INDOCYANINE GREEN
Clinical safety rating: caution
Comprehensive clinical and safety monograph for INDOCYANINE GREEN (INDOCYANINE GREEN).
Indocyanine green (ICG) binds to plasma proteins (primarily albumin) after intravenous injection and is confined to the intravascular compartment. It is taken up exclusively by hepatocytes via organic anion transporting polypeptides (OATP1B1 and OATP1B3) and excreted unchanged into bile, with no enterohepatic recirculation. Its fluorescence (excitation ~805 nm, emission ~835 nm) allows visualization of blood vessels, perfusion, and biliary structures.
| Metabolism | Indocyanine green is not metabolized; it is eliminated unchanged into bile via active transport by hepatocytes. It does not undergo biotransformation, and minimal amounts are excreted in urine (<1%). |
| Excretion | Primarily hepatic uptake and excretion into bile without renal elimination; <4% unchanged in urine. Fecal excretion accounts for >95%. |
| Half-life | Terminal elimination half-life is 2-4 minutes in patients with normal hepatic function. Clinically, rapid clearance limits utility for repeated dosing. |
| Protein binding | Approximately 98% bound to plasma proteins, primarily albumin and alpha-1 lipoproteins. |
| Volume of Distribution | Vd is 0.15-0.25 L/kg indicating limited extravascular distribution primarily within the blood pool. |
| Bioavailability | Not orally bioavailable; administered only intravenously. Bioavailability is 100% via IV. |
| Onset of Action | Intravenous: immediate (within seconds) due to rapid distribution. |
| Duration of Action | Short: plasma fluorescence lasts 10-20 minutes; hepatic clearance nearly complete by 20 minutes. |
0.5 mg/kg intravenously as a single bolus for cardiac output determination; 0.25 mg/kg for hepatic function assessment. Maximum single dose: 2 mg/kg. Repeat doses no sooner than every 10 minutes.
| Dosage form | INJECTABLE |
| Renal impairment | No dose adjustment required for renal impairment; indocyanine green is not significantly renally excreted (biliary excretion > 97%). |
| Liver impairment | Child-Pugh A: no adjustment. Child-Pugh B: reduce dose by 50% (monitor ICG clearance). Child-Pugh C: contraindicated. |
| Pediatric use | Neonates and infants: 0.5 mg/kg IV; children: 0.5 mg/kg IV (maximum 20 mg total). For cardiac output: 0.5 mg/kg IV bolus. |
| Geriatric use | Use standard adult dosing with caution; lower initial dose may be considered due to age-related decreased hepatic clearance and increased risk of adverse effects. |
| 1st trimester | Consult provider |
| 2nd trimester | Consult provider |
| 3rd trimester | Consult provider |
Clinical note
Comprehensive clinical and safety monograph for INDOCYANINE GREEN (INDOCYANINE GREEN).
| Breastfeeding | Excreted in breast milk in small amounts; M/P ratio not established. Risk of hypersensitivity or iodine exposure in neonate. Use with caution, discontinue breastfeeding for 24 hours after administration. |
| Teratogenic Risk | No evidence of teratogenicity in animal studies; human data limited. Theoretical risk of fetal harm from maternal hypotension or hypoxia. Avoid in first trimester unless benefit outweighs risk. |
| Fetal Monitoring |
■ FDA Black Box Warning
None
| Serious Effects |
["Known hypersensitivity to indocyanine green or iodine","Patients with chronic renal failure undergoing hemodialysis (risk of accumulation)","Concurrent use of bisulfite-containing solutions (compatibility issues)"]
| Precautions | ["Hypersensitivity reactions, including anaphylaxis, have occurred, especially in patients with a history of allergic reactions or asthma.","ICG contains sodium iodide (up to 5% by weight); use with caution in patients with iodine sensitivity or thyroid disease (e.g., hyperthyroidism, thyroid nodules).","Do not administer if solution is cloudy or contains precipitate; reconstitute only with sterile water for injection.","May interfere with radioactive iodine uptake studies due to iodine content.","In patients with severe hepatic impairment (Child-Pugh C), ICG clearance is reduced; consider alternative methods for liver function assessment."] |
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| Monitor maternal blood pressure, heart rate, and oxygen saturation during and after administration. Observe for signs of anaphylaxis. Fetal heart rate monitoring recommended during pregnancy. |
| Fertility Effects | No known effects on fertility. No reproductive toxicity studies in humans. |