Prevalence of acute adverse reactions to gadobutrol--a highly concentrated macrocyclic gadolinium chelate: review of 14,299 patients from observational trials

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.

Acute respiratory distress syndrome following administration of gadolinium contrast agent: a case report

Background

Gadolinium-based contrast agents are used extensively in magnetic resonance imaging to assist diagnosis of medical conditions. Despite their documented safety profile, severe adverse events do occur, and their documentation may serve to raise the awareness of the medical community.

Case presentation

We report the case of a 15-year-old white Latin American female patient admitted to the intensive care unit for acute respiratory distress syndrome following administration of gadolinium. She did not have rash or tongue swelling but developed hypotension responsive to fluid administration and severe hypoxemia. Chest computed tomography revealed bilateral pulmonary compromise with multiple confluent consolidations. She received methylprednisolone and noninvasive ventilatory support including bilevel positive airway pressure ventilation and high-flow nasal cannula, and underwent a rapid recovery.

Conclusion

Gadolinium-based contrast agent-induced acute respiratory distress syndrome, albeit rare, should be included in the differential diagnosis of respiratory failure shortly after magnetic resonance imaging, which is nowadays a frequent diagnostic procedure, potentially increasing the awareness of this serious complication.

Delayed anaphylaxis due to gadolinium- A rare clinical scenario

Acute respiratory distress syndrome is a sudden in onset, diffuse inflammatory form of lung injury which may be associated with a variety of etiologies such as pneumonia, sepsis, aspiration, and severe trauma. Prompt recognition and treatment of acute respiratory distress syndrome is critical to reduce the associated high mortality. Severe lung injury presenting as acute respiratory distress syndrome secondary to gadolinium contrast media (gadobutrol) is rarely reported. We describe an interesting case of a 47-year-old woman who presented to the emergency department with acute respiratory failure after gadolinium administration. She was diagnosed with acute respiratory distress syndrome, was admitted to the intensive care unit due to requiring mechanical ventilation. Her condition improved with epinephrine and steroids and she was successfully extubated and discharged from the hospital in one week.

Non-Cardiogenic Pulmonary Oedema Following the use of Gadolinium-Based Contrast Medium: A Case Report

Non-cardiogenic pulmonary oedema can be life threatening and requires prompt treatment. While gadolinium-based contrast is generally considered safe with a low risk of severe side effects, non-cardiogenic pulmonary oedema has become increasingly recognised as a rare, but possibly life-threatening complication. We present a case of a usually well, young 23-year-old female who developed non-cardiogenic pulmonary oedema with a moderate oxygenation impairment and no mucosal or cutaneous features of anaphylaxis following the administration of gadolinium-based contrast. She did not respond to treatment of anaphylaxis but made a rapid recovery following the commencement of positive pressure ventilation. Our case highlights the importance of recognising the rare complication of non-cardiogenic pulmonary oedema following gadolinium-based contrast administration in order to promptly implement the appropriate treatment.

Late-onset acute respiratory distress syndrome induced by a gadolinium-based contrast agent

Rapid decline of pulmonary function in acute respiratory distress syndrome (ARDS) can make ARDS a dangerous and potentially life-threatening condition. Gadolinium-based contrast agents are considered safe alternatives to iodine-based contrast agents, with comparatively fewer adverse effects and a lower incidence of serious adverse events, such as dyspnea or hypotension. There are five reported cases of gadolinium-induced ARDS. A 59-year-old woman with respiratory failure 30 min after gadolinium administration was diagnosed with ARDS; she was admitted to the intensive care unit. Her condition improved by artificial respiration management and adrenaline and steroids administration. She was discharged on day 13. Considering ARDS occurred 30 min after gadolinium administration and findings suggesting anaphylaxis, such as wheezing and failure in organs other than the lungs, were absent, the involvement of any immediate-onset reaction was excluded; thus, a diagnosis of gadolinium-induced ARDS was made.

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.

Acute respiratory distress syndrome after the use of gadolinium contrast agent

Acute respiratory distress syndrome (ARDS) is a life-threatening medical emergency. The etiology of ARDS can involve various causes. ARDS associated with the use of iodinated contrast media is rarely reported, and the literature includes only one case of ARDS due to gadobutrol. A 46-year-old female patient presented to our emergency department with shortness of breath, wheezing, swelling of the lips, and difficulty swallowing about 30 minutes after undergoing magnetic resonance imaging with 6.5 ml (0.1 ml/kg) gadobutrol (Gadovist) contrast for a submandibular mass. She was treated for anaphylaxis, then immediately evaluated using chest x-ray and arterial blood gas analysis. Based on the findings, she was diagnosed with ARDS and started on continuous positive airway pressure (CPAP) ventilatory support and methylprednisolone at a dose of 1 mg/kg/day. On day 3 of follow-up, all symptoms had completely regressed.

Post-marketing surveillance of gadobutrol for contrast-enhanced magnetic resonance imaging in Japan

PURPOSE

To evaluate the safety of gadobutrol for magnetic resonance imaging in a prospective, non-interventional, post-marketing surveillance in Japan.

MATERIALS AND METHODS

Gadobutrol was administered in accordance with Japanese prescribing information over a 2-year enrollment period, using a standardized questionnaire to collect information. The primary outcome was the incidence of adverse reactions (ARs) following gadobutrol injection.

RESULTS

Questionnaire data were analyzed for 3337 patients (age, 58.1 ± 17.4 years [mean±SD]). Gadobutrol was administered at a dose of 0.10 ± 0.02 mL/kg body weight. Thirty-three patients were observed to have 42 ARs suspected to be due to gadobutrol, an incidence proportion of 0.99%; 29 ARs were acute (<1 h post-injection)-including one case of severe acute AR (0.03%). Patient subpopulations (with hepatic, renal, cardiovascular diseases) did not differ markedly in AR proportions categorized by age, sex, presence of comorbidity, or imaging indication. No cases of nephrogenic systemic fibrosis were reported. Investigators rated images as improved or profoundly improved following gadobutrol injection in 91.1% of examinations.

CONCLUSION

Gadobutrol was well tolerated with a good safety profile in this post-marketing surveillance of a large patient population in Japan.

Gadolinium deposition and the potential for toxicological sequelae - A literature review of issues surrounding gadolinium-based contrast agents

Every year, approximately 30 million magnetic resonance imaging scans are enhanced with gadolinium-based contrast agents (GBCAs) worldwide. Although the development of nephrogenic systemic fibrosis in patients with renal impairment is well-documented, over recent years it has become apparent that exposure to GBCAs can potentially result in gadolinium deposition within human bone and brain tissue even in the presence of normal renal function. This review will address some of the controversies surrounding the safety of GBCA administration based on evidence from in vivo experiments, animal studies and clinical studies. We additionally evaluate the potential risk of toxicity from exposure to gadolinium in light of new guidance published by the US Food and Drug Administration and the European Medicines Agency, and discuss whether gadolinium deposition disease exists as a new diagnosis.

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.

Gadobutrol in Renally Impaired Patients: Results of the GRIP Study

Objective

The aim of this study was to assess the potential risk of gadobutrol-enhanced magnetic resonance imaging (MRI) in patients with moderate to severe renal impairment for the development of nephrogenic systemic fibrosis (NSF).

Materials and Methods

We performed a prospective, international, multicenter, open-label study in 55 centers. Patients with moderate to severe renal impairment scheduled for any gadobutrol-enhanced MRI were included. All patients received a single intravenous bolus injection of gadobutrol at a dose of 0.1 mmol/kg body weight. The primary target variable was the number of patients who develop NSF within a 2-year follow-up period.

Results

A total of 908 patients were enrolled, including 586 with moderate and 284 with severe renal impairment who are at highest risk for developing NSF. The mean time since renal disease diagnosis was 1.83 and 5.49 years in the moderate and severe renal impairment cohort, respectively. Overall, 184 patients (20.3%) underwent further contrast-enhanced MRI with other gadolinium-based contrast agents within the 2-year follow-up. No patient developed symptoms conclusive of NSF.

Conclusions

No safety concerns with gadobutrol in patients with moderate to severe renal impairment were identified. There were no NSF cases.

Safety of gadoxetate disodium: results from six clinical phase IV studies in 8194 patients

Background

Safety data on routine clinical use of gadoxetate disodium for liver magnetic resonance imaging (MRI) is not reported yet.

Purpose

To assess the safety profile of gadoxetate disodium for liver MRI in the routine clinical setting.

Material and Methods

Six multicenter studies were performed in Europe, USA, Australia, and Asia to evaluate the safety and efficacy of gadoxetate disodium (Primovist®/Eovist®) enhanced liver MRI. Patients received a single intravenous bolus injection of the standard approved dose of 0.025 mmol/kg body weight (0.1 mL/kg). The number of patients, the characteristics of adverse events, related adverse events, and serious adverse events were analyzed.

Results

A total of 8194 patients were included in the database. A total of 141 patients (1.7%) reported 230 AEs of which 129 were considered being related to the use of gadoxetate disodium by the investigators. None of the AEs in the pediatric population (n = 52) were related. The most frequent AEs independent of relationship to the drug included dyspnea (25/0.31%), nausea (22/0.27%), liver disorders (13/0.16%), and renal disorders (9/0.11%). Nine related SAEs were recorded. No patient died during the studies.

Conclusion

Gadoxetate disodium for liver MRI is safe and well tolerated in the routine clinical setting.

Observational study on the safety profile of gadoterate meglumine in 35,499 patients: The SECURE study

Purpose

To investigate the safety of gadoterate meglumine and identify the incidence of nephrogenic systemic fibrosis (NSF).

Materials and Methods

An international prospective observational study was conducted from November 2008 to June 2013. A total of 35,499 adults and children who were scheduled to undergo contrast‐enhanced MRI using gadoterate meglumine were analyzed (female, 53.1%; mean age: 49.5 years; range: 0‐98 years). At least 3‐month follow‐up was planned for patients with an estimated creatinine clearance or glomerular filtration rate <60 mL/min (/1.73 m2) to detect any suspicion or occurrence of NSF. Adverse events (AEs) were prospectively recorded. Demographic data, risk factors, indications for MRI examinations, characteristics of gadoterate meglumine administration, and efficacy were documented.

Results

MRI examinations were mainly for central nervous system (61%). The most frequent risk factor was renal insufficiency (14.7%). Seventy AEs were observed in 44 patients (0.12%). Among the 70 AEs, 38 in 32 patients (0.09% of all patients) were considered related to gadoterate meglumine and classified as adverse drug reaction (ADR).The most frequent ADRs were urticaria (9 patients, 0.03%), nausea (7 patients, 0.02%), and vomiting (4 patients, 0.01%). Within the pediatric population (1,629 patients), only one AE (vomiting) was observed. Nine adult patients (0.03%) experienced serious AEs. Moderate to severe renal insufficiency at inclusion was reported in 514 patients (1.5%). Among them, 476 (92.6%) were followed‐up. No patients were suspected of having NSF and no cases of NSF were observed.

Conclusion

Our study confirms the excellent safety profile of gadoterate meglumine in routine practice.

Level of Evidence: 1

J. Magn. Reson. Imaging 2017;45:988–997

Pharmacokinetics and Safety of Macrocyclic Gadobutrol in Children Aged Younger Than 2 Years Including Term Newborns in Comparison to Older Populations

OBJECTIVES

This clinical study evaluated the pharmacokinetics (PK) and safety data of macrocyclic extracellular contrast agent gadobutrol in pediatric subjects aged younger than 2 years.

MATERIALS AND METHODS

Pediatric subjects (term newborns to those aged younger than 2 years) with normal renal function undergoing magnetic resonance imaging with gadobutrol (0.1 mmol/kg body weight [BW]) were prospectively enrolled in this open-label, multicenter clinical trial to evaluate PK as a primary end point. Plasma PK was analyzed using a population-based PK approach. Safety and qualitative efficacy (evaluation of images) were secondary end points. Safety and tolerability were assessed throughout study participation (approximately 7 days). Imaging efficacy variables were assessed by investigators.

RESULTS

Forty-four subjects were evaluated for safety and efficacy; 43 subjects were eligible for PK evaluation including 9 term newborns and infants aged younger than 2 months. Gadobutrol PK in pediatric subjects aged younger than 2 years were adequately described by a linear 2-compartmental model with elimination from the central compartment. Total median systemic exposure (area under the curve) of gadobutrol was estimated at 776 μmol · h/L (range, 544-1470 μmol · h/L). Simulated median concentration at 20 minutes after injection of gadobutrol (C20) was 339 μmol/L (range, 230-456 μmol/L). Safety and tolerability profile were similar to older populations. In 1 subject (2.3%), vomiting was reported as a mild adverse event related to gadobutrol, and there were no reported serious adverse events. The evaluation of gadobutrol-enhanced images provided improved diagnosis, increased confidence in diagnosis, and contributed to subject clinical management.

CONCLUSIONS

The PK profile of gadobutrol in children aged younger than 2 years including newborns is similar to that in older children and adults. At the dose of 0.1 mmol/kg BW, gadobutrol had a favorable safety profile and was well tolerated with similar profile across the age range 0 to younger than 2 years and compared with older children and adults. Extrapolation of efficacy data from adults to the younger pediatric population, including term newborns, is justified. The recommended standard dose of gadobutrol (0.1 mmol/kg BW), as used in the population aged 2 years and older, is also appropriate in children aged younger than 2 years.

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.

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.

Severe Acute Cardiopulmonary Failure Related to Gadobutrol Magnetic Resonance Imaging Contrast Reaction: Successful Resuscitation With Extracorporeal Membrane Oxygenation

Nonanaphylactic noncardiogenic pulmonary edema leading to cardiorespiratory arrest related to the magnetic resonance imaging contrast agent gadobutrol has rarely been reported in the literature. Rarer is the association of hypokalemia with acidosis. We report 2 patients who had severe pulmonary edema associated with the use of gadobutrol contrast in the absence of other inciting agents or events. These cases were unique not only for their rare and severe presentations but also because they exemplified the increasing role of extracorporeal membrane oxygenation in resuscitation. Emergency extracorporeal membrane oxygenation resuscitation can be rapidly initiated and successful in the setting of a well-organized workflow, and it is a viable alternative and helps improve patient outcome in cases refractory to conventional resuscitative measures.

Gadolinium deposition within the dentate nucleus and globus pallidus after repeated administrations of gadolinium-based contrast agents-current status

INTRODUCTION

Gadolinium-based contrast agents (GBCAs) have been used clinically since 1988 for contrast-enhanced magnetic resonance imaging (CE-MRI). Generally, GBCAs are considered to have an excellent safety profile. However, GBCA administration has been associated with increased occurrence of nephrogenic systemic fibrosis (NSF) in patients with severely compromised renal function, and several studies have shown evidence of gadolinium deposition in specific brain structures, the globus pallidus and dentate nucleus, in patients with normal renal function.

METHODS

Gadolinium deposition in the brain following repeated CE-MRI scans has been demonstrated in patients using T1-weighted unenhanced MRI and inductively coupled plasma mass spectroscopy. Additionally, rodent studies with controlled GBCA administration also resulted in neural gadolinium deposits.

RESULTS

Repeated GBCA use is associated with gadolinium deposition in the brain. This is especially true with the use of less-stable, linear GBCAs. In spite of increasing evidence of gadolinium deposits in the brains of patients after multiple GBCA administrations, the clinical significance of these deposits continues to be unclear.

CONCLUSION

Here, we discuss the current state of scientific evidence surrounding gadolinium deposition in the brain following GBCA use, and the potential clinical significance of gadolinium deposition. There is considerable need for further research, both to understand the mechanism by which gadolinium deposition in the brain occurs and how it affects the patients in which it occurs.

25 Years of Contrast-Enhanced MRI: Developments, Current Challenges and Future Perspectives

In 1988, the first contrast agent specifically designed for magnetic resonance imaging (MRI), gadopentetate dimeglumine (Magnevist(®)), became available for clinical use. Since then, a plethora of studies have investigated the potential of MRI contrast agents for diagnostic imaging across the body, including the central nervous system, heart and circulation, breast, lungs, the gastrointestinal, genitourinary, musculoskeletal and lymphatic systems, and even the skin. Today, after 25 years of contrast-enhanced (CE-) MRI in clinical practice, the utility of this diagnostic imaging modality has expanded beyond initial expectations to become an essential tool for disease diagnosis and management worldwide. CE-MRI continues to evolve, with new techniques, advanced technologies, and novel contrast agents bringing exciting opportunities for more sensitive, targeted imaging and improved patient management, along with associated clinical challenges. This review aims to provide an overview on the history of MRI and contrast media development, to highlight certain key advances in the clinical development of CE-MRI, to outline current technical trends and clinical challenges, and to suggest some important future perspectives.

FUNDING

Bayer HealthCare.

Safety of gadobutrol in more than 1,000 pediatric patients: subanalysis of the GARDIAN study, a global multicenter prospective non-interventional study

BACKGROUND

Gadobutrol is a gadolinium-based contrast agent, uniquely formulated at 1.0 mmol/ml. Although there is extensive safety evidence on the use of gadobutrol in adults, few studies have addressed the safety and tolerability of gadobutrol in pediatric patients.

OBJECTIVE

This subanalysis of data from the GARDIAN study evaluated the safety and use of gadobutrol in pediatric patients (age <18 years).

MATERIALS AND METHODS

The GARDIAN study was a large phase IV non-interventional prospective multicenter post-authorization safety study performed in Europe, Asia, North America and Africa. A total of 23,708 patients were included who were scheduled to undergo cranial or spinal MRI, liver or kidney MRI, or MR angiography with gadobutrol enhancement. The primary study endpoint was the overall incidence of adverse drug reactions (ADRs) and serious adverse events (SAEs) following gadobutrol administration.

RESULTS

The GARDIAN study included 1,142 children (age <18 years) who received gadobutrol at a mean dose of 0.13 (range 0.04-0.50) mmol/kg body weight. Gadobutrol was well tolerated in these children, with low rates of ADRs (0.5%) and no SAEs, consistent with results in adults enrolled in the GARDIAN study. Rates of adverse events and ADRs were unrelated to pediatric age or gadobutrol weight-adjusted dose. There were no symptoms suggestive of nephrogenic systemic fibrosis. Investigators rated the contrast quality of gadobutrol-enhanced images as good or excellent in 97.8% of pediatric patients, similar to the main study population.

CONCLUSION

Gadobutrol is very well tolerated and provides excellent contrast quality at the recommended weight-adjusted dose in children (age <18 years), similar to the profile in adults.

A Japanese, Multicenter, Open-label, Phase 3 Study to Investigate the Safety and Efficacy of Gadobutrol for Contrast-enhanced MR Imaging of the Central Nervous System

PURPOSE

Gadobutrol 1.0 M is macrocyclic gadolinium-based contrast agent for magnetic resonance imaging (MRI). This multicenter, open-label, phase 3 study aimed to investigate the efficacy and safety of gadobutrol-enhanced versus unenhanced MRI in the visualization and diagnosis of central nervous system (CNS) lesions in Japanese patients.

METHODS

A total of 223 patients referred for contrast-enhanced MRI of the CNS underwent unenhanced and gadobutrol-enhanced (0.1 mmol/kg body weight) MRI. The unenhanced and combined (unenhanced and enhanced) images were evaluated by three independent readers in a blinded manner for degree of contrast enhancement, border delineation, internal morphology, and number of detected lesions (primary variables), and for primary diagnosis and diagnostic confidence. Final clinical diagnoses were established by an independent truth committee consisting of two neurosurgeons. Sensitivity, specificity, and accuracy were calculated for the detection of malignancy and the preciseness of diagnoses (secondary variables) by comparing the results obtained by the blinded readers and the truth committee.

RESULTS

Gadobutrol enhancement significantly improved three visualization parameters in MR images: contrast enhancement, border delineation, and internal morphology (P < 0.0001). Non-inferiority was achieved for mean number of lesions detected. Gadobutrol-enhanced imaging provided significant improvements in sensitivity and accuracy for the detection of malignant disease with no loss in specificity, and also improvements in accuracy of exact match diagnosis and diagnostic confidence. Drug-related adverse events were reported in 6 out of 223 patients (2.7%); all were non-serious.

CONCLUSION

Gadobutrol is an effective and well-tolerated contrast agent for MR imaging of the CNS.

Acute Respiratory Distress Syndrome after the Use of Gadolinium Contrast Media

Acute respiratory distress syndrome (ARDS) is a medical emergency that threatens life. To this day, ARDS is very rarely reported by iodine contrast media, and there is no reported case of ARDS induced by gadolinium contrast media. Here, we present a case with ARDS after the use of gadobutrol (Gadovist) as a magnetic resonance imaging (MRI) contrast medium. A 26 years old female without any medical history, including allergic diseases and without current use of drugs, visited the emergency room for abdominal pain. Her abdominopelvic computed tomography with iodine contrast media showed a right ovarian cyst and possible infective colitis. Eighty-three hours later, she underwent pelvis MRI after injection of 7.5 mL (0.1 mL/kg body weight) of gadobutrol (Gadovist) to evaluate the ovarian cyst. She soon presented respiratory difficulty, edema of the lips, nausea, and vomiting, and we could hear wheezing upon auscultation. She was treated with dexamethasone, epinephrine, and norepinephrine. Her chest X-ray showed bilateral central bat-wing consolidative appearance. Managed with mechanical ventilation, she was extubated 3 days later and discharged without complications.

Feasibility and safety of perfusion MRI for Legg-Calvé-Perthes disease

BACKGROUND

Recent studies have suggested that perfusion magnetic resonance imaging (pMRI) using gadolinium contrast and a subtraction technique can provide useful prognostic information in Legg-Calvé-Perthes disease (LCPD) and allow earlier stratification for outcome. There are, however, sparse data available regarding the feasibility and safety of these studies in children. The purpose of this study was to collect this information across multiple centers using pMRI for LCPD.

METHODS

We retrospectively reviewed a consecutive series of patients with confirmed or suspected LCPD who had undergone pMRI at 1 of 5 large tertiary-care children's hospitals in the United States, UK, and Mexico. Demographic information, type of contrast administered, and requirement for sedation or anesthesia were noted. Records were scrutinized for adverse events associated with the pMRI protocol.

RESULTS

Over the study period, 165 patients underwent 298 pMRI studies. The median age at the time of imaging was 8.6 years (range, 2.5to 16.9 y). A total of 252 scans (85%) were performed for a known diagnosis of LCPD, whereas 46 were performed for a suspected diagnosis. Ninety-two of the 298 (31%) pMRIs required sedation, 48 (16%) required general anesthesia, and 122 (41%) were facilitated by video goggles only. The remaining 36 patients (12%) had their studies performed without additional measures. The ages of patients requiring sedation (mean, 7.2±2.4 y) and anesthesia (mean, 7.7±2.3 y) were significantly younger than those patients requiring neither (mean, 10.2±2.3 y, P<0.001). Four patients (1.3%) reported nausea or vomiting as a result of sedation. Two patients (0.7%) had complications from intravenous cannulation (pull out, difficult access). One child (0.3%) had nausea/vomiting as a result of contrast administration. There were no serious adverse events as a result of the pMRI protocol; specifically none of nephrogenic systemic fibrosis, anaphylaxis, or death.

CONCLUSIONS

pMRI is a safe and feasible imaging technique for LCPD. Almost half of our patients required either sedation or general anesthesia to complete the study.

LEVEL OF EVIDENCE

IV (case series).

Adverse reactions to intravenous contrast media: an unexpected discrepancy between inpatient and outpatient cohorts

Adverse reaction rates to computed tomography (CT) and magnetic resonance imaging (MRI) contrast agents are well published. However, there is no literature regarding systems-based changes to improve contrast reaction management. As part of ongoing quality improvement monitoring at our institution, contrast reaction events were reviewed. Contrast reactions for CT and MRI were captured at lower rates for the inpatient setting compared to outpatient by an order of a magnitude. The documented inpatient events were more likely to be severe in nature. Given this discrepancy, focus is being placed upon identifying potential barriers to capturing and appropriately managing inpatient contrast reactions.

Safety and Efficacy of Gadobutrol for Contrast-enhanced Magnetic Resonance Imaging of the Central Nervous System: Results from a Multicenter, Double-blind, Randomized, Comparator Study

PURPOSE

Contrast-enhanced magnetic resonance imaging (MRI) of the central nervous system (CNS) with gadolinium-based contrast agents (GBCAs) is standard of care for CNS imaging and diagnosis because of the visualization of lesions that cause blood–brain barrier breakdown. Gadobutrol is a macrocyclic GBCA with high concentration and high relaxivity. The objective of this study was to compare the safety and efficacy of gadobutrol 1.0 M vs unenhanced imaging and vs the approved macrocyclic agent gadoteridol 0.5 M at a dose of 0.1 mmol/kg bodyweight.

MATERIALS AND METHODS

Prospective, multicenter, double-blind, crossover trial in patients who underwent unenhanced MRI followed by enhanced imaging with gadobutrol or gadoteridol. Three blinded readers assessed the magnetic resonance images. The primary efficacy variables included number of lesions detected, degree of lesion contrast-enhancement, lesion border delineation, and lesion internal morphology.

RESULTS

Of the 402 treated patients, 390 patients received study drugs. Lesion contrast-enhancement, lesion border delineation, and lesion internal morphology were superior for combined unenhanced/gadobutrol-enhanced imaging vs unenhanced imaging (P < 0.0001 for all). Compared with gadoteridol, gadobutrol was non-inferior for all primary variables and superior for lesion contrast-enhancement, as well as sensitivity and accuracy for detection of malignant disease. The percentage of patients with at least one drug-related adverse event was similar for gadobutrol (10.0%) and gadoteridol (9.7%).

CONCLUSION

Gadobutrol is an effective and well-tolerated macrocyclic contrast agent for MRI of the CNS. Gadobutrol demonstrates greater contrast-enhancement and improved sensitivity and accuracy for detection of malignant disease than gadoteridol, likely because of its higher relaxivity.

The Impact of Flip Angle and TR on the Enhancement Ratio of Dynamic Gadobutrol-enhanced MR Imaging: In Vivo VX2 Tumor Model and Computer Simulation

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is widely used to diagnose cancer and monitor therapy. The maximum enhancement ratio (ERmax) obtained from the curve of signal intensity over time could be a biomarker to distinguish cancer from normal tissue or benign tumors. We evaluated the impact of flip angle (FA) and repetition time (TR) on the ERmax values of dynamic gadobutrol-enhanced MR imaging, obtaining T1-weighted (T1W) MR imaging of VX2 tumors using 2-dimensional fast spoiled gradient echo (2D FSPGR) with various FAs (30°, 60° and 90°) at 1.5 tesla before and after injection of 0.1 mmol/kg gadobutrol. In vivo study indicated significant differences between ERmax values and area under the ER-time curve (AUC100) of VX2 tumors and muscle tissue, with the highest ERmax and AUC100 at FA 90°. Computer simulation also demonstrated the ER as a strictly increasing monotonic function in the closed interval [0°, 90°] for a given TR when using T1W FSPGR, and the highest ER value always occurred at FA 90°. The FA for the highest ER differed from that for the highest signal-to-noise or contrast-to-noise ratio. For long TR, the ER value increases gradually. However, for short TR, the ER value increases rapidly and plateaus so that the ER value changes little beyond a certain FA value. Therefore, we suggest use of a higher FA, near 90°, to obtain a higher ERmax for long TR in 2D SPGR or FSPGR and a smaller FA, much less than 90°, to reach an appropriate ERmax for short TR in 3D SPGR or FSPGR. This information could be helpful in setting the optimal parameters for DCE-MRI.

Compensatory biliary and urinary excretion of gadobenate ion after administration of gadobenate dimeglumine (MultiHance(®)) in cases of impaired hepatic or renal function: a mechanism that may aid in the prevention of nephrogenic systemic fibrosis?

Objective:

To determine whether increased elimination of gadobenate ion via the hepatobiliary pathway might compensate for reduced/absent elimination via the urinary pathway in the event of compromised renal function, as a possible protective mechanism against nephrogenic systemic fibrosis (NSF).

Methods:

15 male Crl:CD^® R(SD)Br rats (Charles River Italia, Como, Italy) randomized to three treatment groups: (1) animals with occluded bile ducts, (2) animals with occluded renal vessels and (3) control animals, each received 0.25 mmol kg⁻¹ of bodyweight of gadobenate dimeglumine (MultiHance^®; Bracco Imaging SpA, Milan, Italy). Urine and bile were collected from 0−30, 30−60, 60−120, 120−240 and 240−480 min after gadobenate dimeglumine administration prior to exsanguination. Determinations of gadobenate ion in blood, bile and urine were performed by high-performance liquid chromatography. Gadolinium (Gd³⁺) levels in excised liver and kidneys were determined by X-ray fluorescence.

Results:

The recovery of gadobenate ion in the urine of rats with bile duct occlusion was significantly higher than that in the urine of normal rats (89.1 ± 4.2% vs 60.6 ± 2.8%; p < 0.0001). Conversely, mean recovery in the bile of rats with renal vessel occlusion was significantly higher than that in the bile of normal rats (96.16 ± 0.55% vs 33.5 ± 4.7%; p < 0.0001). Gadobenate ion was not quantifiable in any group 8 h post-injection.

Conclusion:

Compensatory elimination may be an effective means to overcome compromised renal or hepatobiliary elimination.

Advances in knowledge:

The absence of NSF in at-risk patients administered with gadobenate dimeglumine may in part reflect greater Gd³⁺ elimination via the hepatobiliary route.

Gadolinium contrast agents for CNS imaging: current concepts and clinical evidence

SUMMARY

The aim of this article was to review the properties of the various gadolinium-based contrast agents used for CNS imaging along with the clinical evidence and published data that highlight the impact these different properties can have on diagnostic performance. In addition, approaches to optimizing image acquisition that take into account the different properties of specific gadolinium-based contrast agents and an extensive review of the safety profiles of the various agents are presented.

Phase 3 efficacy and safety trial of gadobutrol, a 1.0 molar macrocyclic MR imaging contrast agent, in patients referred for contrast-enhanced MR imaging of the central nervous system

PURPOSE

Gadobutrol is a 1.0 M macrocyclic magnetic resonance imaging (MRI) contrast agent. A study was performed to evaluate the efficacy and safety of gadobutrol-enhanced versus unenhanced imaging for central nervous system (CNS) lesion visualization and detection.

MATERIALS AND METHODS

An international, multicenter, open-label, Phase III clinical trial. Patients underwent unenhanced and gadobutrol 1.0 M-enhanced (0.1 mmol/kg BW) MR imaging using a standardized protocol. Unenhanced and combined unenhanced/gadobutrol-enhanced images were scored by three independent, blinded readers for degree of lesion enhancement, border delineation, internal morphology, and total number of lesions detected (primary efficacy variables). Exact match of the MR diagnoses with the final clinical diagnosis, detection of malignant CNS lesions, and confidence in diagnosis were secondary efficacy variables.

RESULTS

Of 343 enrolled patients, 321 were evaluated for efficacy. All primary efficacy endpoints were met: superiority was demonstrated for gadobutrol-enhanced versus unenhanced MR images (P < 0.0001 in all cases) for lesion enhancement, border delineation, and internal morphology. Noninferiority was met for mean number of lesions detected. There were improvements in the sensitivity of malignant lesion detection, without a loss in specificity, exact-match diagnostic accuracy, and reader confidence. Treatment-related adverse events were reported in 4.1% (n = 14); all were nonserious.

CONCLUSION

Gadobutrol 1.0M is an effective and well-tolerated contrast agent for CNS MRI.

Gadobutrol: a review of its use for contrast-enhanced magnetic resonance imaging in adults and children

Since the introduction of the first gadolinium-based contrast agent (GBCA) approximately 25 years ago, magnetic resonance imaging (MRI) using GBCAs has revolutionized diagnostic and follow-up imaging of pathological lesions, with clinical applications expanded to encompass almost all fields of medicine. Intravenous gadobutrol (Gadovist™ [EU]; Gadavist(®) [USA]) is a second-generation extracellular non-ionic macrocyclic GBCA that is used in patients undergoing diagnostic contrast-enhanced MRI for visualization of pathological lesions in the CNS and all other body regions or for contrast-enhanced magnetic resonance angiography (MRA) to evaluate perfusion and flow-related abnormalities. Its unique physicochemical profile, along with the high thermostability of macrocyclic GBCAs, means gadobutrol is formulated at twice the gadolinium ion concentration of other currently licensed GBCAs. This reduces the injection volume and provides a narrower bolus, thereby improving image enhancement. Based on extensive clinical experience in a broad range of patients, including paediatric and adult patients (younger and elderly adults), and those with moderate to severe hepatic or renal impairment or cardiovascular disorders, gadobutrol is an effective and generally well tolerated extracellular GBCA for patients undergoing diagnostic contrast-enhanced MRI and contrast-enhanced MRA. As with all macrocyclic GBCAs, the potential for gadobutrol to cause nephrogenic systemic fibrosis appears to be lower than with linear GBCAs.

Contrast-enhanced MR imaging in neuroimaging

MR imaging without and with gadolinium-based contrast agents (GBCAs) is an important imaging tool for defining normal anatomy and characteristics of lesions. GBCAs have been used in contrast-enhanced MR imaging in defining and characterizing lesions of the central nervous system for more than 20 years. The combination of unenhanced and GBCA-enhanced MR imaging is the clinical gold standard for the noninvasive detection and delineation of most intracranial and spinal lesions. MR imaging has a high predictive value that rules out neoplasm and most inflammatory and demyelinating processes of the central nervous system.

Efficacy and Safety of Gadobutrol (1.0 M) versus Gadopentetate Dimeglumine (.5 M) for Enhanced Mri of Cns Lesions: A Phase Iii, Multicenter, Single-blind, Randomized Study in Chinese Patients

The aim of this study was to compare the efficacy and safety of macrocyclic gadobutrol (1.0 M) with linear gadopentetate dimeglumine (0.5 M) for contrast-enhanced magnetic resonance imaging (MRI) of central nervous system (CNS) lesions in Chinese patients (N = 147) with known or suspected CNS lesions, who were enrolled in this single-blind, randomized, parallel-group study. Three blinded independent readers evaluated all efficacy variables. The primary efficacy variable was the difference between the two agents for the change in contrast-to-noise ratio (CNR) between non-enhanced and contrast-enhanced scans of lesions. Secondary outcomes included mean change in number of lesions detected before and after contrast enhancement, diagnostic confidence, and safety and tolerability parameters. Gadobutrol was non-inferior to gadopentetate dimeglumine in respect to the difference in the mean change in CNR (6.94; 95% confidence interval [CI] lower limit: -3.90; predefined maximum 95% CI lower limit: -6.52). The mean change in the number of CNS lesions detected was greater with gadobutrol versus gadopentetate dimeglumine (1.2 vs. 0.2 lesions). Diagnostic confidence was classified as ‘high’ for more patients with gadobutrol versus gadopentetate dimeglumine by the investigators (58.8% vs. 55.4%) and by the three blinded readers (63.6% vs. 55.7%, 23.7% vs. 18.0% and 81.7% vs. 81.0%). Both agents were well tolerated by participating patients. We concluded that in Chinese patients with CNS lesions, gadobutrol (1.0 M) was as effective and well tolerated in contrast-enhanced MRI as gadopentetate dimeglumine (0.5 M). Gadobutrol provided improved visualization of CNS lesions compared with gadopentetate dimeglumine, with a comparable tolerability profile.

Gadolinium in pediatric cardiovascular magnetic resonance: what we know and how we practice

BACKGROUND

The association of gadolinium-based contrast agents (GBCAs) with nephrogenic systemic fibrosis (NSF) has led to a heightened awareness towards patients' renal function. Whereas detailed guidelines exist for the use of GBCAs in adult patients, best practice is less well defined in children, especially in the very young. We aimed at identifying current practice with regards to the use of GBCAs in children who undergo cardiovascular magnetic resonance.

METHODS

We conducted a worldwide survey among cardiac imagers with pediatric expertise. The questionnaire contained 21 questions covering the imagers' work environments, GBCAs used, monitoring of renal function, and a special emphasis was placed on the practice in neonates.

RESULTS

The survey yielded 70 replies. The single most commonly used GBCA was gadopentetate dimeglumine 34/70 (49%). Among the respondents, the choice of GBCA was more importantly based on availability 26/70 (37%) and approval by a pharmaceutical licensing body that most closely reflects the indication 16/70 (23%) than image quality 7/70 (10%) and side effect profile 8/70 (11%). 55/70 (79%) of respondents performed scans in neonates <1 week of age and 52/55 (95%) of them used GBCA in neonates. 65/70 (93%) respondents at least assess some of their patients' renal functions. Formula-based estimate of glomerular filtration rate is the most popular assessment method 35/65 (54%). In patients with a glomerular filtration rate < 30 ml/min/1.73 m(2) 62/70 (89%) of respondents do not administer gadolinium at all. The single most common side effect of gadolinium was noted to be nausea/emesis 34/57 (60%) followed by discomfort at injection site 17/57 (30%).

CONCLUSIONS

Cardiac imagers are aware of the immature renal function and physiological differences of their pediatric patients that place them at risk for NSF. Epidemiological data is needed for pediatric cardiovascular licensure of gadolinium compounds and for the creation of practice guidelines which will replace current-day practice based on individual clinical judgment.

MR imaging of neoplastic central nervous system lesions: review and recommendations for current practice

MR imaging is the preferred technique for the diagnosis, treatment planning, and monitoring of patients with neoplastic CNS lesions. Conventional MR imaging, with gadolinium-based contrast enhancement, is increasingly combined with advanced, functional MR imaging techniques to offer morphologic, metabolic, and physiologic information. This article provides updated recommendations to neuroradiologists, neuro-oncologists, neurosurgeons, and radiation oncologists on the practical applications of MR imaging of neoplastic CNS lesions in adults, with particular focus on gliomas, based on a review of the clinical trial evidence and personal experiences shared at a recent international meeting of experts in neuroradiology, neuro-oncology, neurosurgery, and radio-oncology.

Cerebral neoplastic enhancing lesions: multicenter, randomized, crossover intraindividual comparison between gadobutrol (1.0M) and gadoterate meglumine (0.5M) at 0.1 mmol Gd/kg body weight in a clinical setting

OBJECTIVE

Two macrocyclic extracellular contrast agents, one-molar neutral gadobutrol and ionic gadoterate meglumine, were compared to determine the overall preference for one or the other in a clinical setting.

MATERIALS AND METHODS

Multicenter, randomized, single-blind, intra-individually controlled, comparison study with a corresponding blinded read. Efficacy analysis was based on 136 patients who underwent identical MRI examinations: group A first received 1.0M gadobutrol followed by 0.5M gadoterate meglumine 48 h to 7 days later; group B had a reversed administration order. Three independent blinded readers assessed off-site their overall diagnostic preference (primary efficacy parameter) based on a matched pairs approach.

RESULTS

Superiority of gadobutrol over gadoterate meglumine was demonstrated for the qualitative assessment of overall preference across all readers by a statistically significant difference between both contrast agents for this primary endpoint. Preferences in lesion enhancement (secondary endpoint) were also found significantly in favor of gadobutrol. For preference in lesion delineation from surrounding tissue/edema and for internal structure only a trend towards a higher proportion for gadobutrol was found (except for internal structure reported by one reader, which showed a result of statistical significance). Lesion contrast and relative lesion enhancement (quantitative parameters) were statistically significantly higher for gadobutrol compared to gadoterate meglumine.

CONCLUSION

Contrast-enhanced MRI of neoplastic brain lesions at a dose of 0.1 mmol Gd/kg body weight, assessed in a standardized off-site blinded reading, results in a significantly higher qualitative and quantitative preference for gadobutrol compared to gadoterate meglumine.