Gadobutrol for contrast-enhanced magnetic resonance imaging in elderly patients: review of the safety profile from clinical trial, post-marketing surveillance, and pharmacovigilance data

Clinical Safety of Gadobutrol: Review of Over 25 Years of Use Exceeding 100 Million Administrations

BACKGROUND

The macrocyclic gadolinium-based contrast agent gadobutrol was introduced to the market in February 1998. Over the last 25 years, gadobutrol has been administered more than 100 million times worldwide providing a wealth of data related to safety.

OBJECTIVE

The aim of this study was to perform a thorough review and status update on gadobutrol's safety.

MATERIALS AND METHODS

Safety data from the clinical phase II-IV program and postmarketing surveillance were descriptively analyzed from February 1998 until December 31, 2022. Literature on special at-risk populations and specific safety aspects was critically summarized.

RESULTS

Forty-five clinical phase II-IV studies recruited 7856 patients receiving gadobutrol. Drug-related adverse events (AEs) were reported in 3.4% and serious AEs in <0.1% of patients. Nausea (0.7%) and dysgeusia (0.4%) were the most reported AEs. All other drug-related AEs occurred ≤0.3%. After more than 100 million gadobutrol administrations, overall adverse drug reactions (ADRs) from postmarketing surveillance (including clinical trials) were rare with an overall reporting rate of 0.0356%, hypersensitivity reactions (0.0147%), nausea (0.0032%), vomiting (0.0025%), and dyspnea (0.0010%). All other ADRs were <0.001%. No trend for higher rates of AEs was found in patients with reduced renal or liver function. Seven clinical studies reported safety findings in 7292 children ≤18 years, thereof 112 newborns/toddlers younger than 2 years. Overall, 61 ADRs (0.84%) were reported, including 3 serious ones. Adverse events in patients ≥65 years of age ("elderly") were significantly less frequent than in younger patients. A total of 4 reports diagnostic of or consistent with nephrogenic systemic fibrosis have been received. No causal relationship has been established between clinical signs and symptoms and the presence of small amounts of gadolinium in the body in patients with normal renal function after use of gadobutrol.

CONCLUSIONS

More than 100 million administrations worldwide have shown gadobutrol's well-established benefit-risk profile in any approved indication and populations.

How Safe Is Gadobutrol? Examining the Effect of Gadolinium Deposition on the Nervous System

This study aimed to evaluate the safety of gadobutrol, a gadolinium-based contrast agent used in medical imaging, by investigating its effect on the nervous system under physiological and inflammatory conditions. Male Sprague Dawley rats were divided randomly into four groups, including gadobutrol, saline, LPS + gadobutrol, and LPS + saline, and were given intraperitoneal injections of gadobutrol (2.5 mmol/kg) or saline for 20 days. Weekly sensorimotor and cognitive behavioral tests were performed over 4 weeks, and Gd concentration in nervous tissues was analyzed using inductively coupled plasma mass spectrometry (ICP-MS). Lactate dehydrogenase (LDH) activity was measured to evaluate cytotoxicity, and electromyography (EMG) recordings from the gastrocnemius muscle were also obtained to examine signal transmission in sciatic nerves. The results indicated that gadobutrol did not induce significant behavioral changes under normal conditions. However, when administered along with LPS, the combination led to behavioral dysfunction. ICP-MS analysis revealed a higher concentration of Gd in the cerebrum and spinal cord of gadobutrol + LPS-treated rats, while peripheral nerves showed lower concentrations. In addition, there was a significant increase in LDH activity in the hippocampus of the gadobutrol group. EMG responses to electrical stimulation of the sciatic nerve demonstrated a decreased threshold of nociceptive reflexes in the gadobutrol group. Overall, while gadobutrol may be considered safe under normal physiological conditions, the findings suggest that its safety may be compromised under inflammatory conditions.

Improved display of abdominal contrast-enhanced MRA using gadobutrol: comparison with Gd-DTPA

AIM

To qualitatively and quantitatively compare gadobutrol with gadopentetate dimeglumine (Gd-DTPA) in abdominal contrast-enhanced magnetic resonance angiography (CE-MRA) and contrast-enhanced magnetic resonance imaging (CE-MRI) during one-stop imaging.

MATERIALS AND METHODS

This prospective, blinded, multicentre, intra-individual comparison study was approved by the institutional review board. All patients underwent gadobutrol- and Gd-DTPA-enhanced MRA and MRI. Qualitative analysis for vessels was performed using a three-point scale while quantity analysis was performed by signal-to-noise ratio (SNR). Visceral organs enhancements were also analysed. A Wilcoxon matched-pair signed-rank test was used to evaluate the quality and quantity results.

RESULTS

One hundred and twelve patients were enrolled. Quality analyses results for large vessels and small vessels of gadobutrol and Gd-DTPA were 18.38±1.51 and 6.76±1.58 and 17.87±1.84 and 6.09±1.55, respectively. Wilcoxon signed-rank tests revealed gadobutrol was significantly superior to Gd-DTPA (p=0.036) for small vessels. For large vessel quantity analysis, gadobutrol demonstrated significantly higher signal-to-noise ratios (SNR; p=0.041) than Gd-DTPA, with mean values of 948.156±349.731 and 838.925±248.197. There was no statistically significant in enhancement of liver, spleen, and renal tissue during gadobutrol- and Gd-DTPA-enhanced imaging (p>0.05). One patient reported an adverse event. Dizziness and vomiting occurred after injection of Gd-DTPA.

CONCLUSIONS

The present study demonstrates gadobutrol-enhanced MRA was superior to that of Gd-DTPA without statistical significance in visceral organ enhancement. It indicates gadobutrol may be more suitable for abdominal one-stop imaging for CE-MRA and CE-MRI by improving depiction of vessels in MRA images.

Safety of gadobutrol: results of a non-interventional study of 3710 patients, including 404 children

Background

The safety of gadolinium-based contrast agents is a hot topic in radiology.

Purpose

To evaluate the safety profile of gadobutrol during routine use.

Material and Methods

Prospective, non-interventional study in 80 centers in Germany. The primary outcome was the number of adverse drug reactions (ADR) following gadobutrol administration.

Results

A total of 3710 patients were included in the analysis, including 404 children (10.9%). A total of 6026 magnetic resonance imaging examinations of organs/organ systems and 872 magnetic resonance angiography examinations were performed. A total of 22 (0.59%) patients experienced at least one ADR. Nausea and vomiting were the most frequent ADRs, experienced by nine (0.24%) and three (0.08%) patients, respectively. One serious ADR was recorded (anaphylactoid reaction). No deaths were reported.

Conclusion

This non-interventional study in 3710 patients confirmed gadobutrol as a safe and reliable contrast agent in adults and children.

Gadobutrol: A Review in Contrast-Enhanced MRI and MRA

Intravenous gadobutrol [Gadovist^™ (EU); Gadavist^® (USA)] is a second-generation, extracellular non-ionic macrocyclic gadolinium-based contrast agent (GBCA) that is approved for use in paediatric (including term neonates) and adult patients undergoing diagnostic contrast-enhanced (CE) MRI for visualization of pathological lesions in all body regions or for CE MRA to evaluate perfusion and flow-related abnormalities. Its unique physicochemical profile, including its high thermostability and proton relaxation times, means that gadobutrol is formulated at twice the gadolinium ion concentration of other GBCAs, resulting in a narrower bolus and consequently, improved dynamic image enhancement. Based on >  20 years of experience in the clinical trial and real-world settings (>  50 million doses) and its low risk for developing nephrogenic systemic fibrosis (NSF), gadobutrol represents an effective and safe diagnostic GBCA for use in CE MRI and MRA to visualize pathological lesions and vascular perfusion and flow-related abnormalities in all body regions in a broad spectrum of patients, including term neonates and other paediatric patients, young and elderly adult patients, and those with moderate or severe renal or hepatic impairment or cardiovascular (CV) disease.

Gadolinium-Based Contrast Agents in Kidney Disease: A Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists

PURPOSE OF REVIEW

Use of gadolinium-based contrast agents (GBCA) in renal impairment is controversial, with physician and patient apprehension in acute kidney injury (AKI), chronic kidney disease (CKD), and dialysis because of concerns regarding nephrogenic systemic fibrosis (NSF). The position that GBCA are absolutely contraindicated in AKI, category G4 and G5 CKD (estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73 m2), and dialysis-dependent patients is outdated and may limit access to clinically necessary contrast-enhanced magnetic resonance imaging (MRI) examinations. This review and clinical practice guideline addresses the discrepancy between existing Canadian guidelines regarding use of GBCA in renal impairment and NSF.

SOURCES OF INFORMATION

Published literature (including clinical trials, retrospective cohort series, review articles, and case reports), online registries, and direct manufacturer databases were searched for reported cases of NSF by class and specific GBCA and exposed patient population.

METHODS

A comprehensive review was conducted identifying cases of NSF and their association to class of GBCA, specific GBCA used, patient, and dose (when this information was available). Based on the available literature, consensus guidelines were developed by an expert panel of radiologists and nephrologists.

KEY FINDINGS

In patients with category G2 or G3 CKD (eGFR ≥ 30 and < 60 mL/min/1.73 m2), administration of standard doses of GBCA is safe and no additional precautions are necessary. In patients with AKI, with category G4 or G5 CKD (eGFR < 30 mL/min/1.73 m2) or on dialysis, administration of GBCA should be considered individually and alternative imaging modalities utilized whenever possible. If GBCA are necessary, newer GBCA may be administered with patient consent obtained by a physician (or their delegate) citing an exceedingly low risk (much less than 1%) of developing NSF. Standard GBCA dosing should be used; half or quarter dosing is not recommended and repeat injections should be avoided. Dialysis-dependent patients should receive dialysis; however, initiating dialysis or switching from peritoneal to hemodialysis to reduce the risk of NSF is unproven. Use of a macrocyclic ionic instead of macrocyclic nonionic GBCA or macrocyclic instead of newer linear GBCA to further prevent NSF is unproven. Gadopentetate dimeglumine, gadodiamide, and gadoversetamide remain absolutely contraindicated in patients with AKI, those with category G4 or G5 CKD, or those on dialysis. The panel agreed that screening for renal disease is important but less critical when using macrocyclic and newer linear GBCA. Monitoring for and reporting of potential cases of NSF in patients with AKI or CKD who have received GBCA is recommended.

LIMITATIONS

Limited available literature (number of injections and use in renal impairment) regarding the use of gadoxetate disodium. Limited, but growing and generally high-quality, number of clinical trials evaluating GBCA administration in renal impairment. Limited data regarding the topic of Gadolinium deposition in the brain, particularly as it related to patients with renal impairment.

IMPLICATIONS

In patients with AKI and category G4 and G5 CKD (eGFR < 30 mL/min/1.73 m2) and in dialysis-dependent patients who require GBCA-enhanced MRI, GBCA can be administered with exceedingly low risk of causing NSF when using macrocyclic agents and newer linear agents at routine doses.

Gadolinium-Based Contrast Agents in Kidney Disease: Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists

Use of gadolinium-based contrast agents (GBCAs) in renal impairment is controversial, with physician and patient apprehension in acute kidney injury (AKI), chronic kidney disease (CKD), and dialysis because of concerns regarding nephrogenic systemic fibrosis (NSF). The position that GBCAs are absolutely contraindicated in AKI, CKD stage 4 or 5 (estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m²) and dialysis-dependent patients is outdated, and may limit access to clinically necessary contrast-enhanced MRI examinations. Following a comprehensive review of the literature and reported NSF cases to date, a committee of radiologists and nephrologists developed clinical practice guidelines to assist physicians in making decisions regarding GBCA administrations. In patients with mild-to-moderate CKD (eGFR ≥30 and <60 mL/min/1.73 m²), administration of standard doses of GBCA is safe and no additional precautions are necessary. In patients with AKI, with severe CKD (eGFR <30 mL/min/1.73 m²), or on dialysis, administration of GBCAs should be considered individually and alternative imaging modalities utilized whenever possible. If GBCAs are necessary, newer GBCAs may be administered with patient consent obtained by a physician (or their delegate), citing an exceedingly low risk (much less than 1%) of developing NSF. Standard GBCA dosing should be used; half or quarter dosing is not recommended and repeat injections should be avoided. Dialysis-dependent patients should receive dialysis; however, initiating dialysis or switching from peritoneal to hemodialysis to reduce the risk of NSF is unproven. Use of a macrocyclic ionic instead of macrocyclic nonionic GBCA or macrocyclic instead of newer linear GBCA to further prevent NSF is unproven. Gadopentetate dimeglumine, gadodiamide, and gadoversetamide remain absolutely contraindicated in patients with AKI, with stage 4 or 5 CKD, or on dialysis. The panel agreed that screening for renal disease is important but less critical when using macrocyclic and newer linear GBCAs. Monitoring for and reporting of potential cases of NSF in patients with AKI or CKD who have received GBCAs is recommended.

Safety profile of gadoxetate disodium in elderly patients (≥65 years)

Background

Safety data on routine clinical use of gadoxetate disodium in elderly patients is not reported yet.

Purpose

To assess the safety of liver specific gadoxetate disodium in contrast enhanced magnetic resonance imaging in elderly patients (≥65 years) in comparison to adults (18–64 years).

Material and Methods

Safety data on gadoxetate disodium were analyzed from 12 clinical phase II–III studies and from our pharmacovigilance database. A comparison between elderly (≥65 years) versus adults (18–64 years) was performed with respect to the frequency of drug-related adverse events (AEs) in clinical phase II–III studies and adverse drug reactions (ADRs) in the pharmacovigilance database.

Results

In clinical studies, 1989 patients were enrolled: 675 elderly and 1314 adults. Twenty-three elderly patients (3.4%) suffered at least one drug-related AE in contrast to 58 patients (4.4%) in the group of adults (odds ratio = 0.76; 95% confidence interval = 0.45–1.27). Since marketing authorization in 2004, more than 3.5 million patients have been exposed to gadoxetate disodium worldwide: 1.7 million (48.6%) in elderly and 1.8 million (51.4%) in adults. The number of patients with post-marketing ADRs (total n = 793) was 354 (0.021%) in the elderly group and 439 (0.024%) in the adult group. Thus, there were significantly fewer patients with ADRs reported in the group of elderly versus adults (P = 0.028). Hypersensitivity/immune system disorders, gastrointestinal disorders, and respiratory disorders were the most frequent ADRs in both groups, elderly and adults.

Conclusion

The incidence of drug-related AEs in clinical studies was similar and that of patients with ADRs in the post-marketing setting was lower in elderly (≥65 years) compared with younger adults aged 18–64 years. Overall, gadoxetate disodium shows a favorable safety profile in both age groups.

Fatal anaphylactic reaction to intravenous gadobutrol, a gadolinium-based MRI contrast agent

We present the rare case of a fatal anaphylactic reaction to gadobutrol, a magnetic resonance imaging contrast agent, in a 42-year-old man. The patient underwent elective magnetic resonance imaging for diagnostic clarification of a suspicious finding in the abdomen. The patient had undergone contrast-enhanced computed tomography previously without the occurrence of any adverse effects. Adverse drug reactions in gadobutrol have a very low prevalence of 0.32%-3.5%, with serious adverse drug reactions in <0.1%. There are only a few cases of fatal anaphylactoid reactions to gadolinium-based contrast agents in general. However, if an anaphylactoid reaction occurs, it can present itself with a fulminant course within minutes.

Gadobutrol in India-A Comprehensive Review of Safety and Efficacy

Gadobutrol is a gadolinium (Gd)-based contrast agent for magnetic resonance imaging (MRI). In India, gadobutrol is approved for MRI of the central nervous system (CNS), liver, kidneys, breast and for MR angiography for patients 2 years and older. The standard dose for all age groups is 0.1 mmol/kg body weight. The safety profile has been demonstrated in 42 clinical phase 2 to 4 studies (>6800 patients), 7 observational studies, and by assessing pharmacovigilance data of 29 million applications. Furthermore, studies in children, adults, and elderly and in patients with impaired liver or kidney function did not show any increased adverse event rate. Diagnostic efficacy was demonstrated in numerous studies and various indications, such as diseases of the CNS, peripheral and supra-aortic vessels, kidneys, liver, and breast.

Is gender still a predisposing factor in contrast-media associated adverse drug reactions? A systematic review and meta-analysis of randomized trials and observational studies

OBJECTIVE

To evaluate the role of gender as a risk factor for developing contrast media-associated adverse drug reactions (CM-ADRs) by comparing the incidence of CM-ADR between male and female patients according to study design, ADR type, and computed tomography (CT) examination.

MATERIAL AND METHODS

We systematically searched three electronic databases for eligible studies. In the studies included (n=18), we assessed effect estimates of the relative incidence of CM-ADR, analysed by experimental design, ADR type and CT examination. This was calculated by using a random effects model if clinical conditions showed heterogeneity; otherwise, a fixed effects model was used.

RESULTS

We identified 10,776 patients administered CM. According to the designs, studies were classified into randomised controlled trials (RCTs) and observational studies. Results were as follows: risk ratio (RR)=1.07 (95% confidence interval (CI): 0.79-1.46, P=0.66) for RCTs, and RR=0.77 (95% CI: 0.58-1.04, P=0.09) for observational studies. The results of analysis according to ADR type and for undergoing CT demonstrated that the incidence of CM-ADR did not differ between males and females.

CONCLUSIONS

We found no significant difference in the incidence of CM-ADRs between male and female patients according to study design, ADR type, or CT examination. Future studies to determine why gender has shown different roles as a risk factor between CM-ADRs and non-CM ADRs are needed.

Preventing Allergic Reactions to Gadolinium-Based Contrast Agents

Although the low incidence of immediate-type gadolinium-based contrast agent (GBCA) allergic reactions is widely known, preventing these reactions and properly managing them to reduce their adverse sequel can improve the already exceedingly favorable GBCA safety profile. This review article should help those who order, supervise, or administer GBCA contrast agents, including recognizing and handling allergic reaction risks intrinsic to their use. Areas of focus include factors indicating increased allergic reaction risk, patient selection strategies, skin testing, premedication, and treatment of adverse events.

Safety of Gadobutrol: Results From 42 Clinical Phase II to IV Studies and Postmarketing Surveillance After 29 Million Applications

OBJECTIVE

The aim of this study was to provide a systematic safety analysis of gadobutrol after more than 29 million applications in clinical routine.

MATERIALS AND METHODS

Forty-two clinical development phase II to IV studies on gadobutrol or comparator and the postmarketing safety surveillance database for gadobutrol (1998-2015) were analyzed. Adverse events (AEs) and drug-related AEs were evaluated in the clinical development database and spontaneous adverse drug reactions (ADRs) in the postmarketing database. Subgroup analyses were run on patients with special medical history and on patients of different age groups.

RESULTS

In the clinical development studies, 6809 and 2184 patients received gadobutrol or comparators, respectively. The incidence of drug-related AEs was 3.5% for both groups. With the exception of nausea (0.7% related cases in both groups), all other drug-related AEs were 0.3% or less in both groups. Hypersensitivity reactions were sporadic (<0.1%). Patients with history of allergies to contrast agents experienced slightly more drug-related AEs. No differences were seen between age groups.The overall reporting rate of ADRs from postmarketing surveillance was 0.05%. The most frequent ADRs were anaphylactoid/hypersensitivity reactions, nausea, vomiting, and dyspnea.For 3 single-agent reports of nephrogenic systemic fibrosis, using a conservative approach, association with gadobutrol could not be excluded.

CONCLUSIONS

Gadobutrol is well tolerated and has a favorable safety profile for patients of all age groups.

Clinical characteristics of adverse reactions to nonionic low osmolality contrast media in patients transferred from the CT room to the emergency room

Nonionic low osmolality contrast media (LOCMs) are used universally in computed tomography (CT) imaging. Although adverse reactions due to nonionic LOCMs are a common cause of emergency room (ER) admissions, few studies have investigated these adverse reactions. In the present study, we evaluated the characteristics of patients who were transferred from the CT room to the ER due to adverse reactions to contrast media, and we determined the risk factors for severe adverse reactions. A single-center retrospective study was conducted over a 41-month period. Baseline and clinical characteristics were evaluated and analyzed according to moderate and severe severity. In particular, risk factors of severe reactions were determined using logistic regression analysis. In total, 70 patients were admitted to the ER with adverse reactions due to nonionic LOCMs. Of these, 33 developed a moderate reaction, and 37 developed a severe reaction. Compared with the moderate reaction group, the severe reaction group was older, had higher blood pressures, showed more symptoms indicating the cardiovascular and central nervous system, and developed faster reactions to LOCMs. According to the multivariate logistic regression analysis, the age of the patient and time to onset of reaction demonstrated a statistical relationship with severe adverse reactions. In the receiver operating characteristic analysis, the optimal cutoff values for age and time to onset were 60 years and 5 min. In conclusion, clinicians should be attentive to anaphylaxis due to nonionic LOCM, in particular, for elderly patients aged older than 60 years and a time to reaction onset of less than 5 min.

Safety of gadobutrol in over 23,000 patients: the GARDIAN study, a global multicentre, prospective, non-interventional study

OBJECTIVES

To investigate the safety and tolerability of gadobutrol at the recommended dose in patients requiring contrast-enhanced magnetic resonance imaging/angiography (MRI/MRA) in the routine setting.

METHODS

GARDIAN prospectively enrolled 23,708 patients undergoing routine gadobutrol-enhanced MRI/MRA for approved indications at 272 study centres in Europe, Asia, North America, and Africa and monitored for adverse events.

RESULTS

Median gadobutrol dose was 0.11 mmol/kg body weight. The overall incidence of adverse drug reactions (ADRs) was 0.7 % (n = 170 patients), with similar incidences in patients with renal impairment or cardiac disease, from different geographic regions and in different gadobutrol dose groups. Patients at risk for contrast media reaction had an ADR incidence of 2.5 %. Five patients (0.02 %) experienced serious adverse events, four were drug-related. One patient experienced a fatal anaphylactoid shock, assessed to be related to injection of gadobutrol. The contrast quality of gadobutrol-enhanced images was rated by treating physicians as good or excellent in 97 % cases, with similar ratings in all patient subgroups and indications.

CONCLUSIONS

The GARDIAN study shows that gadobutrol at the recommended dose is well tolerated across a large, diverse patient population.

KEY POINTS

• Gadobutrol at recommended dose shows low rates of adverse drug reactions • Gadobutrol demonstrates a uniform safety profile across diverse patient groups • Gadobutrol provides excellent contrast quality in routine practice.