cardinal health 414, llc - Medication Listings

11.1 Chemical Characteristics Ammonia N-13 Injection, USP is a positron emitting radiopharmaceutical that is used for diagnostic purposes in conjunction with positron emission tomography (PET) imaging. The active ingredient, [ 13 N] ammonia, has the molecular formula of 13 NH 3 with a molecular weight of 16.02, and has the following chemical structure: Ammonia N-13 Injection, USP is provided as a ready to use sterile, pyrogen-free, clear and colorless solution. Each mL of the solution contains between 0.138 GBq to 1.387 GBq (3.75 mCi to 37.5 mCi) of [ 13 N] ammonia, at the end of synthesis (EOS) reference time, in 0.9% aqueous sodium chloride. The pH of the solution is between 4.5 to 7.5. The recommended dose of radioactivity (10-20 mCi) is associated with a theoretical mass dose of 0.5-1.0 picomoles of ammonia. Chemical Structure 11.2 Physical Characteristics Nitrogen N-13 decays by emitting positron to Carbon C-13 (stable) and has a physical half-life of 9.96 minutes. The principal photons useful for imaging are the dual 511 keV gamma photons that are produced and emitted simultaneously in opposite direction when the positron interacts with an electron (Table 2). Table 2: Principal Radiation Emission Data for Nitrogen 13 Radiation/Emission % Per Disintegration Energy Positron(β+) 100 1190 keV (Max.) Gamma(±) Produced by positron annihilation. 200 511.0 keV The specific gamma ray constant (point source air kerma coefficient) for nitrogen N-13 is 5.9 R/hr/mCi (1.39 x 10 -6 Gy/hr/kBq) at 1 cm. The half-value layer (HVL) of lead (Pb) for 511 keV photons is 4 mm, or 2.9 mm tungsten (W) alloy. Selected coefficients of attenuation are listed in Table 3 as a function of lead shield thickness. For example, the use of 39 mm thickness of lead or 28 mm of tungsten alloy will attenuate the external radiation by a factor of about 1000. Table 3: Radiation Attenuation of 511 keV Photons by Lead (Pb) Shielding Shield Thickness (Pb) mm Shield Thickness (W) Alloy mm Coefficient of Attenuation 0 0 0.00 4 2.9 0.50 8 5.8 0.25 13 9.4 0.10 26 18.7 0.01 39 27.6 0.001 Table 4 lists fractions remaining at selected time intervals from the calibration time. This information may be used to correct for physical decay of the radionuclide. Table 4: Physical Decay Chart for Nitrogen N-13 Minutes Fraction Remaining 0 calibration time 1.000 5 0.706 10 0.499 15 0.352 20 0.249 25 0.176 30 0.124 60 0.016

11.1 Chemical Characteristics Fludeoxyglucose F-18 Injection is a positron emitting radiopharmaceutical that is used for diagnostic purposes in conjunction with positron emission tomography (PET) imaging. The active ingredient 2-deoxy-2-[ 18 F]fluoro-D-glucose has the molecular formula of C 6 H 11 18 FO 5 with a molecular weight of 181.26, and has the following chemical structure: Fludeoxyglucose F-18 Injection is provided as a ready to use sterile, pyrogen free, clear, colorless citrate buffered solution. Each mL contains between 0.74 - 18.5 GBq (20 - 500 mCi/mL) of 2-deoxy-2-[ 18 F]fluoro-D-glucose at the EOS, 4.5 mg of sodium chloride in citrate buffer. The pH of the solution is between 4.5 and 7.5. The solution is packaged in a multiple-dose glass vial and does not contain any preservative. Chemical Structure 11.2 Physical Characteristics Fluorine F-18 has a physical half-life of 109.7 minutes and decays to Oxygen O-18 (stable) by positron decay. The principal photons useful for imaging are the dual 511 keV “annihilation” gamma photons that are produced and emitted simultaneously in opposite directions when the positron interacts with an electron (Table 2). Table 2. Principal Radiation Emission Data for Fluorine F-18 Radiation/Emission % Per Disintegration Mean Energy * Produced by positron annihilation From: Kocher, D.C. Radioactive Decay Tables DOE/TIC-I 1026, 89 (1981) Positron(β+) 96.73 249.8 keV Gamma(±)* 193.46 511.0 keV The specific gamma ray constant (point source air kerma coefficient) for fluorine F-18 is 5.7 R/hr/mCi (1.35 x 10 -6 Gy/hr/kBq) at 1 cm. The half-value layer (HVL) for the 511 keV photons is 4 mm lead (Pb) or 2.9 mm tungsten (W) alloy. The range of attenuation coefficients for this radionuclide as a function of shield thickness is shown in Table 3. For example, the interposition of an 8 mm thickness of Pb or 5.8 mm thickness of W alloy, with a coefficient of attenuation of 0.25, will decrease the external radiation by 75%. Table 3. Radiation Attenuation of 511 keV Photons by Lead (Pb) and Tungsten (W) Alloy Shielding Shield Thickness (Pb) mm Shield Thickness (W) Alloy mm Coefficient of Attenuation 0 0 0.00 4 2.9 0.50 8 5.8 0.25 13 9.4 0.10 26 18.7 0.01 39 27.6 0.001 52 37.4 0.0001 For use in correcting for physical decay of this radionuclide, the fractions remaining at selected intervals after calibration are shown in Table 4. Table 4. Physical Decay Chart for Fluorine F-18 Minutes Fraction Remaining * calibration time 0* 1.000 15 0.909 30 0.826 60 0.683 110 0.500 220 0.250 440 0.060

Chemical Characteristics The active ingredient in Lymphoseek, a radioactive diagnostic agent, is technetium Tc 99m tilmanocept. Technetium Tc 99m binds to the diethylenetriaminepentaacetic acid (DTPA) moieties of the tilmanocept molecule. • Chemically, technetium Tc 99m tilmanocept consists of technetium Tc 99m, dextran 3-[(2-aminoethyl)thio]propyl 17-carboxy-10,13,16-tris(carboxymethyl)-8-oxo-4-thia-7,10,13,16-tetraazaheptadec-1-yl 3-[[2-[[1-imino-2-(D-mannopyranosylthio)ethyl]amino]ethyl]thio]propyl ether complexes. • The molecular formula of technetium Tc 99m tilmanocept is [C 6 H 10 O 5 ] n .(C 19 H 28 N 4 O 9 S 99m Tc) b .(C 13 H 24 N 2 O 5 S 2 ) c .(C 5 H 11 NS) a . It contains 3-8 conjugated DTPA (diethylenetriaminepentaacetic acid) molecules (b); 12-20 conjugated mannose molecules (c) with 0-17 amine side chains (a) remaining free. • The calculated average molecular weight of tilmanocept ranges from 15,281 to 23,454 g/mol. • Technetium Tc 99m tilmanocept has the following structural formula: Lymphoseek is supplied as a kit which contains five vials, 250 mcg tilmanocept per vial. Each Lymphoseek vial contains the non-radioactive ingredients needed to produce technetium Tc 99m tilmanocept. The vial contains a sterile, non-pyrogenic, white to off-white lyophilized powder (under nitrogen) that consists of a mixture of 250 mcg tilmanocept, 20 mg trehalose dihydrate, 0.5 mg glycine, 0.5 mg sodium ascorbate, and 0.075 mg stannous chloride dihydrate. Sodium hydroxide and hydrochloric acid may be used to adjust the pH prior to lyophilization. The DILUENT for Lymphoseek contains 4.5 mL sterile buffered saline consisting of 0.04% (w/v) potassium phosphate, 0.11% (w/v) sodium phosphate (heptahydrate), 0.5% (w/v) sodium chloride, and 0.4% (w/v) phenol. Physical Characteristics Technetium Tc 99m decays by isomeric transition with a physical half-life of approximately 6 hours. The principal photon that is useful for detection and imaging studies is listed in Table 4 . Table 4. Principal Radiation Emission Data From: Kocher, D.C. Radioactive decay data tables. DOE/TIC-11026, 108 (1981). Radiation Mean % Disintegration Mean Energy (keV) Gamma-2 89.1 140.5 External Radiation The linear mass energy absorption attenuation coefficient for Tc 99m is 18.9 cm -1 . The first half-value layer is 0.037 cm of lead (Pb). The use of a 0.25 cm thick standard radiation lead shield will attenuate the radiation emitted by millicurie amounts of technetium Tc 99m by a factor of about 100. A range of values for the relative attenuation of the radiation of technetium Tc 99m that results with various thicknesses of lead shielding are displayed in Table 5 . Table 5. Radiation Attenuation by Lead Shielding Shield Thickness, cm of lead (Pb) Coefficient of Attenuation 0.037 0.5 0.12 10 -1 0.24 10 -2 0.36 10 -3 0.49 10 -4 To correct for physical decay of the radionuclide, the fractions that remain at selected intervals after the time of calibration are shown in Table 6 . Table 6. Physical Decay Chart; Tc 99m, Half-Life of approximately 6 Hours Hours Fraction Remaining 0 1 1 0.891 3 0.708 6 0.501 12 0.251 15 0.178 Structural Formula

Each reaction vial contains a sterile, nonpyrogenic, nonradioactive lyophilized mixture of 20 mg medronic acid, 1 mg ascorbic acid, 0.13 mg (minimum) stannous fluoride, SnF 2 and 0.38 mg total tin, maximum (as stannous fluoride, SnF 2 ). The pH is adjusted with sodium hydroxide or hydrochloric acid to 6.5 (6.3 to 6.7) prior to lyophilization. The vial does not contain a preservative. The contents of the vial are lyophilized and sealed under nitrogen at the time of manufacture. The pH of the reconstituted product is 5.4 to 6.8. The structure of medronic acid is given below: The precise structure of technetium Tc 99m medronate is unknown at this time. When sterile, pyrogen-free sodium pertechnetate Tc 99m injection is added to the vial, the diagnostic agent technetium Tc 99m medronate is formed for administration by intravenous injection. Structure of Medronic Acid

Each 5 mL vial contains a sterile, non-pyrogenic, lyophilized mixture of: • Tetrakis (2-methoxy isobutyl isonitrile) Copper (I) tetrafluoroborate - 1.0 mg • Sodium Citrate Dihydrate - 2.6 mg • L-Cysteine Hydrochloride Monohydrate - 1.0 mg • Mannitol - 20 mg • Stannous Chloride, Dihydrate, minimum (SnCl 2 •2H 2 O) - 0.025 mg • Stannous Chloride, Dihydrate (SnCl 2 •2H 2 O) - 0.075 mg • Tin Chloride (stannous and stannic) Dihydrate, maximum (as SnCl 2 •2H 2 O) - 0.086 mg Prior to lyophilization the pH is 5.3 to 5.9. The contents of the vial are lyophilized and stored under nitrogen. This drug is administered by intravenous injection for diagnostic use after reconstitution with sterile, non-pyrogenic, oxidant-free Sodium Pertechnetate Tc 99m Injection. The pH of the reconstituted product is 5.5 (5.0–6.0). No bacteriostatic preservative is present. The precise structure of the technetium complex is Tc 99m[MIBI] 6 + where MIBI is 2-methoxy isobutyl isonitrile. Tetrakis (2-methoxy isobutyl isonitrile) Copper (I) tetrafluoroborate has the following structural formula: 11.1 Physical Characteristics Technetium Tc 99m decays by isomeric transition with a physical half-life of 6.02 hours 2 . Photons that are useful for detection and imaging studies are listed below in Table 3 . Table 3 Principal Radiation Emission Data Radiation Mean %/Disintegration Mean Energy (KeV) Gamma -2 89.07 140.5 2 Kocher, David, C., Radioactive Decay Data Tables, DOE/TIC-11026, 108(1981). 11.2 External Radiation The specific gamma ray constant for Tc 99m is 5.4 microcoulombs/Kg-MBq-hr (0.78R/mCi-hr) at 1 cm. The first half value layer is 0.017 cm of Pb. A range of values for the relative attenuation of the radiation emitted by this radionuclide that results from interposition of various thicknesses of Pb is shown in Table 4 . To facilitate control of the radiation exposure from Megabequerel (millicurie) amounts of this radionuclide, the use of a 0.25 cm thickness of Pb will attenuate the radiation emitted by a factor of 1,000. Table 4 Radiation Attenuation by Lead Shielding Shield Thickness (Pb) cm Coefficient of Attenuation 0.017 0.5 0.08 10 –1 0.16 10 –2 0.25 10 –3 0.33 10 –4 To correct for physical decay of this radionuclide, the fractions that remain at selected intervals after the time of calibration are shown in Table 5 . Table 5 Physical Decay Chart; Tc 99m Half-Life 6.02 Hours Hours Fraction Remaining Hours Fraction Remaining 0 Calibration Time 1.000 7 0.447 1 0.891 8 0.398 2 0.794 9 0.355 3 0.708 10 0.316 4 0.631 11 0.282 5 0.562 12 0.251 6 0.501 Structural Formula

11.1 Chemical Characteristics Sodium Fluoride F-18 Injection, USP, is a positron emitting radiopharmaceutical, containing no-carrier-added, radioactive fluoride F-18 that is used for diagnostic purposes in conjunction with PET imaging. It is administered by intravenous injection. The active ingredient, sodium fluoride F-18, has the molecular formula Na[ 18 F] with a molecular weight of 40.99, and has the following chemical structure: Na +18 F – Sodium Fluoride F-18 Injection, USP, is provided as a ready-to-use, isotonic, sterile, pyrogen-free, preservative-free, clear and colorless solution. Each mL of the solution contains between 370 MBq to 7,400 MBq (10 mCi to 200 mCi) sodium fluoride F-18, at the EOS reference time, in 0.9% aqueous sodium chloride. The pH of the solution is between 4.5 and 8. The solution is presented in 30 mL multiple-dose glass vials with variable total volume and total radioactivity in each vial. 11.2 Physical Characteristics Fluoride F-18 decays by positron (β+) emission and has a half-life of 109.7 minutes. Ninety-seven percent of the decay results in emission of a positron with a maximum energy of 633 keV and 3% of the decay results in electron capture with subsequent emission of characteristic X-rays of oxygen. The principal photons useful for diagnostic imaging are the 511 keV gamma photons, resulting from the interaction of the emitted positron with an electron ( Table 2 ). Fluorine F-18 atom decays to stable 18 O-oxygen. Table 2. Principal Emission Data for Fluoride F-18 Radiation/Emission % Per Disintegration Mean Energy Positron(β+) 96.73 249.8 keV Gamma(±) Produced by positron annihilation From: Kocher, D.C. Radioactive Decay Data Tables DOE/TIC-11026, 69, 1981 193.46 511.0 keV The specific gamma ray constant for fluoride F-18 is 5.7 R/hr/mCi (1.35 x 10 -6 Gy/hr/kBq) at 1 cm. The half-value layer (HVL) for the 511 keV photons is 4.1 mm lead (Pb) or 2.9 mm tungsten (W) alloy. A range of values for the attenuation of radiation results from the interposition of various thickness of Pb or Tungsten alloy. The range of attenuation coefficients for this radionuclide is shown in Table 3 . For example, the interposition of an 8.3 mm thickness of Pb or 5.8 mm thickness of W alloy with a coefficient of attenuation of 0.25 will decrease the external radiation by 75%. Table 3. Radiation Attenuation of 511 keV Photons by lead (Pb) and Tungsten (W) alloy shielding Shield Thickness (Pb) mm Shield Thickness (W) Alloy mm Coefficient of Attenuation 0 0 0.00 4 3 0.50 8 6 0.25 13 9 0.10 26 19 0.01 39 28 0.001 53 37 0.0001 Table 4 lists the fraction of radioactivity remaining at selected time intervals from the calibration time. This information may be used to correct for physical decay of the radionuclide. Table 4. Physical Decay Chart for Fluoride F-18 Time Since Calibration Fraction Remaining 0 calibration time 1.00 15 minutes 0.909 30 minutes 0.826 60 minutes 0.683 110 minutes 0.500 220 minutes 0.250 440 minutes 0.060 12 hours 0.011 24 hours 0.0001