment of gadolinium agents used in body scans and recommends regulatory actions, including suspension for some marketing authorisations.  EMA/157486/2017.  http://www.ema.europa.eu/docs/en_GB/document_library/Press_release/2017/03/WC500223209.pdf

MRI brain signal changes reported in a child

The November 2015 issue of Pediatrics includes a case study by Miller et al.  The article, MRI Brain Signal Intensity Changes of a Child During the Course of 35 Gadolinium Contrast Examinations, describes the quantitative signal intensity changes in the brain of a pediatric patient who had 35 MRIs with a linear gadolinium-based contrast agent (GBCA) between the ages of 8 and 20 years.  The authors report that progressive increases were the most evident in the dentate nuclei, the globus pallidus, and the thalamus.  They noted that the pattern of regional brain hyperintensity observed is consistent with findings from recent adult studies.

High signal intensity in the dentate nucleus and globus pallidus on unenhanced T1-weighted images was first reported by Kanda et al in late 2013 and has been found to be the result of gadolinium deposition in the brain.

Sharon Williams

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Miller, J. H., Hu, H. H., Pokorney, A., Cornejo, P., & Towbin, R. (2015). MRI Brain Signal Intensity Changes of a Child During the Course of 35 Gadolinium Contrast Examinations. Pediatrics, peds.2015–2222–. http://doi.org/10.1542/peds.2015-2222

Kanda, T., Ishii, K., Kawaguchi, H., Kitajima, K., & Takenaka, D. (2013). High Signal Intensity in the Dentate Nucleus and Globus Pallidus on Unenhanced T1-weighted MR Images: Relationship with Increasing Cumulative Dose of a Gadolinium-based Contrast Material. Radiology, 131669. http://doi.org/10.1148/radiol.13131669

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