Making bone inflammation/infection simpler to detect Scintimun® 1mg

Monograph

New active ingredient according to Spanish Royal Decree 1344/2007

New product under intensive monitoring in United Kingdom Scintimun® Monograph

Scintimun® Monograph

2 | IBA | Scintimun® Monograph 1. Osteomyelitis

Prof. Daniel P.Lew

Geneva University Hospital, Department of Internal Medicine, Infectious Diseases Service 1211 Geneva 14 - Switzerland

1.1. Definition and pathogenesis S aureus adheres to bone by expressing receptors for components of bone matrix. This bacteria has Osteomyelitis is a progressive infectious process the capacity to grow as a biofilm in a metabolically involving the various components of bone, namely altered state, on the surface of dead bone or periosteum, medullary cavity, and cortical bone. foreign material. It can also penetrate and survive The disease is characterized by progressive, in healthy cells, such as osteoblasts. These inflammatory destruction of bone, by necrosis, and features may explain how S aureus may escape by new bone apposition(1). from immune responses and antibiotics, possibly The pathogenesis of osteomyelitis has been for years, and the necessity of prolonged antibiotic explored in various animal models; these studies therapy and often of surgery to achieve cure(2,3). have found that normal bone is highly resistant to infection, which can only occur as a result of very During infection, phagocytes attempt to contain large inocula, trauma or in the presence of foreign invading microorganisms and, in the process, bodies. generate toxic oxygen radicals and proteolytic Although many bacteria can cause osteomyelitis enzymes that lyse surrounding tissues. The formed the predominant microorganism is Staphylococcus pus spreads into vascular channels, raising the aureus in up to 50% of cases. In the other cases intraosseus pressure and impairing blood flow. The Coagulase Negative Staphyloccoci, Enteric Gram ischemic necrosis of bone results in the separation Negative rods, Pseudomonas sp, anaerobes, of devascularized and dead bone fragments, Mycobacteria, yeasts or mixed infections may be which are called sequestra. encountered(2,3).

Vertebral Osteomyelitis Staphylococcus aureus Gram negative Aerobic Bacilli Prosthetic Joint Infection Streptococcus sp Coagulase Negative Staphylococci Mycobacterium tuberculosis Staphylococcus aureus Polymicrobial Streptococcus sp

Diabetic Foot Infection Staphylococcus aureus Streptococcus sp Prostraumatic Infection Enterococcus sp Staphylococcus aureus Coagulase Negative Staphylococci Gram negative Aerobic Bacilli Gram Negative Aerobic Bacilli Anaerobes Anaerobes

Various types and microbial causes of osteomyelitis

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1.2. Acute versus chronic Osteomyelitis

Acute osteomyelitis evolves over several days to weeks: the term "acute" is used in opposition to chronic osteomyelitis, a disease characterized by clinical symptoms that persist for several weeks followed by longstanding infection that evolves over months or even years, by the persistence of microorganisms, by low-grade inflammation, by the Development of osteomyelitis secondary to a contiguous presence of necrotic bone (sequestra) and foreign focus of infection; inflammatory cells and necrotic bone material, and by fistulous tracts. The terms acute and chronic do not have a sharp demarcation and are often used somewhat loosely. Nevertheless, they are useful clinical concepts in infectious disease, as they describe two different patterns of the same disease, due to the same microorganisms, but with different evolutions(3).

Histopathology of osteomyelitis Radiology of chronic tibial osteomyelitis

4 | IBA | Scintimun® Monograph 1.3. Types of osteomyelitis 1.4. Diagnosis

From a practical point of view, it is useful to 1.4.1 Imaging modalities in the setting of distinguish three types of osteomyelitis(1,2,3). suspected osteomelitis Imaging is an useful tool in the setting of Hematogenous osteomyelitis follows bacteremic suspected osteomyelitis, particularly for supporting spread, is seen mostly in prepubertal children and a presumed clinical diagnosis, delineating the in elderly patients, and is characterized by local extent of disease, and planning therapy. multiplication of bacteria within bone during ➤ Conventional radiography is necessary at both septicemia. In most cases infection is located in presentation and follow up but suffers from poor the metaphyseal area of long bones or in the sensitivity and specificity. Plain films show soft spine- vertebral osteomyelitis. Typically in tissue swelling, narrowing or widening of joint hospitalized patients who develop nosocomial spaces, and signs of chronic infection such as bacteremia or candidemia, usually from bone destruction and periostal reaction. However intravenous devices, secondary osteomyelitis may bone destruction is not apparent on plain films until develop. after 10-21 days of infection. ➤ Ultrasound can be useful for early diagnosis or Osteomyelitis secondary to a contiguous focus of for detection of a purulent collection in soft tissue. infection without vascular insufficiency follows ➤ Nuclear imaging is a reasonably early trauma, perforation, or a surgical orthopedic diagnostic choice and as an alternative for MRI or procedure. It implies a first infection, which by CT scans. Various radiopharmaceuticals are continuity gains access to bone. By definition, it currently used for bone scintigraphy. can occur at any age, and can involve any bone. The most commonly used methylene It is useful to distinguish in this group the patients diphosphonate binds to sites of increased bone with a foreign body implant because of its high metabolic activity and is highly sensitivity but susceptibility and necessity to remove the suffers from poor specificity for infection due to prosthesis to achieve cure in most cases. With the other bone diseases such as diabetic (Charcot ) larger utilization of prosthetic devices (knee, hip, arthropathy, gout, trauma and surgery. shoulder and other), prosthetic joint infections Leukocyte scanning with radiolabeled blood cells associated with osteomyelitis is becoming a very or specific antibodies are more recent nuclear large problem, usually in elderly patients. techniques increasingly used and are reported to have high sensitivity and especially higher Osteomyelitis secondary to vascular insufficiency specificity for detecting infections. They have the and neuropathy is the consequence of poor blood advantage of not being influenced by metal supply, usually to the lower extremities. Often hardware but large studies in humans are lacking. associated with diabetes, this last disease entity ➤ Magnetic resonance imaging (MRI) is the best has several important contributing factors: modality for obtaining detailed anatomic diabetes and its metabolic consequences, bone delineation of the extent of bone marrow and soft ischemia, neuropathy, vascular insufficiency and tissue inflammation. It is useful for evaluation of infection probably all contribute to bone osteomylitis in the foot (in the setting of diabetes) destruction(4). and in the vertebrae (given its excellent delineation of the spinal cord). However MRI is not specific for infection and other causes may create bone marrow edema (such as contusion, post-surgery and Charcot disease). MRI may also overestimate

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the extent of infection in surrounding tissues and administration of antibiotics may be followed with remain positive even after successful treatment. an equal success rate by oral therapy for several Computed tomography (CT) can also provide weeks, provided that the organism is known, alternative anatomic delineation of infection in clinical signs abate rapidly, patient compliance is cases MRI cannot be obtained. However as with good, and serum antibiotic levels can be MRI, metal hardware may limit the use of CT. monitored. This approach has now also been The specificity of positron-emission tomography validated in small series of adult patients. Another with fluorodeoxyglucose (FDG)-PET associated approach that has gained significant acceptance with CT needs further evaluation. because of its reduced cost is parenteral administration of antibiotics, first in hospital, then 1.4.2. Microbiological and pathological on an outpatient basis. Long-term oral therapy criteria extending over months and more rarely years is If there is one area where adequate sampling for aimed at palliation of acute flare-ups of chronic, bacteriology is important, this is the case of refractory osteomyelitis. Local administration of osteomyelitis because treatment will be given for antibiotics, either by instillation or by gentamicin- many weeks, most often by a parenteral route laden beads, has its advocates both in the United following the results of the initial culture. Adequate States and in Europe, but it has not been submitted sampling of deep infected tissue is thus extremely to critical, controlled studies; antibiotics diffusion is useful (in contrast to specimens obtained limited in time and space, but may be of some superficially from ulcers or from fistula which are additional benefit in osteomyelitis secondary to a often misleading). Usually this may be done under contiguous focus of infection. The 8- CT guidance. fluoroquinolones have been one of the most Results of gram stain and culture, obtained ideally interesting developments in this domain and have before therapy, should be carefully analyzed. If been shown to be quite efficient in experimental classical bacteria do not grow in suspicious cases, infections and in several randomized and non tissue should be available to perform fungal and randomized studies in adults. Whereas their mycobacterial cultures as well as broad range efficacy in the treatment of osteomyelitis due to PCR. Tissue specimens prepared for most Enterobacteriaceae seems undisputed, their histopathology are useful for observing the advantage over conventional therapy in presence of neutrophils and the use of special osteomyelitis due to Pseudomonas or Serratia stains for various microorganisms may be species as well as gram-positive organisms (in sometimes useful to confirm diagnosis. particular multiresistant S. aureus) remains to be demonstrated(6). 1.4.3. Antimicrobial and Surgical Therapy Single-agent antibiotic therapy is usually adequate Finally, considerable progress has been achieved for the treatment of osteomyelitis of any type. As a in the development of novel surgical approaches general principle, these antibiotics should be given (bone graft, revascularization procedure, muscle intravenously for 4 to 6 weeks, as substantiated by flaps) that allow more rapid formation of new bone. experimental models and many clinical reports. They should be adapted carefully to the cultured 1.4.4. Clinical Response microorganisms(5). Because of the protracted characteristics of In recent years, new approaches to antimicrobial osteomyelitis, cure is defined as the resolution of therapy have been developed experimentally and all signs and symptoms of active disease at the validated clinically. Thus, in hematogenous end of therapy and after a minimal post treatment osteomyelitis of childhood, parenteral observation period of 1 year. By contrast, failure is

6 | IBA | Scintimun® Monograph defined as a lack of apparent response to therapy, fever, weight loss, bone pain); and (4) progression as evidenced by one or more of the following: (1) of bone infection shown by imaging methods (e.g., persistence of drainage; (2) recurrence of a sinus radiography, computed tomography, magnetic tract or failure of a sinus tract to close; (3) resonance imaging). persistence of systemic signs of infection (chills,

General conclusion for the Management of Osteomyelitis

The many pathogenic factors, modes of end of the spectrum (e.g., hematogenous acute contamination, clinical presentations, and types osteomyelitis) adequate antibiotics are sufficient of orthopedic procedures related to osteomyelitis and surgery usually is unnecessary, at the other have precluded a very scientific approach to end (a consolidated chronically infected fracture) therapy, with well-controlled, statistically valid cure may be achieved with minimal antibiotic studies; however, experimental models have treatment provided the foreign material and helped to understand some basic principles of necrotic bone are removed. In the presence of a antibiotic therapy. Thus, except for the foreign body (prosthetic joint infection) both fluoroquinolones, which penetrate unusually well careful surgery (early debridement or prosthesis into bone, bone antibiotic levels 3 to 4 hours after exchange) and prolonged antibiotic therapy are administration are usually quite low when often required. compared to serum levels; antibiotic treatment given parenterally has to be given for several Nowadays a multidisciplinary approach is weeks to achieve an acceptable cure rate; and required for success in treating osteomyelitis, early antibiotic treatment, given before extensive involving multiple experts in radiology and bone destruction has occurred, produces the nuclear medicine, microbiology and infectious best results. diseases as well as orthopedic, vascular and A combined antimicrobial and surgical approach plastic surgery. should always be considered: whereas at one

References

1. Waldvogel F A, Medoff G, Swartz M N. Osteomyelitis: 5. Mader J T, Norden C, Nelson J D, Calandra G B. a review of clinical features, therapeutic considerations Evaluation of new anti-infective drugs for the treatment of and unusual aspects. N Engl J Med 282: 198-206, 1970. osteomyelitis in adults. Infectious Diseases Society of America and the Food and Drug Administration. Clin 2. Lew D.P., Waldvogel FA, Osteomyelitis. N Engl J med Infect Dis 15 Suppl 1: S155-S161, 1992. 1997; 336: 999-1007, 1997. 6. Lew DP and Waldvogel FA, Use of quinolones for 3. Lew DP, Waldvogel FA, Osteomyelitis. Lancet 364: treatment of osteomyelitis and septic arthritis. In 369-379, 2004. Quinolone antimicrobial agents. D.C. Hooper and J.S. 4. Lipsky BA et al, Diagnosis and treatment of diabetic Wolfson, editors. American Society for Microbiology, foot infections. Clin Inf Dis 39:885-910, 2004. Washington, D.C.. 371-379.1993.

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2. Inflammation / infection and neutrophils

Prof. Marie-Anne Gougerot-Pocidalo

Professeur in Immunology Department of Haematology and Immunology Groupe Hospitalier Bichat-Claude Bernard 46 Rue Henri Huchard 75018, Paris.

2.1. Role of granulocytes as bacteria, fungi, parasites, and viruses which have crossed the mucocutaneous barrier, and Inflammation is a coordinated process induced by against all bodies recognized as foreign, such as microbial infection or tissue injury. The main altered endogenous cells and molecules. function of inflammation is to resolve the infection ➤ Neutrophils are highly motile phagocytic cells or repair the damage and return to a state of that are the first immune cells to migrate from the homeostasis. Intrinsic to the efficacy of such a circulating blood to the inflammatory site. system is the ability to mount a rapid response ➤ Monocyte migration occurs in a secondary step. appropriate to the particular type of inflammatory Mobilization of inflammatory neutrophils is trigger while limiting the damaging aspects of coordinated by a complex network of inflammatory inflammation as much as possible(1). mediators that are produced in the context of the inflammatory process triggered by infection. The hallmark of inflammation associated with Neutrophils are physiologically at rest in the microbial infection (i.e., redness, heat, swelling and circulating blood. pain) are initiated by innate immune recognition. These symptoms are mainly due to vasodilatation, But when they are prompted by different stimuli increased vascular permeability and leukocyte from the infectious or inflammatory site, they infiltration. adhere to endothelial cells, slip between them and They are triggered by inflammatory mediators are oriented (chemotaxis) to their tissue target(2). induced by pathogen recognition such as The effector responses are triggered by the complement-derived peptides (C3a, C5a); recognition of microbes by “pattern recognition pathogen-derived chemoattractants such as N- receptors”, adherence to and engulfment of the formyl peptides or inflammatory mediators target, together with interaction at the membrane of (leucotriène B4, Platelet Activating factor, different molecules derived from the pathogen, chemokines, pro and anti-inflammatory cytokines) such as N-formyl peptides, endotoxins or products produced by resident macrophages in the of cellular origin such as the cytokines(3). infection/inflammation context. These responses include the production and Phagocytes, neutrophils and monocytes/ release of killer and degrading substances such macrophages constitute one of our most potent as reactive oxygen species, the contents of defence systems against pathogenic agents such

8 | IBA | Scintimun® Monograph granules and cytokines(4). Furthermore, neutrophils prolonged neutrophil stimulation can lead to severe are clearly involved in the regulation of the other collateral damages that are observed in certain cells present at the inflammatory site and in the chronic infection or inflammatory disorders. This regulation of the adaptative immune response highlights the need for fine tuning of activation of namely via the regulation of dendritic cell neutrophils, which are necessary to the maturation. If the inflammatory response is able to maintenance of the host’s biological integrity but contain microbial infection, then the overall are also the source of diseases when they are response is shifted toward resolution of excessively or inappropriately activated(5). inflammation. However, excessive, inapropriate or

Pathogen Blood Tissue Complement Endotoxins stream C3a C5a N-Formyl peptides

Neutrophil recruitement Upregulation of resident Enhancement of Macrophage vascular permeability Neutrophil response Inflammatory mediators: Resident Enzymes, chemokines, Macrophage pro and anti-inflammatory cytokines

Amplification of phagocyte Monocyte recruitement Regulation of immune responses Ag Adaptive immunity

Natural killer cell Dendritic cell

The innate immune response function is the first line of defense against infection

References

1-Barton GM A calculated response: control of inflammation by 5-Dang PM, Stensballe A, Boussetta T, Raad H, Dewas C, the innate immune system. J. Clin. Invest. 2008. 118: 413-420. Kroviarski Y, Hayem G, Jensen ON, Gougerot-Pocidalo MA, El- Benna J. A specific p47phox -serine phosphorylated by 2-Witko-Sarsat V, Rieu Ph, Descamps-latscha B, lesavre P, convergent MAPKs mediates neutrophil NADPH oxidase Halwachs-mecarelli L. Lab. Invest. 2000. 80: 617-653 priming at inflammatory sites. J Clin Invest. 2006 3-El-Benna J, Dang PMC, Gougerot-Pocidalo MA. Sem. Jul;116(7):2033-43. Immunopathol. 2008. 30: 279-289.

4-Segal AW. How neutrophils kill microbes. Annu Rev Immunol 2005. 23: 197-223.

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3. Scintimun®

99mTc

Scintimun®: murine monoclonal antibody BW 250/183 (besilesomab) labelled with 99mTc

3.1. Clinical indication 3.2. Presentation

“Scintigraphic imaging, in conjunction with other Besilesomab is a murine immunoglobulin of IgG1 appropriate imaging modalities, for determining the isotype that specifically binds to NCA-95 (non location of inflammation/infection in peripheral specific cross-reacting antigen 95), an epitope bone in adults with suspected osteomyelitis. expressed at the cell membrane of granulocytes Scintimun® should not be used for the diagnosis of and granulocyte precursors. Besilesomab cross- diabetic foot infection”. reacts with tumours expressing carcinoembryonic antigen (CEA). Besilesomab has been demonstrated to have no effect neither on activation of complement, nor on granulocytes function and platelets(1). Besilesomab has an affinity for NCA-95 antigen of 2 x 109 L/mol(2).

NCA-95 antigen over expressed in activated granulocyte.

High affinity binding 2.109 L/mol

Labeling to already migrated granulocyte (passive)

Direct labeling in blood stream (active)

10 | IBA | Scintimun® Monograph 3.3. Pharmacodynamics profile Cross-reactivity with CEA Tissue specificity of besilesomab was evaluated Mechanism of action on a broad panel of human cryopreserved normal Although the mechanism of accumulation of as well as cancer tissues derived from various besilesomab at the site of infection/inflammation individuals using immunohistochemistry. has not been fully elucidated, it is postulated that it Besilesomab showed strong binding to colon is mainly passive (increased vascular permeability) carcinomas and granulocytic cells in normal and partly active (migration of human granulocytes tissues (i.e. normal liver, lung and bone marrow(8)). carrying besilesomab to the infection/inflammation Furthermore, besilesomab binds to pancreatic, site) because only 10% to 20% of the injected(3) some lung and some breast carcinomas but does radiolabelled antibody bind in vivo to human not bind to blood vessels and connective tissue. circulating granulocytes. Specific binding of Finally, CD66 expression on bone marrow cells of besilesomab to already migrated and activated patients with multiple myeloma was shown ex vivo granulocytes may be the major part of the by flow cytometry using besilesomab as anti CD66. detection signal. Therefore, false positive images are possible in case of CEA expressing tumours or Granulocytes and granulocytic function haematological malignancies such as myeloma(9). Besilesomab binds to 99.6% of mature human granulocytes in whole blood samples analysed by 3.4. Pharmacokinetic profile flow cytometry but does not bind to early granulocyte precursors in human bone marrow Whole blood concentration-time radioactivity CD34+ cells(4). curves show a two-phase course, which can be subdivided into an early phase (0-2 h) and a late Despite its binding capacity to human phase (5-24 h). After correcting for the decay of granulocytes, besilesomab does not significantly radionuclide, the calculated half-life of the early influence granulocyte-mediated functions phase is 0.5 h whereas the late phase shows a ➤ (enzyme release, pinocytosis, half-life of elimination of 16 h. In plasma the data chemiluminescence)(5) and show comparable pharmacokinetics, with an early ➤ does not induce any lytic effects to epitope phase with a half-life of 0.5 h and a late phase with positive cells via complement-dependent or a half-life of 16 h. antibody-dependent cell-mediated cytotoxicity (CDC or ADCC)(6). ➤ It does not impair bone marrow cell proliferation(7).

Interaction with other blood cells No significant binding of besilesomab to other human peripheral blood cells was observed: erythrocytes (0.1% to 1.3%), platelets (0% to 0.9%), lymphocytes (0.2% to 5%) and monocytes (0.4% to 3.5%). Another study confirmed the non cross-reactivity of besilesomab with human platelets (<3%)(1).

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PK blood References

12 1) Mimouni “Cross reactivity of besilesomab with human

10 platelets and granulocytes from doses – Report 348 44EP.

8 2) Steinsträsser A et al. Binding of the monoclonal antibody BW 6 250/183 to human granulocytes. Nucl Med 1992; 31: 57-63. 4 2 3) Clinical trial ref 7 MN-302SZ-A. 0

0 5 10 15 20 25 30 4) Hirt. Orpegen Pharma report 9-14-02. Flow cytometric

Time (hr) analysis of human bone marrow CD34+ cells labelled with MAb BW 250/183. February 13, 2008.

➤ Six hours after injection, about 1.5% of the 5) Bosslet “ Influence of MAb BW 250/183 on grabulocytes whole body radioactivity is found in the liver functions” Studu n0 MAb 250.183-BS-12, Sep. 6, 1988. whereas about 3.0% is found in the spleen. 6) Bosslet “ Immunological characteristics of MAb 250/183” ➤ Twenty-four hours after injection, the Study n0 MAb 250/183-BS-11, Sep.6, 1988. percentages of radioactivity are 1.6% in the 7) Krumwieh “ influence of Anti-Granulocyte Monoclonal liver and 2.3% in the spleen. Antibody (MAb 250/183) on human marrow cell proliferation “ ➤ Measurement of radioactivity levels in urine Study n° M 258/1998-4-12W, Aug 18, 1988. shows that up to 14% of the administered 8) Bosslet “ Specificity of MAb BW 250/183 on cryopreserved activity is excreted via the bladder during the tissues”n° BS-10, Sep.7, 1988. 24 h post-injection. 9) Satoch “Expression of CD66 antigen in multiple myeloma: J ➤ The low renal clearance of activity (0.2 l/h for Clin Lab anal 2002, 16(2) 79-95. a glomerular filtration rate around 7 l/h) 10) Clinical trial ref 7D-101 SZ-A, 7MN-302 SZ-A, 306340. indicates that the kidney is not the major route of besilesomab elimination(10).

Non pathological unusual accumulations may be observed in the spleen (up to 6% of the patients), in the bowel (up to 4% of the patients), in the liver and bone marrow (up to 3% of the patients), and in the thyroid and kidneys (up to 2% of patients).

12 | IBA | Scintimun® Monograph 3.5. Overview on efficacy versus 73%) in acute osteomyelitis than in chronic osteomyelitis. 3.5.1. Pivotal trial Study AG-PH3 was a prospective, open label, In a post-hoc analysis based on a surrogate, which randomized, cross-over, confirmatory clinical was an evaluation by an expert panel of all data phase III trial according to today’s quality available from the study CRFs plus all additional standards. It compared blinded reading of data available from the investigators, the overall ® 99m Scintimun and Tc-White Blood Cells (WBCs) diagnostic performance of technetium (99mTc) images in 119 patients with suspected besilesomab in this analysis, sensitivity (76%) and osteomyelitis. The population consisted of 120 specificity (69%) appeared similar to that of the patients. All of them had a history of previous previous analysis based on the investigator disease or surgery and presented with either diagnosis at 1 month, 75% and 72%, respectively. clinical symptoms and/or biological signs and/or imaging findings of osteomyelitis at study entry. Image quality was assessed by three independent Sixty-two (62) patients were suspected of infected readers and was compared to that of 99mTc-WBCs. joint prosthesis, and 58 were suspected of Frequency distribution of image quality was in osteomyelitis (including 25 patients with infected favour of Scintimun®. The difference between the 2 diabetic foot). tracers was statistically significant (74.9% of excellent and good images with Scintimun® versus The agreement rate between the two methods in 55.4% with 99mTc-WBCs). 119 patients evaluable for efficacy was 83% (lower 95% confidence interval limit: 80%). On the basis 3.5.2. Impact on patient management ® of 1-month follow-up by the investigator, Scintimun An evaluation of potential impact of Scintimun® by had a sensitivity of 75% [95% CI 67%-84%], a the investigators demonstrated that Scintimun® specificity of 72% [95% CI 59%-84%] and an could change clinical management in 59% or accuracy of 74% [95% CI 67%-81%]. It showed a improve clinical outcome in 55% of 198 patients statistically significant higher sensitivity than that with suspected osteomyelitis (study 7MN-301 SZ- 99m achieved by Tc-WBCs scanning (75% versus A). In 43% of these patients Scintimun® was 59% p < 0.0001) with a slight decrease in presumed to provide clinical benefit not achievable specificity as compared to 99mTc-WBCs imaging by other available diagnostic imaging methods. (72% versus 79% NS). Accuracy was found to be significantly higher compared to 99mTc-WBCs 3.5.3. Data on diagnostic efficacy from imaging (74% versus 66% p = 0.0346). peer-reviewed literature On the basis of a meta-analysis of published The clinical results of subgroup analyses indicate literature including 14 publications, Scintimun® that among different presentations of osteomyelitis, demonstrated a weighted sensitivity of 89% [95% Scintimun® can show different results. The product CI 74%-87%] and a weighted specificity of 81% shows a trend being more sensitive (75% versus [95% CI 84%-95%]. 57%) and equally specific (80% versus 78%) in diagnosing osteomyelitis in patients with prosthesis For comparison, additional meta-analysis were than in patients with other sites of long bone done for competitors such as 99mTc-WBCs, MRI osteomyelitis. The clinical results also demonstrate and 99mTc-sulesomab. Weighted sensitivities and that Scintimun® shows a trend to be more sensitive specificities are reported in the table below. (84% versus 73%) and equally specific (70%

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Table 1: Weighted results (BN model) 100%

80%

60%

40% 99mTc-besilesomab 20% 99mTc-WBCs 99mTc-sulesomab 0 Weighted Weighted Proportion of studies MRI sensitivity specificity with blinded read

More details are provided in the following respective meta-analysis tables.

Table 2: Diagnostic performance of 99mTc-besilesomab (in literature)

Mean Source / Year Enrollment 99mTc- Scan Interpre- Blinding Reference Se Sp Acc PPV NPV N° of patients Study design age of [Appendix] criteria activity time tation type used standard % % % % % patients

Lind 1990 Osteomyelitis 555 4-6 h and 100 83 10 patients Prospective NR Qualitative NR SU / FU 90 80 100 [37] = 10 (0.5 mg Ab) 24 h p.i. 4/4 5/6

Infection in early post- 300-400 Reuland 1991 operative 2 – 4 h SU / MI / HI 82 93 86 95 76 106 patients Prospective NR (0.3 – 0.4 Qualitative Yes [45] stage in p.i. / FU 54/66 37/40 91/106 54/57 37/49 mg Ab) orthopaedic patients

Suspicion of Hotze 1992 4 and 20- 89 64 75 67 88 peripheral 20 patients Prospective 47 500 Qualitative Yes MI / HI / IM [26] 24 h p.i. 8/9 7/11 15/20 8/12 7/8 osteomyelitis

Suspected infection of Sciuk 1992 43 patients 4 and 24 SU / MI / HI 89 84 86 80 91 prostheses Prospective 61 400-500 Qualitative Yes [46] (48 prosthesis) h p.i. / FU 16/18 21/25 37/43 16/20 21/23 (hip and knees)

Dominguez- Qualitative Diabetic foot 25 patients 4-6 and SU in 10, 93 78 84 74 95 Gadea 1993 Prospective 58 555 and semi- NR infection (38 lesions) 24 h p.i. FU in 28 14/15 18/23 32/38 14/19 18/19 [18] quantitative

Suspected Boubaker 1995 57 patients 1, 6, 24 h SU (48)/ 64 66 65 37 85 infection of hip Prospective 73 490 - 1400 Qualitative No [10] (78 prostheses) p.i FU (30) 7/11* 23/35* 30/46* 7/19* 23/27* prostheses

Suspicion of chronic SU / MI Kaim 1997 osteomyelitis 555 =19 84 50 74 79 60 24 patients Prospective 47 17 h p.i. Qualitative Yes [27] of (0.5 mg Ab) FU / IM 11/13** 3/6** 14/19** 11/14** 3/5** appendicular =5 skeleton

92 90 91 92 90 Guhlmann Chronic 42 patients 420 4 and 24 SU*** 12/13 9/10 21/23 12/13 9/10 1998 peripheral (only 38 Prospective 48 (0.3 – 0.5 Qualitative Yes h p.i MI / HI*** 71 100 87 100 80 [22] osteomyelitis evaluable) mg Ab) 5/7 8/8 13/15 5/5 8/10

Kaim 2000 Post-traumatic 18 patients 555 SU / MI / HI 77 50 61 58 71 Retrospective 45 17 h p.i. Qualitative Yes [28] osteomyelitis (19 lesions) (0.5 mg Ab) / FU 7/9 5/10 12/19 7/12 5/7

79 82 80 600-800 4-6 h p.i. 86 85 Klett 2001 Qualitative 11/14 23/28 12/15 Hip prosthesis 28 patients Prospective 70 (0.33 mg 23-25 h Yes HI / MI 12/14 11/13 [30] Quantitative 93 96 93 Ab) p.i. 100 100 (13/14) 27/28 (14/15)

Gallowitsch Qualitative Peripheral 4 – 6 and 100 100 100 2002 10 patients Retrospective 56 740 and semi- NR MI osteomyelitis 24 h p.i 5/5 5/5 10/10 [21] quantitative

Complication 4-6 h p.i. of knee 600-800 Klett 2003 26 patients 23-25 h 80 89 81 prosthesis with Retrospective 69 (0.33 mg Quantitative Yes HI / MI 100 100 [29] (28 prostheses) p.i. 12/15 25/28 13/16 histological Ab) findings

Qualitative Horger 2003 Bone infection 27 patients 750 1, 3-4, 24 95 75 90 91 86 Prospective 48 and Yes SU [25] after trauma (29 sites) (0.5 mg Ab) h p.i. 20/21 6/8 26/29 20/22 6/7 quantitative

Infection on 600-800 4-6 and Qualitative Kordelle 2004 100 82 91 83 100 knee 32 patients Retrospective 70 (0.33 mg 23-25 h and semi- Yes HI / MI / SU [31] 15/15 14/17 29/32 15/18 14/14 prosthesis Ab) p.i. quantitative NR: not reported. *: results are reported for 46 evaluable patients with objective proof of infection (microbiology); ** results in 19 patients with surgical confirmation and exclusion of patients with clinical follow-up confirmation (5 negative cases) ***: sub-analysis in patients with surgery or in patients with microbiology or histology. Reference standard: HI: histologic examination; SU: surgery; MI : microbiological cultures; IM : imaging including X-ray, ultrasonography, CT, and MRI., FU : follow-up (being either uncomplicated or leading to delayed surgical intervention).

14 | IBA | Scintimun® Monograph Table 3: Diagnostic performance of 99mTc-WBCs (in literature)

Mean Source / Year Enrollment N° of 99mTc- Scan Interpre- Blinding Reference Se Sp Acc PPV NPV Study design age of [Appendix] criteria examinations activity time tation type used standard % % % % % patients

Clinical suspicion of bone infection 30-60 MI / HI in Moragas 1991 50 patients 80.9 93.7 including prospective NR 370 min and qualitative NR 18 88.7 89.5 88.2 [39] (53 sites) 17/21 30/32 prostheses (35), 4-6 h p.i. FU in all osteomyelitis (17)

Suspected Devillers 1995 116 patients MI / HI / SU 95 90 92 88 96 osteoarticular retrospective NR 200 4h p.i. qualitative No [14] (143 sites) / IM / FU 60/63 72/80 132/143 60/68 72/75 infections

Diabetic patients Devillers 1998 with single or 42 patients MI / HI / IM 88.4 96.6 prospective 63 200 4 h p.i. qualitative Yes 92.9 95.8 90 [15] multiple infectious (56 lesions) / FU 23/26 29/30 foot lesions

Diabetic patient Harwood 1999 with foot ulcer and 79 67 111 sites prospective 58 NR NR qualitative NR H / MI 75 83 60 [24] suspicion of 59/75 24/36 osteomyelitis

Diabetic patient Vesco 1999 4 and 77 82 with suspicion of 24 patients prospective 59 450 NR NR IM 79 83 75 [52] 24 h p.i 10/13 9/11 osteomyelitis

Suspected bone or joint infection including diabetic Devillers 2000 23 patients 1 and 93 100 foot (11), prospective 67 200 qualitative No MI / HI / IM 97 100 95 [16] (32 sites) 4–5 h p.i. 13/14 18/18 prosthesis (8), joint (4) and others (9)

2.5 to 5 h HI/MI/SU/I 97.7 96.8 Wolf 2001 [55] Bone infection 324 patients retrospective 55 11-185 qualitative NR NR NR NR p.i. M/FU 216/221 100/103

qualitative HI / MI in van Acker Painful knee 4 – 24 h 100 53 65 42 100 20 patients prospzctive 66 185 and semi- NR 15 pats 2001 [51] arthroplasty p.i. 5/5 8/15 13/20 5/12 8/8 quantitative FU

Ertugrul 2006 Diabetic patient 91 67 26 patients prospective NR 400 - 500 NR qualitative NR MI / HI / SU 88 95 50 [20] with foot lesions 21/23 2/3

66 (76 sites) 51 scintigraphies with 99mTc WBCs Suspicion of (other 25 Simonsen MI/ HI / SU 81.5 93.8 infection of scintigraphies retrospective 73 630 NR qualitative Yes 89.5 88 90.2 2007 [47] / FU 22/27 46/49 prosthesis done with 111In- WBCs) Global performances

20 min Liberatore 94.3 100 96.5 100 92 Osteomyelitis 18 ( 57 sites) retrospective 45 340 4h and qualitative No MI/FU/IM 2007 [36] 33/35 22/22 55/57 33/33 22/24 20 h p.i.

NR: not reported. Reference standard: H: histologic examination; SU: surgery; MI: microbiological cultures; IM: imaging including X-ray, ultrasonography, CT, and MRI, FU: follow-up.

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Table 4: Diagnostic performances of Magnetic Resonance Imaging (in literature)

Mean Source / Year N° of Blinding Reference Se Sp Acc PPV NPV Enrollment criteria Study design age of MRI characteristics [Appendix] examinations used standard % % % % % patients

Unger 1988 Acute T1-weighted spin echo 92 96 35 patients Prospective 52 Yes SU / FU 94 92 96 [50] osteomyelitis T2- weighted spin echo 11/12 22/23

Erdman 1991 Suspected T1-weighted spin echo 98 75 86 79 98 110 patients Prospective 37 No HI / MI [19] osteomyelitis T2- weighted spin echo 53/54 42/56 95/110 53/67 42/43

Weinstein Diabetic foot 47 patients T1-weighted spin echo 100 81 95 94 100 prospective 49 Yes SU / HI / FU 1993 [53] infection (62 scans) T2- weighted spin echo 46/46 13/16 59/62 46/49 13/13

T1-weighted spin echo Diabetic foot with Morrison 1993 59 patients before and after gadolinium 86 89 87 91 83 suspicion of Prospective 51 Yes MI / HI / FU [40] (62 MRIs) administration in all 30/35 24/27 54/62 30/33 24/29 osteomyelitis T2 weighted

Levine 1994 Diabetic foot 27 patients T1-weighted spin echo HI (18) / SU 77 100 90 100 81 prospective 52 [35] infection (29 scans) T2- weighted spin echo (7) / FU (4) 10/13 16/16 23/29 10/10 13/16

Diabetic foot T1-weighted spin echo 89 100 96 95 Croll 1996 [13] 27 patients Prospective 66 NR HI / MI /FU 100 infections T2- weighted spin echo 8/9 18/18 26/27 18/19

T1-weighted spin echo T1 weighted fat saturated images before and after Craig 1997 Diabetic foot 90 71 79 13 (57 bones) Prospective 57 gadolinium injection No HI NR NR [12] infections 19/21 26/36 45/57 T2- weighted spin echo and fast fat –suppressed T2- weighted

T1-weighted spin echo 80 – 100 80 – 91 * Diabetic foot with Morrison 1998 before and after gadolinium FU (30)/ SU # # 82 – 94 74 – 100 suspicion of 62 (71 feet) Retrospective 56 Yes NR [41] administration in all (34) / MI (9) R1 40/42 26/29 * * osteomyelitis T2 weighted R2 38/42 24/29

T1-weighted spin echo Diabetic patient Vesco 1999 before and after gadolinium 82 92 87 with suspicion of 24 patients prospective 59 NR IM 100 100 [52] administration 9/11 22/24 13/15 osteomyelitis T2- weighted spin echo

T1-weighted spin echo Relapse of before and after gadolinium infection in chronic Ledermann 15 (17 body administration in all SU (11) / FU 100 29 posttraumatic Retrospective 41.2 Yes 71 67 100 2000 [33] areas) T2 weighted with fat (4) 10/10 2/7 osteomyelitis of saturation technique in 5 lower extremities patients

T1-weighted spin echo sat Al Khawari before and after gadolinium 100 63 84 79 100 Diabetic foot 19 sites prospective 61 Yes HI / FU 2005 [7] administration and fat 11/11 5/8 16/19 11/14 5/5 suppressed T2 weighted

T1-weighted spin echo and 37.5 Ertugrul 2006 Diabetic patient 78 60 75 90 28 sites prospective NR T1 fat sat before and after NR MI / HI / SU 3/8 [20] with foot lesions 18/23 3/5 21/28 18/20 gadolinium administration

# average of two readers (table 2 of article) NR: not reported. * depending on reader and technique of MRI Reference standard: HI : histologic examination ; SU: surgery; MI : microbiological cultures; IM: imaging including X-ray, ultrasonography, CT, and MRI., FU : follow-up ; #: R1 reader 1; R2 reader 2.

16 | IBA | Scintimun® Monograph Table 5: Diagnostic performances of 99mTc-sulesomab (in literature)

Mean NPV Enrollment N° of 99mTc- Scan Interpretati Blinding Reference Se Sp Acc PPV Source / Year Study design age of % criteria examinations activity time on type used standard % % % % patients

Pakos et al Prosthesis 75 86 79 90 66 19 Prospective 67 740 2 Qualitative Yes CC, SU, FU 2007 infection 9/12 6/7 15/19 9/10 6/9

Iyengar et al Prosthetic joint 91 81 84 67 96 38 Retrospective 54-89 650 4-5 NR NR HI, CC, IM 2005 infections 10/11 22/27 32/38 10/15 22/23

Delcourt et al, Semiquantit 67 85 74 86 65 Diabetic foot 31 Prospective 59 555–925 3 4 No HI, IM, FU 2005 ative 12/18 11/13 23/31 12/14 11/17

75 95 87 92 83 Osteomyelitis Vicente et al, 37 12/16 20/21 32/37 12/13 20/24 Septic prosthesis NR 64 740 3–4, 7–8 Qualitative Yes CC, HI,FU 2004 81 80 89 87 63 91 loosening 12/15 59/66 71/81 12/19 59/62

92 87.5 91 96.6 73.6 Rubello et al, Diabetic foot 78 Semiquantit 57/62 14/16 61/78 57/59 14/19 retrospective 47 740 4, 18–24 Yes CC, IM, FU 2004 Prosthesis 78 ative 84 85.7 84.6 94.1 66.6 48/57 18/21 66/78 48/51 18/27

63 92 80 83 79 Prosthesis Gratz et al, 20 5/8 11/12 16/20 5/6 11/14 Peripheral Retrospective 555–925 1, 4, 24 Qualitative NR IM 2003 21 66 83 76 75 77 osteomyelitis 6/9 10/12 16/21 6/8 10/13

Von Peripheral 1, 2, 6, CC, HI, IM, 95 67 87 87 86 Rothenburg et 30 Retrospective 57 740 Qualitative NR osteomyelitis 24 FU 20/21 6/9 26/30 20/23 6/7 al, 2003

Osteomyelitis, Devillers et al, prosthesis, CC, HI, IM, 86 72 78 71 87 23 (32 sites) Prospective 67 900 1, 4–6 Qualitative NR 2000 diabetic foot FU 12/14 13/18 25/32 12/17 13/15 infection

Harwood et al, Semiquantit 91 56 80 80 77 Diabetic foot 122 Prospective 58 555–925 1–2, 5–8 No CC, HI 1999 ative 74/81 23/41 97/122 74/92 23/30

Becker et al, 90 85 88 90 85 osteomyelitis 53 (66 lesions) Prospective 740 1–6, 24 Qualitative No CC, HI, IM 1996 36/40 22/26 58/66 36/40 22/26

Soft tissue Becker et al, 1, 3–4, CC, HI, IM, 88 75 80 70 90 infection and 20 NR 60 185–900 Qualitative No 1994 24 FU 7/8 9/12 16/20 7/10 9/10 osteomyelitis

NR: not reported. Study design: PR: prospective; RE: retrospective; UN: unclear Reference standard: CC: cell cultures; FU: follow-up; H: histologic examination; SU: surgery; MI: microbiological cultures; IM: imaging including X-ray, ultrasonography, CT, and MRI.

3.5.4. Conclusion on diagnostic efficacy

The results of the phase III and those from the This lower specificity is acceptable if technetium literature, suggest that the sensitivity of technetium (99mTc)-besilesomab is used in conjunction with (99mTc) besilesomab is equivalent to that of 99mTc other imaging modalities to determine the WBCs but that specificity is likely lower. appropriate diagnosis.

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3.6. Overview on main safety The effective dose as defined in ICRP 103 was aspects (for complete estimated at 8.63x10-3 mSv per MBq of technetium (99mTc)-besilesomab administered. In an adult, this information refer to SPC) examination would cause low to moderate Dosimetry exposure of a few mSv (6.9 mSv for 800 MBq Technetium (99mTc) is produced by means of a administered). This is in the range of other 99Mo/99mTc generator and decays with the emission diagnostic nuclear medicine techniques, e.g. of gamma radiation with a mean energy of 140 keV 99mTc–sulesomab (6-9 mSv), but more than and a half-life of 6.02 hours to technetium (99Tc) 99mTc–WBCs (~3 mSv). This exposure is not which, in view of its long half-life of 2.13 x 105 considered to constitute a safety concern except in years can be regarded as quasi stable. pregnancy, which is a contraindication.

Values of the absorbed doses calculated HAMA (Human Anti-Mouse Antibody) for the individual male and female of Of the 116 patients who had at least one HAMA reference assessment after administration of technetium 99m Organ mSv/MBq ( Tc) besilesomab in the phase III study, 16 patients (14%) showed positive HAMA levels. Reference male Reference female Brain 2.36 E-03 3.12 E-03 Adverse events Heart 4.95 E-03 5.97 E-03 Since its marketing launch more than 15 years ago, Colon 4.50 E-03 5.76 E-03 around 100,000 patients have been administered Stomach 4.45 E-03 5.35 E-03 technetium (99mTc)-besilesomab without relevant Liver 1.00 E-02 1.26 E-02 safety concerns. Small Intestine 4.80 E-03 5.75 E-03 Bone marrow (red) 2.42 E-02 2.29 E-02 The table below reports adverse reactions by Muscles 3.17 E-03 3.91 E-03 MedDRA system organ classes. The frequencies are based on the most recent clinical trial and non Ovaries 5.94 E-03 interventional safety survey. Pancreas 6.90 E-03 8.26 E-03 Skin 1.78 E-03 2.16 E-03 The frequency listed below is defined using the Lungs 1.25 E-02 1.60 E-02 following convention: Spleen 2.71 E-02 3.24 E-02 Very common (≥ 1/10); common (≥ 1/100 to <1/10); Kidney 2.10 E-02 2.34 E-02 uncommon (≥ 1/1,000 to <1/100); rare (≥ 1/10,000 Breast 3.01 E-03 to <1/1,000). Adrenal 7.59 E-03 9.37 E-03 MedDRA System Testis 1.82 E-03 Adverse reactions Frequency Organ Classes Thymus 3.51 E-03 4.23 E-03 Immune system Hypersensitivity, including Uncommon Thyroid 2.79 E-03 3.21 E-03 disorders angioedema, urticaria Anaphylactic/anaphylactoid Bone 1.77 E-02 2.27 E-02 Rare reaction Uterus 5.01 E-03 Vascular disorders Hypotension Common Gallbladder 5.91 E-03 6.81 E-03 Musculoskeletal and Bladder 3.05 E-03 3.80 E-03 connective tissue Myalgia, arthralgia Rare disorders Whole body 4.45 E-03 5.52 E-03 Human anti-mouse antibody Investigations Very common Effective Dose 8.63 E-03mSv / MBq positive

18 | IBA | Scintimun® Monograph 3.7. Dosage and administration for immediate use in the event of an adverse reaction. Posology and method of administration The single injection of Technetium Since allergic reactions to the murine protein ( 99mTc)–besilesomab must be given strictly cannot be excluded, cardiovascular treatment, intravenously. corticosteroids, and antihistamines must be ➤ 99m The recommended activity of technetium ( Tc) available during administration of the product. besilesomab should be between 400 MBq and 800 MBq. Fructose intolerance This corresponds to the administration of Scintimun® contains sorbitol therefore patients with 0.25 to 1 mg of besilesomab. rare hereditary problems of fructose intolerance ➤ Acquisition of images should start 3 to 6 hours should not be administered this product. after administration. An additional acquisition 24 hours after initial injection is recommended. Interactions ➤ Acquisition can be performed using planar or Active substances which inhibit inflammation or SPECT (Single Photon Emission Computed affect the haematopoietic system (such as Tomography) imaging. antibiotics and corticosteroids) may lead to false negative results. Contra-indications Hypersensitivity to the active substance, to other Such substances should therefore not be murine antibodies or to any of the excipients. administered together with, or a short time before Positive screening test for human anti-mouse the injection of Scintimun®. antibody (HAMA). Established or suspected pregnancy or when Pregnancy and lactation pregnancy cannot be excluded. Scintimun® is contraindicated in pregnancy. Before administering a radioactive medicinal Special warnings product to a mother who is breast-feeding, Administration of mouse monoclonal antibodies consideration should be given as to whether the can lead to the development of Human Anti-Mouse investigation could reasonably be delayed until the Antibodies (HAMA). Patients who are HAMA mother has ceased breast-feeding and as to positive may have a greater risk for hypersenstivity whether the most appropriate choice of reactions. Inquiry on possible previous exposure to radiopharmaceutical has been made, bearing in murine monoclonal antibodies and a HAMA test mind the secretion of activity in breast milk. If the should be made prior to administration of administration is considered necessary, breast- Scintimun® ; a positive response would feeding should be interrupted for three days and contraindicate the administration of Scintimun®. the expressed milk discarded. These three days Data on repeated dosing of Scintimun® are very correspond to 10 half-lives of Technetium-99m limited. Scintimun® should only be used once in a (60 hours). At that time the remaining activity patient’s lifetime. represents about 1/1000 of the initial activity in the body. Anaphylactic or anaphylactoid reactions may occur A close contact with the child should also be after administration of the medicinal product. avoided during the first 12 hours after the injection. Appropriate cardiopulmonary resuscitation facilities and trained personnel should be available

19 | IBA | Scintimun® Monograph Scintimun® Monograph

3.8. Product description 2. After complete dissolution, disinfect the septum and allow to dry. Transfer 1 ml of this solution Kit composed of 1 or 2 multidose vials Scintimun® with a hypodermic syringe into a vial Scintimun (green crimped aluminium capsule). Without Vial Scintimun® removing the needle, withdraw an equivalent - Besilesomab (1mg) volume of air in order to avoid excess pressure - Sodium dihydrogen phosphate, anhydrous in the vial. Swirl carefully, the content of vial - Disodium monohydrogen phosphate, anhydrous Scintimun will dissolve within one minute - Sorbitol E240 (DO NOT shake). - Under nitrogen atmosphere 3. After 1 min, check that the contents of vial Scintimun have completely dissolved. Place vial Vial Solvent for Scintimun® Scintimun in an appropriate lead shielding - 1, 1, 3, 3-propane tetraphosphore acid, container. Disinfect the septum and allow to dry. tetrasodium salt, dihydrate (PTP) Using a hypodermic syringe, introduce through - Stannous chloride dihydrate the rubber seal 2-7 ml of pertechnetate (99mTc) - Sodium hydroxide / Hydrochloric acid (for pH (the eluate complies with the requirements of adjustment) current Eur. Ph.). Without removing the needle, - Nitrogen withdraw an equivalent volume of air in order to The vials have to be reconstitued with sodium avoid excess pressure in the vial. Swirl carefully pertechnetate (99mTc) solution for injection before to mix the whole solution (DO NOT shake). The administration. activity must be between 400 and 1800 MBq depending on the volume of pertechnetate Method of preparation (99mTc). Total volume in vial Scintimun equals 3 to 8 ml. To ensure the highest labelling efficiency: 4. Fill in the enclosed label and fix it to the - Radiolabelling is performed using freshly eluted radiolabelled solution. 99m sodium pertechnetate ( Tc). 5. 10 min after the addition of pertechnetate (99mTc) - Eluates should only be taken from a technetium the solution is ready for injection. (99mTc)-generator that has been eluted within the past 24 hours (i.e. with less than 24h in-grow). Notes on the instructions: - The first eluate taken from a technetium (99mTc)- - Solvent for Scintimun must NEVER be radiolabelled first generator that has not been eluted over the and then added to Scintimun. weekend must NOT be used. - The final radiolabelled injection solution must be Radiopharmaceuticals should be prepared by the protected from oxygen. user in a manner which satisfies both radiation safety and pharmaceutical quality requirements. Appropriate aseptic precautions should be taken, complying with the requirements of Good Manufacturing Practice for pharmaceuticals. 5 ml of Sodium Chloride Solution Procedure Vial 1. Take a vial Solvent for Scintimun (yellow crimped solvent

aluminium capsule) from the kit. Disinfect the 2 - 7 ml septum and allow to dry. Using a syringe, introduce through the rubber seal 5 ml of 0.9% 99mTcO4 - (400-800 MBq) sodium chloride solution. Without removing the

needle, withdraw an equivalent volume of air in Vial order to avoid excess pressure in the vial. Shake Scintimun®

smoothly. Scintimun: 2 steps labelling reaction

20 | IBA | Scintimun® Monograph Quality control 99mTc-MAb oligomers, 99mTc-MAb fragments, 99mTc- PTP and 99mTc-sorbitol) : Rf : 0.0, free The radiochemical purity of the final radiolabelled technetium (pertechnetate ion) migrates around preparation can be tested according to the Rf 1.0. following procedure: Measure the radioactivity of each considered Method: Instant thin layer chromatography impurity spot by integration of the peaks. Materials and reagents : • Methylethylketone R (MEK). Calculations • RBM-1 strips (2.5 x 20 cm), cut so that the mobile 8) Calculate the percentage of technetium (99mTc)- phase runs in the direction of the grain of the Besilesomab (radiochemical purity) as follows: paper. % technetium (99mTc)-Besilesomab (RCP) = • Glass tank (as a chromatographic chamber) 100 % - % Free 99m provided with a device to suspend and lower the chromatographic paper without opening the The radiochemical purity (the percentage of chamber. bound Technetium (99mTc)) must be more than • Forceps, scissors, syringes, needles, appropriate 95% or equal to 95%. counting assembly. Abbreviations used in the text Abbreviations Terms Procedures: AE Adverse event Do not let air enter the vial to be tested and store CEA Carcinoembryonic antigen all vials containing radioactive solution in lead CI Confidence interval shielding. CT Computed tomography h Hour(s) 1. Place into the glass tank a layer of 1.5 cm deep HAMA Human anti-mouse antibody of the mobile phase and allow equilibrating for International commission on ICRP about 5-10 minutes. radiological protection 2. Trace two thin lines parallel to the ends of the MAb BW 250/183 Monoclonal antibody BW 250/183 MBq Megabecquerel strip: one is called “deposit line” at 2.0 cm from mg Milligram(s) the bottom, the other one is called “solvent line” mL milliliter at 10 cm above from the deposit line. MRI Magnetic-resonance imaging 3. Apply a spot of the radiolabelled preparation to mSv Millisievert(s) the deposit line of the paper strip using a SAE Serious adverse event SD Standard deviation syringe and needle. Do not let dry the spot. Sens Sensitivity 4. Using forceps, suspend the paper strip into the Spec Specificity tank and close the lid. Lower the paper into the Single-photon emission computed SPECT mobile phase (letting the deposit line above the tomography solvent surface) and allow the solvent to migrate 99mTc Technetium-99m to the solvent line. Technetium-99m labeled monoclonal 99mTc MAb BW 250/183 5. Remove the paper strip and dry in the air. antibody BW 250/183 6. Cut the strip in two separate parts at Rf = 0.5 7. Determine distribution of radioactivity with an appropriate detector. Identify each radioactive spot by calculating the Rf. Radiolabelled forms of bound technetium (including 99mTc-MAb monomer,

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3.9. References

References used for meta-analysis of References used for meta-analysis of 99mTc–WBCs efficacy 99mTc–besilesomab efficacy

Moragas M, Lomena F, Herranz R, Garcia A, Piera C, Muxi A, Catafau A, Lind P, Langsteger W, Költringer P, Dimai HP, Passl R, Eber O. Pavia A, Setoain J. 99Tcm – HMPAO leucocyte scintigraphy in the Immunoscintigraphy of inflammatory processes with a Tc-99m labelled diagnosis of bone infection. Nucl Med Comm 1991; 12 : 417 – 427. monoclonal antigranulocyte antibody (MAb 250/183). J Nucl Med 1990; 31 : 417-23.

Devillers A, Moisan A, Jean S, Arvieux C, Bourguet P.Technetium-99m hexamethylpropylene amine oxime leukocyte scintigraphy for the Reuland P, Winker KH, Heuchert T, Ruck P, Müller-Schauenburg W, Weller diagnosis of bone and joint infections : a retrospective study in 116 S, Feine U. Detection of infection in post-operative orthopaedic patients patients. Eur J. Nucl Med 1995; 22 : 302-307. with technetium-99m labelled monoclonal antibodies against granulocytes. J. Nucl Med 1991; 32 : 2209 – 2214.

Devillers A, Moisan A, Hennion F, Garin E, Poirier JY, Bourguet P. Contribution of technetium-99m hexamethylpropylene amone oxime Hotze A, Briele B, Overbeck B, Kropp J, Gruenwald F, Mekkawy MA, von labelled leukocyte scintigraphy to the diagnosis of diabetic foot Smekal A, Moeller F, Biersack HJ. Technetium-99m labelled anti- infection. Eur j Nucl Med 1998; 25 : 132 – 138. granulocyte antibodies in suspected bone infections. J. Nucl Med 1992; 33 : 526-531.

Harwood SJ, Valdivia S, Hung GL, Quenzer RW. Use of sulesomab, a radiolabeled antibody fragment, to detect osteomyelitis in diabetic Sciuk J, Puskas C, Greitemann B, Schober O. White blood cell patient with foot ulcers by leukoscintigraphy. scintigraphy with monoclonal antibodies in the study of the infected Clin Inf Dis 1999; 28 : 1200 -5. endoprosthesis. Eur J Nucl Med 1992; 19 : 497-502.

Vesco L, Boulahdour H, Hamissa S, Kretz S, Montazel JL, Perlemuter L, Dominguez-Gadea L, Martin-Curto LM, de la Calle H and Crespo A. Meignan M, Rahmouni A. The value of combined radionuclide and Diabetic foot infections : scintigraphic evaluation with 99mTc-labelled magnetic resonance imaging in the diagnosis and conservative antigranulocyte antibodies. Nucl Med Comm 1993; 14 : 212-218. management of minimal or localized osteomyelitis of the foot in diabetic patients. Metabolism 1999; 48 (7) : 922-927. Boubaker A, Bischof-Delaloye A, Blanc CH, Dutoit M, Leyvraz PF, Delaloye B. Immunoscintigraphy with antigranulocyte monoclonal Devillers A, Garin E, Polard JL, Poirier JY, Arvieux C, Girault S, Moisan A, antibodies for the diagnosis of septic loosening of hip prostheses. Eur J Bourguet P.Comparison of Tc-99m-labelled antileukocyte fragment Fab’ Nucl Med 1995; 22 : 139 – 147. and Tc-99m-HMPAO leukocyte scintigraphy in the diagnosis of bone and joint infections : a prospective study. Nucl med Comm 2000; 21 : 747- 753. Kaim A, Maurer T, Ochsner P, Jundt G, Kirsch E, Mueller-Brand J. Chronic complicated osteomyelitis of the appendicular skeleton: diagnosis with technetium-99m labelled monoclonal antigranulocyte Wolf G, Aigner RM, Schwartz T. Diagnosis of bone infection using 99mTc- antibody-immunoscintigraphy. Eur J Nucl Med 1997; 24 : 732-738. HMPAO labelled leukocytes. Nucl.Med Comm. 2001; 22 : 1201-1206

Guhlmann A, Brecht-Krauss D, Suger G, Glatting G, Kotzerke J, Kinzl L, van Acker F, Nuyts J, Maes A, Vanquickenborne B, Stuyck J, Bellemans Reske SN. Fluorine-18-FDG PET and Technetium-99m Antigranulocyte J, Vleugels S, Bormans G, Mortelmans L. FDGPET, 99mTc-HMPAO white Antibody Scintigraphy in Chronic Osteomyelitis. J Nucl Med 1998; 39 blood cell SPET and bone scintigraphy in the evaluation of painful total (12): 2145-52 knee arthroplasties. Eur J Nucl Med 2001; 28:1496–1504.

Kaim A, Ledermann HP, Bongartz G, Messmer P, Mueller-Brand J, Ertugrul MB, Baktiroglu S, Salmant S, Unal S, Aksoy M, Berberoglu K, Steinbrich W. Chronic post-traumatic osteomyelitis of the lower extremity: Calangu S. The diagnosis of osteomyelitis of the foot in diabetes: comparison of MRI and combined bone scintigraphy / microbiological examination vs magnetic resonance imaging and immunoscintigraphy with radiolabelled monoclonal antigranulocyte labelled leucocyte scanning. Diabetic Med 2006; 23 : 649-653. antibodies. Skeletal Radiol 2000; 29 : 378-386.

Simonsen L, Buhl A, Oersnes T, Duus B. White blood cell scintigraphy for Klett R, Steiner D, Puille M, Khalisi A, Matter HP, Sturz H, Bauer R. differentiation of infection and aseptic loosening. Acta Orthopaedica Antigranulocyte scintigraphy of septic loosening of hip prosthesis: 2007; 78(5):640 -647 influence of different analyzing methods. Nuklearmedizin 2001; 40:75–79.

Liberatore M, Calandri E, Pavoni GL, Baiocchi P, Iurilli AP, Venditti M, Al- Nahhas AA, Rubello D. Reliability of white blood cell scan in the follow- Gallowitsch HJ, Heinisch M, Mikosch P, Kresnik E, Kumnig G, Gomez I, up of osteomyelitis. Biomedicine & Pharmacology 2007; 61 : 272-276. Lind P; Tc-99m ciprofloxacin in clinically selected patients suspected for peripherial osteomyelitis, spondylodiscitis and fever of unknown origin: preliminary results. Nuklearmedizin 2002; 41:30-6.

22 | IBA | Scintimun® Monograph Klett R, Kordelle J, Stahl U, Khalisi A, Puille M, Steiner D, Bauer R. Al Khawari H, Al Saeed OM, Jumaa TH, Chishti F. Evaluating diabetic Immunoscintigraphy of septic loosening of knee endoprosthesis: a foot infection with magnetic resonance imaging : Kuwait experience. retrospective evaluation of the antigranulocyte antibody BW 250/183. Med Princ Pract 2005; 14 : 165-172. Eur J Nucl Med Mol Imaging. 2003 Nov;30(11):1463-6. Ertugrul MB, Baktiroglu S, Salmant S, Unal S, Aksoy M, Berberoglu K, Calangu S. The diagnosis of osteomyelitis of the foot in diabetes: Horger M, Eschmann SM, Pfannenberg C, Storek D, Dammann F, microbiological examination vs magnetic resonance imaging and Vonthein R, Claussen CD, Bares R. The value of SPET/CT in chronic labelled leucocyte scanning. Diabetic Med 2006; 23 : 649-653. osteomyelitis. Eur J Nucl Med Mol Imaging. 2003 Dec;30(12):1665-73 References used for meta-analysis of Kordelle J, Klett R, Stahl U, Hossain H, schleicher I, Haas H. 99m Infektdiagnostik nach Knie-TEP-Implantation. Z. Orthop. 2004:142:337- Tc–sulesomab efficacy 343. Pakos EE, Koumoulis HD, Fotopoulos AD, Ioannidis JPA. Osteomyelitis: Antigranulocyte Scintigraphy with 99mTc Radiolabeled Monoclonal Antibodies for Diagnosis -Meta-Analysis 1. Radiology 2007; 245 (3) : References used for meta-analysis of MRI 732-741. efficacy Iyengar KP, Vinjamuri S. Role of 99mTc Sulesomab in the diagnosis of prosthetic joint infections. Nucl Med Comm 2005; 26: 489-496. Unger E, Moldofsky, Gatenby, Hartz W, Broder G. Diagnosis of osteomyelitis by MR Imaging. AJR 1988; 150 : 605-610 Delcourt A, Huglo D, Prangere T, Benticha H, Devemy F, Tsirtsikoulou D, Lepeut M, FontaineL, Steinling M. Comparison between Leukoscan® Erdman WA, Tamburro F, Jayson HT, Weatherall PT, Ferry KB, Peshock (Sulesomab) and Gallium-67 for the diagnosis of osteomyelitis in the RM. Osteomyelitis: characteristics and pitfalls of diagnosis with MR diabetic foot. Diabetes Metab 2005, 31:125-133. imaging. Radiology 1991; 180 : 533-39.

Vicente AG, Almoguera M, Alonso JC, et al. Diagnosis of orthopedic Weinstein D, Wang A, Chambers R, Stewart CA, Motz HA. Evaluation of infection in clinical practice using Tc-99m sulesomab (antigranulocyte MRI in the diagnosis of osteomyelitis in diabetic foot infections. Foot monoclonal antibody fragment Fab’2). Clin Nucl Med 2004; 29:781–785. Ankle 1993; 14 : 18-22.

Rubello D, Casara D, Maran A, Avogaro A, Tiengo A, Muzzio PC. Role of Morrison WB, Schweitzer ME, Bock GW, Mitchell DG, Hume EL, pathria anti-granulocyte Fab’ fragment antibody scintigraphy (LeukoScan) in MN, Resnick D. Diagnosis of osteomyelitis: utility of fat-suppressed evaluating bone infection: acquisition protocol, interpretation criteria and contrast-enhanced MR imaging. Radiology 1993; 189 : 251 -257. clinical results. Nucl Med Commun 2004; 25:39–47.

Levine SE, Neagle CE, Esterhai JL, Wright DG, Dalinka MK. Magnetic Gratz S, Schipper ML, Dorner J, et al. LeukoScan for imaging infection in resonance imaging for the diagnosis of osteomyelitis in the diabetic different clinical settings: a retrospective evaluation and extended review patient with a foot ulcer. Foot Ankle 1994; 15 : 151 – 156. of the literature. Clin Nucl Med 2003;28:267–276.

Croll SD, Nicholas GG, Osborne MA, Wasser TE, Jones S. Role of Von Rothenburg T, Schaffstein J, Ludwig J,Vehling D, Koster O, Schmid magnetic resonance imaging in the diagnosis of osteomyelitis in G. Imaging osteomyelitiswith Tc-99m-labeled antigranulocyte antibody diabetic foot ifections. J Vasc Surg 1996; 24 : 266-70. Fab’ fragments. Clin Nucl Med 2003; 28:643–647.

Craig JG, Amin MB, Wu K, Eyler WR, van Holsbeeck MT, Bouffard JA, Devillers A, Garin E, Polard JL, et al. Comparison of Tc-99m-labelled Shirazi K. Osteomyelitis of the diabetic foot: MR imaging – pathologic antileukocyte fragment Fab’ and Tc-99m-HMPAO leukocyte scintigraphy correlation. Radiology 1997; 203:849-855 in the diagnosis of bone and joint infections: a prospective study. Nucl Med Commun 2000; 21:747–753. Morrisson WB, Schweitzer ME, Granville Batte W, Radack DP, Russel KM. Osteomyelitis of the foot: relative importance of primary and secondary Harwood SJ, Valdivia S, Hung GL, Quenzer RW. Use of Sulesomab, a MR imaging signs. Radiology 1998; 207 : 625-632. radiolabeled antibody fragment, to detect osteomyelitis in diabetic patients with foot ulcers by leukoscintigraphy. Clin Infect Dis 1999; Vesco L, Boulahdour H, Hamissa S, Kretz S, Montazel JL, Perlemuter L, 28:1200– 1205. Meignan M, Rahmouni A. The value of combined radionuclide and magnetic resonance imaging in the diagnosis and conservative Becker W, Palestro CJ, Winship J, et al. Rapid imaging of infections with management of minimal or localized osteomyelitis of the foot in diabetic a monoclonal antibody fragment (LeukoScan). Clin Orthop Relat Res patients. Metabolism 1999; 48 (7) : 922-927. 1996; 329:263–272.

Ledermann HP, Haim A, Bongartz G, Steinbrich W. Pitfalls and limitations Becker W, Bair J, Behr T, et al. Detection of soft-tissue infections and of magnetic resonance imaging in chronic posttraumatic osteomyelitis. osteomyelitis usinga technetium-99m-labeled anti-granulocyte Eur Radiol 2000; 10: 1815-1823. monoclonal antibody fragment. J Nucl Med 1994; 35:1436–1443.

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Summary of Product Characteristics

1. NAME OF THE MEDICINAL PRODUCT Scintimun1 mg kit for radiopharmaceutical preparation

2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each vial of Scintimun contains 1 mg of besilesomab. Besilesomab is an anti-granulocyte monoclonal antibody (BW 250/183), produced in murine cells. The radionuclide is not part of the kit.

Excipients: Each vial of Scintimun contains 2 mg of sorbitol. One ml of the labelled solution contains less than 4 mg of sodium. For a full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM Kit for radiopharmaceutical preparation Scintimun: white powder Solvent for Scintimun: white powder

4. CLINICAL PARTICULARS 4.1 Therapeutic indications This medicinal product is for diagnostic use only. Scintigraphic imaging, in conjunction with other appropriate imaging modalities, for determining the location of inflammation/infection in peripheral bone in adults with suspected osteomyelitis. Scintimun should not be used for the diagnosis of diabetic foot infection. 4.2 Posology and method of administration This medicinal product is for use in designated nuclear medicine facilities only, and should only be handled by authorised personnel. Posology Adults The recommended activity of technetium (99mTc) besilesomab should be between 400 MBq and 800 MBq. This corresponds to the administration of 0.25 to 1 mg of besilesomab. For repeated use, see section 4.4. Elderly No dose adjustment is required. Renal and hepatic impairment Formal studies have not been performed in patients with renal or hepatic impairment. However, due to the nature of the molecule and the short half-life of technetium (99mTc) besilesomab, dose adjustment is not necessary in such patients. Paediatric population Scintimun is not recommended for use in children below the age of 18 years due to insufficient data on safety and efficacy (see section 5.1 and 5.2).

Method of administration and scintigraphic examination Before administration to the patient, this medicinal product should be reconstituted with the solvent provided and then radiolabelled with sodium pertechnetate (99mTc) injection to obtain a clear and colourless technetium (99mTc) besilesomab injection. The radiolabelled solution should be administered intravenously as a single dose only. For instructions for preparation of the radiopharmaceutical, see section 12. For disposal and other handling, see section 6.6. Patient preparation Scintimun should be given to sufficiently hydrated patients. In order to obtain images of best quality and to reduce the radiation exposure of the bladder, patients should be encouraged to drink sufficient amounts and to empty their bladder prior to and after the

24 | IBA | Scintimun® Monograph scintigraphic examination. Images acquisition should start 3 to 6 hours after administration. An additional acquisition 24 hours after initial injection is recommended. Acquisition can be performed using planar imaging. 4.3 Contra-indications Hypersensitivity to the active substance, to other murine antibodies or to any of the excipients. Positive screening test for human anti-mouse antibody (HAMA). Pregnancy (see section 4.6). 4.4 Special warnings and precautions for use Indication of the examination For all patients, the radiation exposure must be justifiable by the expected diagnostic achieved with the lowest possible radiation dose. An interval of at least 2 days must be observed between any previous scintigraphy with other technetium (99mTc)-labelled agents and administration of Scintimun. Interpretation of the Scintimun images There are currently no criteria to distinguish infection and inflammation by means of Scintimun imaging. Scintimun images should be interpreted in the context of other appropriate anatomical and/or functional imaging examinations. Only limited data is available about binding of technetium (99mTc) besilesomab to CarcinoEmbryonic Antigen (CEA) expressing tumours in vivo. In vitro, besilesomab cross-reacts with CEA. False positive findings in patients with CEA expressing tumours cannot be excluded. False results may be obtained in patients with diseases involving neutrophil defects and to patients with haematological malignancies including myeloma. General warnings Radiopharmaceuticals should be received, used and administered only by authorised persons in designated clinical settings. Their receipt, storage, use, transfer and disposal are subject to the regulations and the appropriate authorisations of the competent authorities. Warnings related to excipients Fructose intolerance Scintimun contains sorbitol therefore patients with rare hereditary problems of fructose intolerance should not be administered this product. This medicinal product contains less than 1 mmol sodium (23 mg) per dose administered, i.e. is essentially ‘sodium- free’. Other important warnings Human Anti-Mouse Antibodies (HAMA) Administration of murine monoclonal antibodies can lead to the development of Human Anti-Mouse Antibodies (HAMA). Patients who are HAMA positive may have a greater risk for hypersensitivity reactions. Inquiry on possible previous exposure to murine monoclonal antibodies and a HAMA test should be made prior to administration of Scintimun; a positive response would contraindicate the administration of Scintimun (see section 4.3). Repeated use Data on repeated dosing of Scintimun are very limited. Scintimun should only be used once in a patient’s lifetime. Hypersensitivity reactions Anaphylactic or anaphylactoid reactions may occur after administration of the medicinal product. Appropriate cardiopulmonary resuscitation facilities and trained personnel should be available for immediate use in the event of an adverse reaction. Since allergic reactions to the murine protein cannot be excluded, cardiovascular treatment, corticosteroids, and antihistamines must be available during administration of the product. 4.5 Interaction with other medicinal products and other forms of interaction Active substances which inhibit inflammation or affect the haematopoietic system (such as antibiotics and corticosteroids) may lead to false negative results. Such substances should therefore not be administered together with, or a short time before the injection of Scintimun. 4.6 Fertility, pregnancy and lactation Women of childbearing potential When it is necessary to administer radioactive medicinal products to women of childbearing potential, information should always be sought about pregnancy. Any woman who has missed a period should be assumed to be pregnant until proven otherwise. Where uncertainty exists, it is important that radiation exposure should be the minimum consistent with achieving the desired clinical information. Alternative techniques which do not involve ionising radiation should be considered. Pregnancy Scintimun is contraindicated in pregnancy (see section 4.3).

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Available data is insufficient to address the effects of the product during pregnancy. No reproductive studies have been carried out in animals. Radionuclide procedures carried out on pregnant women also involve radiation doses to the foetus. The dose delivered to foetus varies with the stage of pregnancy and is reported in the following table: Stage of pregnancy Equivalent dose in mSv/MBq Three months 0.00379 Six months 0.00335 Nine months 0.00300 Breast-feeding It is not known if the product is excreted in human milk. A risk to a breast-fed child cannot be excluded. Before administering a radioactive medicinal product to a mother who is breast-feeding, consideration should be given as to whether the investigation could reasonably be delayed until the mother has ceased breast-feeding and as to whether the most appropriate choice of radiopharmaceutical has been made, bearing in mind the secretion of activity in breast milk. If the administration is considered necessary, breast-feeding should be interrupted for three days and the expressed milk discarded. These three days correspond to 10 half-lives of technetium (99mTc) (60 hours). At that time the remaining activity represents about 1/1000 of the initial activity in the body. A close contact with the child should also be avoided during the first 12 hours after the injection. 4.7 Effects on ability to drive and use machines No studies on the effects on the ability to drive and use machines have been performed. At the recommended activity for diagnostic procedures, Scintimun is not likely to have any influence on the ability to drive and use machines. 4.8 Undesirable effects In the most recent clinical study in which 123 patients were administered Scintimun, the most commonly reported adverse reaction was the development of anti-mouse antibodies (HAMA) in 14% of the patients, after a single administration (16 positive over 116 assayed one and/or three months after the administration). The table below reports adverse reactions by MedDRA system organ classes. The frequencies are based on the most recent clinical trial and non interventional safety survey. The frequency listed below is defined using the following convention: Very common (≥ 1/10); common (≥ 1/100 to <1/10); uncommon (≥ 1/1,000 to <1/100); rare (≥ 1/10,000 to <1/1,000) MedDRA System Organ Classes Adverse reactions Frequency Hypersensitivity, including angioedema, urticaria Uncommon Immune system disorders Anaphylactic/anaphylactoid reaction Rare Vascular disorders Hypotension Common Musculoskeletal and connective tissue disorders Myalgia, arthralgia Rare Investigations Human anti-mouse antibody positive Very common For all patients, the radiation exposure must be justifiable by the expected diagnostic achieved with the lowest possible radiation dose. Exposure to ionising radiation is linked with cancer induction and a potential for development of hereditary defects. For diagnostic nuclear medicine investigations the frequency of these adverse reactions is not known. After administration of the maximum recommended activity of technetium (99mTc) besilesomab of 800 MBq, the effective dose is about 6.9 mSv. 4.9 Overdose No case of overdose has been reported. If an overdose of technetium (99mTc) besilesomab has been administered, the radiation dose delivered to the patient must be reduced by increasing as much as possible the elimination of the radionuclide by forced diuresis and frequent micturitions, and by the use of laxatives to promote faecal excretion.

5. PHARMACOLOGIC PROPERTIES 5.1 Pharmacodynamic properties Pharmacotherapeutic group: Diagnostic Radiopharmaceuticals ATC code: V09HA03 Besilesomab is a murine immunoglobulin of IgG1 isotype that specifically binds to NCA-95 (non specific cross-reacting antigen 95), an epitope expressed at the cell membrane of granulocytes and granulocyte precursors. Besilesomab cross-reacts with tumours expressing carcinoembryonic antigen (CEA). Besilesomab has no effect on activation of complement, granulocyte function or platelets. At the recommended activities, it does not exert any clinically relevant pharmacodynamic effects. In a randomised cross-over trial comparing blinded reading of Scintimun and 99mTc-White Blood Cells (WBCs) images in 119 patients with

26 | IBA | Scintimun® Monograph suspected osteomyelitis, the agreement rate between the two methods was 83% (lower 95% confidence interval limit: 80%). However, based on the investigator’s diagnosis after one month of follow-up, Scintimun had a slightly lower specificity (71.8%) than 99mTc-WBCs (79.5%). There are insufficient data on the use of Scintimun for the diagnosis of diabetic foot infection. 5.2 Pharmacokinetic properties Whole blood concentration-time radioactivity curves show a two-phase course, which can be subdivided into an early phase (0-2 h) and a late phase (5-24 h). After correcting for the decay of radionuclide, the calculated half-life of the early phase is 0.5 h whereas the late phase shows a half-life of elimination of 16 h. Six hours after injection, about 1.5% of the whole body radioactivity is found in the liver whereas about 3.0% is found in the spleen. Twenty- four hours after injection, the percentages of radioactivity are 1.6% in the liver and 2.3% in the spleen. Measurement of radioactivity levels in urine shows that up to 14% of the administered activity is excreted via the bladder during the 24 h post-injection. The low renal clearance of activity (0.2 l/h for a glomerular filtration rate around 7 l/h) indicates that the kidney is not the major route of besilesomab elimination. Non pathological unusual accumulations may be observed in the spleen (up to 6% of the patients), in the bowel (up to 4% of the patients), in the liver and bone marrow (up to 3% of the patients), and in the thyroid and kidneys (up to 2% of patients). 5.3 Preclinical safety data Preclinical toxicity and safety studies were performed using commercial kits reconstituted with decayed technetium and thus the effect of radiation has not been assessed. Preclinical data obtained with the non-radioactive compound reveal no special hazard for humans based on conventional studies of safety pharmacology, single-dose and repeated-dose toxicity, although antimurine antibodies were found in all dose groups (including controls) in a repeated-dose study in monkeys. Genotoxicity studies conducted to test for potentially genotoxic impurities were also negative. No animal studies regarding carcinogenic potential and toxicity to reproduction were performed.

6. PHARMACEUTICAL PARTICULARS 6.1 List of excipients Scintimun Sodium dihydrogen phosphate, anhydrous Disodium monohydrogen phosphate, anhydrous Sorbitol E420 Under nitrogen atmosphere Solvent for Scintimun 1, 1, 3, 3-propane tetraphosphonic acid, tetrasodium salt, dihydrate (PTP) Stannous chloride dihydrate Sodium hydroxide / Hydrochloric acid (for pH adjustment) Nitrogen 6.2 Incompatibilities This medicinal product must not be mixed with other medicinal products except those mentioned in section 12. 6.3 Shelf life 2 years. Do not store the reconstituted and radiolabelled product above 25°C and use within 3 hours. 6.4 Special precautions for storage Store in a refrigerator (2°C – 8°C). Keep the vial in the outer carton in order to protect from light. For storage conditions of the reconstituted and radiolabelled medicinal product, see section 6.3. This product should be stored in accordance with national regulations concerning radioactive products. 6.5 Nature and contents of container Vial Scintimun 10 ml, colourless, type I glass vial, closed with chlorobutyl rubber stopper and aluminium crimped capsule (green). Vial Solvent for Scintimun 6 ml, colourless, type I glass vial, closed with chlorobutyl rubber stopper and crimped aluminium capsule (yellow). Pack sizes: Kit of one multidose vial Scintimun and one vial Solvent for Scintimun. Kit of two multidose vials Scintimun and two vials Solvent for Scintimun. Not all pack sizes may be marketed.

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6.6 Special precautions for disposal and other handling The administration of radiopharmaceuticals creates risks for other persons from external radiation or contamination from spills of urine, vomiting, expectoration or other biological fluids. Radiation protection precautions in accordance with national regulations must be taken. Any unused product or waste material should be disposed of in accordance with local requirements.

7. MARKETING AUTHORISATION HOLDER CIS bio international B.P.32 F-91192 Gif-sur-Yvette Cedex France

8. MARKETING AUTHORISATION NUMBER(S) EU/1/09/602/001 EU/1/09/602/002

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 11/01/2010

10. DATE OF REVISION OF THE TEXT 01/2010

11. DOSIMETRY Technetium (99mTc) is produced by means of a (99Mo/99mTc) generator and decays with the emission of gamma radiation with a mean energy of 140 keV and a half-life of 6.02 hours to technetium (99Tc) which, in view of its long half-life of 2.13 x 105 years can be regarded as quasi stable. For each organ, or group of organs, the absorbed doses have been calculated using the methodology developed by the MIRD (Medical Internal Radiation Dose). The effective dose has been calculated by using the absorbed doses determined for each individual organ, taking into account the weighting factors (radiation and tissue) to use according to the recommendations of the ICRP (International Commission of Radiological Protection, Publication 103). Table 1: Values of the absorbed doses calculated for the individual male and female of reference.

Organ mSv/MBq Reference male Reference female Brain 2.36 E-03 3.12 E-03 Heart 4.95 E-03 5.97 E-03 Colon 4.50 E-03 5.76 E-03 Stomach 4.45 E-03 5.35 E-03 Liver 1.00 E-02 1.26 E-02 Small Intestine 4.80 E-03 5.75 E-03 Bone marrow (red) 2.42 E-02 2.29 E-02 Muscles 3.17 E-03 3.91 E-03 Ovaries 5.94 E-03 Pancreas 6.90 E-03 8.26 E-03 Skin 1.78 E-03 2.16 E-03 Lungs 1.25 E-02 1.60 E-02 Spleen 2.71 E-02 3.24 E-02 Kidney 2.10 E-02 2.34 E-02 Breast 3.01 E-03 Adrenal 7.59 E-03 9.37 E-03 Testis 1.82 E-03 Thymus 3.51 E-03 4.23 E-03 Thyroid 2.79 E-03 3.21 E-03 Bone 1.77 E-02 2.27 E-02 Uterus 5.01 E-03 Gallbladder 5.91 E-03 6.81 E-03 Bladder 3.05 E-03 3.80 E-03 For this product, the Effective Dose Whole body 4.45 E-03 5.52 E-03 resulting from an administered activity of Effective Dose 8.63 E-03mSv / MBq 800 MBq is 6.9 mSv.

28 | IBA | Scintimun® Monograph 12. INSTRUCTIONS FOR PREPARATION OF RADIOPHARMACEUTICALS Scintimun is a sterile powder containing 1 mg of besilesomab per vial Scintimun. After reconstitution with the solvent provided and then radiolabelling with sodium pertechnetate (99mTc) injection, the resulting clear and colourless solution for injection of technetium (99mTc) besilesomab has a pH of 6.5-7.5. Radiopharmaceuticals should be prepared by the user in a manner which satisfies both radiation safety and pharmaceutical quality requirements. Appropriate aseptic precautions should be taken, complying with the requirements of Good Manufacturing Practice for pharmaceuticals.

Method of preparation To ensure the highest labelling efficiency: - Radiolabelling is performed using freshly eluted sodium pertechnetate (99mTc). - Eluates should only be taken from a technetium (99mTc)-generator that has been eluted within the past 24 hours (i.e. with less than 24h in-grow). - The first eluate taken from a technetium (99mTc)-generator that has not been eluted over the weekend must NOT be used.

Procedure: 1. Take a vial Solvent for Scintimun (yellow crimped aluminium capsule) from the kit. Disinfect the septum and allow to dry. Using a syringe, introduce through the rubber seal 5 ml of 0.9% sodium chloride solution. Without removing the needle, withdraw an equivalent volume of air in order to avoid excess pressure in the vial. Shake smoothly. 2. After complete dissolution, disinfect the septum and allow to dry. Transfer 1 ml of this solution with a hypodermic syringe into a vial Scintimun (green crimped aluminium capsule). Without removing the needle, withdraw an equivalent volume of air in order to avoid excess pressure in the vial. Swirl carefully, the content of vial Scintimun will dissolve within one minute (DO NOT shake). 3. After 1 min, check that the content of vial Scintimun have completely dissolved. Place vial Scintimun in an appropriate lead shielding container. Disinfect the septum and allow to dry. Using a hypodermic syringe, introduce through the rubber seal 2-7 ml of pertechnetate (99mTc) (the eluate complies with the requirements of current Eur. Ph.). Without removing the needle, withdraw an equivalent volume of air in order to avoid excess pressure in the vial. Swirl carefully to mix the whole solution (DO NOT shake). The activity must be between 400 and 1800 MBq depending on the volume of pertechnetate (99mTc). Total volume in vial Scintimun equals 3 to 8 ml. 4. Fill in the enclosed label and fix it to the radiolabelled solution. 5. 10 min after the addition of pertechnetate (99mTc) the solution is ready for injection.

Notes on the instructions: - Solvent for Scintimun must NEVER be radiolabelled first and then added to Scintimun. - The final radiolabelled injection solution must be protected from oxygen.

Quality control The radiochemical purity of the final radiolabelled preparation can be tested according to the following procedure:

Method Instant thin layer chromatography

Materials and reagents - Adsorbent: strips for thin layer chromatography (2.5 x 20 cm) coated with silica gel. Trace a starting line 2.5 cm from the bottom of the paper strip. - Solvent: methyl ethyl ketone (MEK) - Containers: appropriate containers such as chromatography tank or 1 000 ml Erlenmeyer flasks. - Miscellaneous: forceps, scissors, syringes, appropriate counting assembly.

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Procedure Do not let air enter the vial to be tested and store all vials containing radioactive solution in lead shielding. 1. Introduce the solvent into the chromatography tank to a depth of approximately 2 cm. Cover the tank and allow to equilibrate for at least 5 minutes. 2. Apply a spot (2 µl) of the radiolabelled solution to the starting line of the ITLC paper strip using a syringe and a needle. 3. Introduce the ITLC paper strip immediately into the chromatography tank using forceps to avoid formation of pertechnetate (99mTc) due to oxygen. 4. When the solvent has reached the top of the strip (about 10 minutes), use the forceps to remove the strip and dry in the air. 5. Cut the strip in two separate parts at Rf = 0.5. 6. Separately count each cut part of the strip and record the obtained values (use an appropriate detection apparatus with a constant counting time, and known geometry and background noise). 7. Calculations The radiochemical purity corresponds to the percentage of bound technetium (99mTc) and is calculated as follows after correcting data for background noise:

% bound technetium (99mTc) = 100% - % free Technetium (99mTc)

Activity of cut strip from Rf 0.5 to Rf 1.0 Where, % free technetium (99mTc) = x 100 Total activity of strip

8. The radiochemical purity (the percentage of bound Technetium (99mTc) must be more than or equal to 95%. 9. The solution should be inspected visually prior to use. Only clear solutions, free of visible particles should be used.

Any unused product or waste material should be disposed of in accordance with local requirements.

Detailed information on this medicinal product is available on the website of the European Medicines Agency (EMEA) http://www.emea.europa.eu/.

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Monograph

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