Products Affected - Description

• • Methylene Blue injection, Akorn, 10 mg/mL, 10 mL vial, 10 count, NDC 17478-0504-10

Reason for the Shortage

• • Akorn has no current plans on manufacturing methylene blue.[1]

Available Products

• • ProvayBlue injection, American Regent, 5 mg/mL, 10 mL ampule, 5 count, NDC 00517-0374-01

• • Akorn has no current dates for further production.[1]

• • ProvayBlue is approved for use in children and adults with acquired methemoglobinemia.[4] Methylene blue is a dye also used off-label in a variety of procedures such as lymph node biopsy, endoscopic evaluation of lesions, and urologic evaluations and pulmonary nodule evaluations. Methylene blue has also been used to treat methemoglobinemia due to toxic chemicals or substance abuse

• • Ensure appropriate dosing and indications when alternative dyes are used.

• • Consider reserving a supply of methylene blue for the treatment of methemoglobinemia.[5]
  • There is no single dye that can replace methylene blue. Table 1 summarizes potential alternatives to methylene blue for selected clinical scenarios.
  • Table 2 compares indigo carmine, methylene blue, and indocyanine green with regard to indication for use, dosing, metabolism and drug interactions. Table 3 summarizes the published primary literature for intravenous use of marker dyes to evaluate ureter patency during intraoperative cystoscopy. Table 4 summarizes the use of these products given by direct instillation for urologic or gynecologic procedures.

  Table 1. Potential Alternatives to Methylene Blue for Selected Clinical Situations Including Off-Labeled Uses3,6-9

  Use	Treatment Regimen	Comments
  Methemoglobinemia	Supportive care	Methylene blue is the drug of choice to treat drug induced methemoglobinemia dosed at 1 mg/kg intravenously and repeated if needed.3
  Lymph node and vessels delineation	Isosulfan blue: usual dose is 0.5 mL subcutaneously into 3 interdigital spaces of each extremity per study (maximum 3 mL).	Sentinel lymph node biopsy for patients with neoplasms such as breast cancer or other delineation of lymphatic vessels such as patients with lymphedema or chyluria.6
  Endoscopy procedures	Indigo carmine	Methylene blue is used for endoscopic evaluation in patients with Barrett's esophagus or gastroesophageal reflux disease.3,7
  Urology	Indigo carmine	Methylene blue is used for endoscopic evaluations of ureteral or pelvic injuries.3 Indigo carmine is used during cystoscopy and ureteral catheterization as a marker dye.8-9

  
  

  Table 2. Comparative Summary of Indications for Use, Dosing, and Pharmacokinetic Properties of Marker Dyes4,9-13

  Properties	Indigo Carmine	Methylene Blue	Indocyanine Green
  FDA approved product	No	Yes	Yes
  How supplied	8 mg/mL, 5 mL ampule	5 mg/mL 10 mL vial	25 mg vial
  Package insert indication	Localize ureteral orifices during cystoscopy and ureteral catheterization9	Acquired methemoglobinemia4	To determine cardiac output, liver blood flow and hepatic function, and for use in ophthalmic angiography11
  Common doses	Localizing ureteral orifices: 5 mL intravenous9 Usual dose when used as marker dye: 40 mg or 5 to 10 mL of 0.8% solution.10	Drug induced methemoglobinemia: 1 mg/kg intravenous slowly over 5 to 30 minutes. Repeat one time if needed. Consider alternative management if second dose does not resolve symptoms.4,10 Doses > 7 mg/kg can cause methemoglobinemia12-13	Cardiac output dilution studies: 5 mg via cardiac catheter.11 Hepatic function studies: 0.5 mg/kg intravenous.11 Ophthalmic angiography: 40 mg intravenous.11
  Drug interactions	No known drug interactions	Methylene blue is a monoamine oxidase inhibitor. Serotonin syndrome can occur in patients taking other serotonergic agents.10	Heparin preparations containing sodium bisulfite reduce peak absorption of indocyanine green in blood.
  Metabolism	Renal excretion	Renal excretion	Not metabolized. Indocyanine green is bound to plasma proteins, taken up by hepatocytes, and excreted unaltered into bile 20 minutes after injection.10
  Metabolites	None	Leucomethylene blue is the active metabolite that reduces iron from the ferric state to ferrous state. Azure B which is 8 times less potent than the parent compound.	None
  Half-life, intravenous	4 to 5 minutes(blue urine usually appears within 10 minutes of intravenous administration)9	Approximately 24 hours	3.2 to 3.5 minutes

  
  

  Table 3. Summary of Published Primary Literature for Intravenous Use of Marker Dyes to Evaluate Ureter Patency During Intraoperative Cystoscopy 14-23

  Indigo Carmine	Methylene Blue	Indocyanine Green
  There are 7 published reports of intravenous indigo carmine use to confirm ureteral patency.14-20 Dose and timing was not reported in 3 reports.14-16 Indigo carmine dose was 5 mL intravenous in two reports.16,18 Harris et al used indigo carmine 5 mL intravenously prior to intraoperative cystoscopy in 224 women undergoing reconstructive pelvic surgery.16 Jelovsek et al reported the results of intraoperative cystoscopy with intravenous indigo carmine in 126 patients undergoing total laparoscopic hysterectomy. The dose of indigo carmine was 1 ampule (5 mL) intravenous.18 Song and Kim used indigo carmine 5 mL intravenously one hour prior to operation and then repeated at time of skin incision to help identify ureters in 37 patients with ureteral obstruction.19	There are 3 published reports of intravenous methylene blue used to confirm ureteral patency.21-23 The dose of methylene blue in all three studies varied. Joel et al published a case report of 2 patients who received methylene blue 1% 10 mL intravenous to confirm ureteral patency. No methylene blue was visualized after administration. Authors speculate the methylene blue was metabolized to leukomethylene, which is colorless. Both patients received subsequent doses of indigo carmine and blue urine was observed.21 Wang reported the use of intravenous 1% methylene blue in 34 women undergoing intraoperative transurethral urethrocystoscopy. The dose was 6 mL (0.1 mL/kg). Delayed emission of the dye was observed in one patient with a right ureter stricture.22 Verbeek et al evaluated the use of methylene blue in 12 patients undergoing lower abdominal surgery exposing the ureters. Methylene blue was given intravenously at a dose of 0.25 mg/kg, 0.5 mg/kg, or 1 mg/kg. Patients underwent near infrared fluorescence imaging for up to 60 minutes after injection. Ureters were visualized within 10 minutes after methylene blue infusion. The authors recommend using methylene blue 0.25 mg/kg, as there were no differences found among the dose groups.23	There are no studies describing intravenous indocyanine green to evaluate ureter patency during intraoperative cystoscopy.

  
  

  Table 4. Summary of Published Primary Literature for Direct instillation of Marker Dyes for Urologic or Gynecologic Indications (non-tumor related)24-29,31-37

  Indigo Carmine	Methylene Blue	Indocyanine Green
  Rauh-Hain and Laufer report one successful case of indigo carmine injected transcervically to confirm patency of fallopian tubes. Indigo carmine dose was not provided.24 Furuya et al injected 1 to 5 mL of indigo carmine into midline cysts of the prostate in 68 patients to aid in the classification of the cysts.25	Moore et al reported a retrospective review of 5 patients who underwent robot-assisted laparoscopic bladder diverticulectomy. Methylene blue 1% solution was instilled into bladder to aid surgeon in identifying the diverticular neck of the bladder.26 Hanash et al instilled 150 mL to 200 mL of diluted methylene blue solution into the vagina during cystoscopy to aid in the identification of urinary fistulas in two patients. Concentration of methylene blue not provided.27 Volkmer et al used color Doppler ultrasound to identify vesicovaginal fistulas in 12 women. Methylene blue was instilled into the bladder but dosage of methylene blue was not specified.28 Nyarangi-Dix et al evaluated the efficacy of the methylene blue test in 103 men undergoing radical prostatectomy. A solution of methylene blue 5 mL and normal saline 95 mL was instilled into the bladder for 15 seconds.29 Six studies have reported the use of methylene blue injections into the testicles to assist with artery-sparing or lymphatic vessel-sparing varicocelectomy or hydrocele localization.30-35	Lee et al used indocyanine green visualization under near-infrared light to identify ureteral strictures. Indocyanine green 25 mg in 10 mL distilled water was injected via ureteral catheter or nephrostomy tube. In all 7 patients, the surgeon was able to identify the healthy and diseased ureter.36 Siddighi et al used indocyanine green visualization under near-infrared light to identify ureters during robot-assisted laparoscopic pelvic organ prolapse repair. Indocyanine green 25 mg in 10 mL of sterile water was injected into each ureter. Bilateral ureters were visualized in all patients. The specific number of patients who underwent this procedure was not specified but authors indicated > 10 patients.37

  
  

• 1. Akorn (personal communications). August 23, September 9, and October 4, November 9, 2016; January 18, March 23, June 12, July 11, September 5, November 2, 2017; January 28, April 5, May 23, July 30, September 26, November 30, and December 26, 2018; January 30, March 12, April 3, and July 26, 2019.
  2. American Regent (personal communications and website). August 23, September 9 and 27, November 4, 2016; March 24, September 5, 2017; October 4, 2018; March 12 and 14, May 1, and July 25, 2019.
  3. Methylene Blue. In McEvoy, GK, Snow EK, et al., Eds. AHFS Drug Information Online. Accessed September 17, 2013.
  4. American Regent. ProvayBlue injection [product information]. Shirley, NY, American Regent, 2018.
  5. The University of Utah Poison Control Center. Antidotes for Poisoned Patients. Available online at https://secure.uuhsc.utah.edu/poison/healthpros/antidote.pdf
  6. Mylan Institutional LLC. Isosulfan blue 1% injection [product information]. Rockford, IL, Mylan Institutional LLC, 2013.
  7. Kiesslich R, Neurath MF, Galle PR. Chromoendoscopy and magnifying endoscopy in patients with gastroesophageal reflux disease. Useful or negligible? Dig Dis.2004;22(2):142-7.
  8. Indigotindisulfonate sodium. In McEvoy, GK, Snow EK, et al., Eds. AHFS Drug Information Online. Accessed September 17, 2013.
  9. Akorn. Indigo carmine injection [product information]. Lake Forest, IL, Akorn, 2013.
  10. Anon, editor. Drugdex System. Micromedex 2.0 [internet database]. Greenwood Village, CO: Truven Health Analytics; 2014.
  11. Akorn. IC-Green Injection [product information]. Lake Forest, IL, Akorn, 2011.
  12. Lee M, Sharifi R. Methylene blue versus indigo carmine. Urology 1996;47(5):783-4.
  13. Gilmour D. Urinary tract injury in gynecologic surgery: evaluation and management. In: UpToDate [internet database]. Wolters Kluwer Health, 2014.
  14. Ibeanu OA, Chesson RR, Echols KT, et al. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol 2009; 113:6-10.
  15. Gustilo-Ashby AM, Jelovsek JE, Barber MD, et al. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol 2006; 194:1478-85.
  16. Harris RL, Cundiff GW, Theofrastous JP, Yoon H, et al. The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Obstet Gynecol 1997; 177:1367-71.
  17. Kwon CH, Goldberg RP, Koduri S et al. The use of intraoperative cystoscopy in major vaginal and urogynecologic surgeries. Am J Obstet Gynecol 2002; 187:1466-72.
  18. Jelovsek JE, Chen G, Roberts SL, et al. Incidence of lower urinary tract injury at the time of total laparoscopic hysterectomy. J Soc Laparoendoscopic Surg 2007; 11:422-27.
  19. Song JE, Kim SK. The use of indigo carmine in ureteral operations. J Urology 1968;98:669-70.
  20. Speights SE, Moore RD, Miklos JR. Frequency of lower urinary tract injury at laparoscopic burch and paravaginal repair. J Am Assoc Gynecol Laparosc. 2000; 7:515-8.
  21. Joel AB, Mueller MD, Pahira JJ, Mordkin RM. Nonvisualization of intravenous methylene blue in patients with clinically normal renal function. Urology 2001; 58: 607vii.
  22. Wang AC. The techniques of trocar insertion and intraoperative urethrocystoscopy in tension-free vaginal taping: an experience of 600 cases. Acta Obstet Gynecol Scand 2004; 83:293-8.
  23. Verbeek FP, van der Vorst JR, Schaafsma BE, et al. Intraoperative near infrared fluorescence guided identification of the ureters using low dose methylene blue: a first in human experience. J Urology 2013; 190:574-9.
  24. Rauh-Hain JA, Laufer MR. Increased diagnostic accuracy of laparoscopy in endometriosis using indigo carmine: a new technique. Fertil Steril 2011; 95:1113-4.
  25. Furuya R, Furuya S, Kato H, et al. New classification of midline cysts of the prostate in adults via a transrectal ultrasonography-guided opacification and dye-injection study. BJU International 2008;102:475-8.
  26. Moore CR, Shirodkar SP, Avallone MA, et al. Intravesical methylene blue facilitates precise identification of the diverticular neck during robot-assisted laparoscopic bladder diverticulectomy. J Laparoendoscopic Adv Surg Tech 2012; 22:492-5.
  27. Hanash KA, Al Zahrani H, Mokhtar AA, Aslam M. Retrograde vaginal methylene blue injection for localization of complex urinary fistulas. J Endourology 2003; 17(10):941-3.
  28. Volkmer BG, Kuefer R, Nesslauer T et al. Colour Doppler ultrasound in vesicovaginal fistulas. Ultrasound Med Biol 2000; 26:771-5.
  29. Nyarangi-Dix, JN, Pahernik S, Bermejo JL et al. Significance of the intraoperative methylene blue test for postoperative evaluation of the vesicourethral anastomosis. Adv Urology 2012:1-6.
  30. Campobasso P. Blue venography in adolescent varicocelectomy: a modified surgical approach. J Pediatr Surg 1997;32:1298-1301.
  31. Barot P, Neff M, Cantor B, et al. Laparoscopic varicocelectomy with lymphatic preservation using methylene blue dye. J Laparoendosc Adv Surg Tech A 2004; 14:183-5.
  32. Sowande OA, Olajide TA. Using methylene blue for perioperative localization of the hydrocele sac in boys. Ann Afr Med 2011; 10:38-40.
  33. Calleary JG, Wiseman O, Masood J et al. Definitive identification of a patent processus vaginalis by intraoperative injection of methylene blue into the hydrocele sac. J Pediat Urol 2008; 4:218-20.
  34. Belloli G, D'Agostinon S, Musi L et al. Adolescent varicocele: operative anatomy and tricks for successful correction. Eur J Pediatr Surg 1995;5:219-21.
  35. Rabah DM, Adwan AA, Seida MA. Lymphatic preservation using methylene blue dye during laparoscopic varicocelectomy: early results. Can J Urol 2009; 16:4826-30.
  36. Lee Z, Simhan J, Parker DC et al. Novel use of indocyanine green for intraoperative, real-time localization of ureteral stenosis during robot-assisted ureteroureterostomy. Urology 2013; 82:729-33.
  37. Siddighi S, Yune JJ, Hardesty J. Indocyanine green for intraoperative localization of ureter. Am J Obstet Gynecol 2014;211: epub.