Spy Agent Green (indocyanine green)

In the determination of cardiac output, the usual dose of indocyanine green is 5 mg for adults, 2.5 mg for children, and 1.25 mg for infants, diluted, if necessary, with sterile water for injection or 0.9% sodium chloride injection to make a final volume of 1 mL. These doses are repeated periodically to obtain several dilution curves. The manufacturer recommends that the total dose of indocyanine green not exceed 2 mg/kg.

Indocyanine green solution is injected as rapidly as possible into the right atrium, right ventricle, or pulmonary artery through a cardiac catheter. The residual dye should be flushed from the catheter with saline to prevent hemolysis. The measurement of indocyanine green should begin immediately after administration of the dye using either a dichromatic ear densitometer or continuous arterial blood withdrawal and a cuvette densitometer. Cardiac output is calculated using the data derived from the initial peak of the blood level-time curve. Specialized references should be consulted for specific procedures and to determine the most appropriate method of calculation and the interpretation of the results of cardiac output studies.

In the determination of hepatic function, the usual dose of indocyanine green is 0.5 mg/kg, although doses as low as 0.1 mg/kg and as high as 5 mg/kg have been used. It has been reported that doses of 5 mg/kg allow detection of mild hepatic dysfunction not otherwise detectable with indocyanine green.

The patient should be studied in a fasting, basal state. If the photometric method is used, a 6-mL sample of blood is obtained from a vein in the arm for use as a blank, and the dye is injected through the same needle as rapidly as possible without allowing the dye to escape. Disappearance of the dye from the plasma may be measured using a dichromatic ear densitometer, or blood samples may be obtained from a vein of the opposite arm at 5-minute intervals for 15 minutes to determine the percentage disappearance rate (PDR) of the dye. An additional sample should be obtained 20 minutes after injection to determine the percentage retention of the dye. PDRs range from 18-24 in healthy adult males and 24-30 in healthy infants. Specialized references should be consulted for specific procedures, methods of calculating PDR, and interpretation of results of hepatic function studies.

Indocyanine green has been administered IV in the determination of hepatic blood flow. Blood from a peripheral artery and a hepatic vein is sampled, and the hepatic blood flow is calculated using the Fick principle. For specific dosage, procedures, and methods of calculating hepatic blood flow specialized references should be consulted.

No dosing information is available for this tab.

No dosing information is available for this tab.

No dosing information is available for this tab.

The half-life of indocyanine green may be decreased in patients who are taking phenobarbital, presumably due to an increase in hepatic dye transport induced by phenobarbital. Other drugs which have been reported to decrease the half-life of indocyanine green include phenylbutazone, primidone, phenytoin, opiate derivatives (in addicts), haloperidol, nitrofurantoin, and sulthiame; however, the importance of the effect of these drugs is not well established.

Administration of probenecid to dogs in doses of 25-100 mg/kg decreases the elimination rate of indocyanine green and the possibility of this occurrence in humans should be considered.

The half-life of indocyanine green may be decreased in patients who are taking phenobarbital, presumably because of an increase in hepatic dye transport induced by phenobarbital. Other drugs which have been reported to decrease the half-life of indocyanine green include phenylbutazone, primidone, phenytoin, opiate derivatives (in addicts), haloperidol, nitrofurantoin, and sulthiame; however, the importance of the effect of these drugs is not well established.

Administration of probenecid to dogs in doses of 25-100 mg/kg decreases the elimination rate of indocyanine green and the possibility of this occurrence in humans should be considered.

Simultaneous administration of indocyanine green and sulfobromophthalein sodium (BSP) may result in an impairment of hepatic excretion of BSP, particularly in patients with hepatic impairment. The presence of BSP in blood may cause changes in the maximum absorption spectrum of indocyanine green, and simultaneous use of these agents should be avoided.

There are no contraindication interactions for this drug.

Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

Agents That Affect Iodide/Radioactive Iodide

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Many compounds can affect iodide protein binding and alter iodide pharmacokinetics and pharmacodynamics.(1)

CLINICAL EFFECTS: Compounds that affect iodide pharmacokinetics and pharmacodynamics may impact the effectiveness of radioactive iodide.(1)

PREDISPOSING FACTORS: Compounds that affect iodide pharmacokinetics and pharmacodynamics are expected to have the most impact during therapy using radioactive iodide. Diagnostic procedures would be expected to be impacted less.

PATIENT MANAGEMENT: Discuss the use of agents that affect iodide pharmacokinetics and pharmacodynamics with the patient's oncologist.(1) Because indocyanine green contains sodium iodide, the iodine-binding capacity of thyroid tissue may be reduced for at least one week following administration. Do not perform radioactive iodine uptake studies for at least one week following administration of indocyanine green.(2) The manufacturer of iopamidol states administration may interfere with thyroid uptake of radioactive iodine and decrease therapeutic and diagnostic efficacy. Avoid thyroid therapy or testing for up to 6 weeks post administration of iopamidol.(3)

DISCUSSION: Many agents interact with radioactive iodine. The average duration of effect is: anticoagulants - 1 week antihistamines - 1 week anti-thyroid drugs, e.g: carbimazole, methimazole, propylthiouracil - 3-5 days corticosteroids - 1 week iodide-containing medications, e.g: amiodarone - 1-6 months expectorants - 2 weeks Lugol solution - 3 weeks saturated solution of potassium iodine - 3 weeks vitamins - 10-14 days iodide-containing X-ray contrast agents - up to 1 year lithium - 4 weeks phenylbutazone - 1-2 weeks sulfonamides - 1 week thyroid hormones (natural or synthetic), e.g.: thyroxine - 4 weeks tri-iodothyronine - 2 weeks tolbutamide - 1 week topical iodide - 1-9 months (1)

Agents That Affect Iodide/Sodium Iodide I 131

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Many compounds can affect iodide protein binding and alter iodide pharmacokinetics and pharmacodynamics.(1,2)

CLINICAL EFFECTS: Compounds that affect iodide pharmacokinetics and pharmacodynamics may impact the effectiveness of radioactive iodide.(1,2)

PREDISPOSING FACTORS: Compounds that affect iodide pharmacokinetics and pharmacodynamics are expected to have the most impact during therapy using radioactive iodide. Diagnostic procedures would be expected to be impacted less.

PATIENT MANAGEMENT: Discuss the use of agents that affect iodide pharmacokinetics and pharmacodynamics with the patient's oncologist.(1,2) Because indocyanine green contains sodium iodide, the iodine-binding capacity of thyroid tissue may be reduced for at least one week following administration. Do not perform radioactive iodine uptake studies for at least one week following administration of indocyanine green.(3) The manufacturer of iopamidol states administration may interfere with thyroid uptake of radioactive iodine and decrease therapeutic and diagnostic efficacy. Avoid thyroid therapy or testing for up to 6 weeks post administration of iopamidol.(4)

DISCUSSION: Many agents interact with radioactive iodine. The average duration of effect is: anticoagulants - 1 week antihistamines - 1 week anti-thyroid drugs, e.g: carbimazole, methimazole, propylthiouracil - 3-5 days corticosteroids - 1 week iodide-containing medications, e.g: amiodarone - 1-6 months expectorants - 2 weeks Lugol solution - 3 weeks saturated solution of potassium iodine - 3 weeks vitamins - 10-14 days iodide-containing X-ray contrast agents - up to 1 year lithium - 4 weeks phenylbutazone - 1-2 weeks sulfonamides - 1 week thyroid hormones (natural or synthetic), e.g.: thyroxine - 4 weeks tri-iodothyronine - 2 weeks tolbutamide - 1 week topical iodide - 1-9 months (1,2)

There are no moderate interactions for this drug.

There is no enhanced messaging for this drug.

There are no contraindication contraindications for this drug.

There are no severe contraindications for this drug.

• No disease contraindications

There is no enhanced messaging for this drug.

Rare or Very Rare

• Anaphylaxis

Less Frequent

• Headache disorder
• Hyperhidrosis
• Pruritus of skin

Rare or Very Rare

• Hyperbilirubinemia
• Urticaria

No enhanced messaging available.

No enhanced messaging available.

Safe use of indocyanine green during pregnancy has not been established.

Safe use of indocyanine green during pregnancy has not been established.

No enhanced messaging available.

No enhanced messaging available.