link
Bookmarks
Contrast Reactions
Golbahar Houshmand, MD
To access 4,300 diagnoses written by the world's leading experts in radiology, please log in or subscribe.Log inSubscribe

KEY FACTS

  • Clinical Implications

    • Reactions to ICM

      • Reactions to GBCM

        • Premedication if Prior Reaction

          TERMINOLOGY

          • Abbreviations

            • Iodinated contrast media (ICM)
            • Gadolinium-based contrast media (GBCM)
            • Gadolinium-based contrast agent (GBCA)
          • Definitions

            • Acute allergic-like reactions are known complication of IV contrast
            • Acute adverse effects are classified into allergic-like and physiologic reactions
              • Although symptoms of allergic-like reactions resemble hypersensitivity reactions, exact mechanism is unknown and does not appear to result from antigen-antibody interaction in most cases; classified as "anaphylactoid," "allergic-like," or "idiosyncratic"
            • Frequency of adverse reactions is low
              • 0.5-3.0% for low-osmolality ICM (LOCM); recent large analysis: 0.48% (95%CI 0.45 to 0.52)
              • 0.004-0.7% for GBCM; recent large analysis: 0.17% (95%CI 0.15 to 0.19)
            • Reactions categorized as mild, moderate, or severe
              • Mild reactions are most common 0.44% (77-91% of total reactions)
                • Usually require only observation, reassurance, &/or supportive measures
                • Include wide variety of manifestations; most common is cutaneous (urticaria)
                • Other less common mild reactions include hives, pruritus, erythema or rash, scratchy throat, nasal congestion, sneezing, conjunctivitis, localized facial swelling, transient cough, rigors or chills, tachycardia or palpitations, nausea and vomiting
              • Moderate nonionic ICM reactions are rare, occurring in only 0.04-0.1% (8-15% of total reactions)
                • Diffuse skin urticaria, diffuse erythema
                • Shortness of breath, wheezing, mild bronchospasm
                • Facial edema, tongue swelling
                • Hypotension, hypertension, diaphoresis, vasovagal reaction, cardiac-like symptoms
              • Severe, potentially life-threatening adverse reactions are very rare and unpredictable with overall rate of 0.04% (~ 1-3% of all reactions)
                • Profound laryngeal edema, cardiopulmonary arrest, anaphylactoid shock, loss of consciousness, seizure
                • Nearly all life-threatening contrast reactions occur within first 20 minutes after injection
          • Risk Factors for Hypersensitivity Reactions, Premedication

            • Risk factors for allergic-like hypersensitivity reactions
              • Contrast reactions are sporadic and unpredictable; no known risk factors in vast majority of patients
              • Greatest risk with prior allergic-like reaction or unknown-type reaction to same class
                • Allergic-like reactions to either LOCM or GBCM extremely rare
                • ~ 5x ↑ risk (estimated 10-35%) in high-risk, nonpremedicated patients vs. 10% risk in high-risk premedicated patients
              • Severe delayed (up to 1 week after contrast) cutaneous reactions described in individuals with systemic lupus erythematosus (SLE), reported fatality
              • History of atopia, asthma ↑ risk; patients are more prone to bronchospasm; however, restriction of ICM is not recommended
              • 2-3x ↑ risk in patients with unrelated allergies, but restricting ICM use or premedicating is not recommended on this basis
              • Patients with shellfish or povidone-iodine (e.g., Betadine) allergies are at no greater risk from ICM than are patients with other allergies
              • No cross-reactivity between different classes of contrast medium; prior reaction to GBCM carries same risk as unrelated allergy to predict future reaction to ICM, or vice versa; institutional variations in premedication policy
              • Pheochromocytoma; no evidence that IV administration of modern ICM or GBCM ↑ risk of hypertensive crisis in patients with pheochromocytoma
              • Sickle cell trait or sickle cell disease; no evidence of ↑ risk of acute sickle crisis with modern ICM or GBCM
              • Myasthenia gravis controversial as relative contraindication for ICM
                • Questionable relationship between IV ICM and exacerbations of myasthenic symptoms; myasthenic exacerbation in ~ 6% following CT with ICM vs. 1% after NECT
              • Hyperthyroidism; no restrictions in general, but avoid ICM in patients with acute thyroid storm; ICM exposure can potentiate thyrotoxicosis
              • ICM can interfere with radioactive iodine therapy or in patients undergoing radioactive iodine thyroid imaging; washout period is suggested to minimize interaction
                • Ideally, 3-4 weeks washout for patients with hyperthyroidism; 6 weeks for patients with hypothyroidism
            • Premedication
              • History of prior severe contrast reaction considered relative contraindication to receiving same class of contrast medium (e.g., ICM vs. GBCM) in future
                • Premedication does not prevent all reactions
                  • No proof of ↓ incidence of moderate or severe reactions or deaths
              • History of mild immediate hypersensitivity reaction relative contraindication to receiving same agent
                • Rate of recurrent reaction 31% with same agent; ↓ to 12% with change in agent (Park)
                • Premedication indicated if receiving same class of agent; antihistamine further ↓ recurrent reaction to 7.6%
              • Premedication regimens recommended by ACR
                • Methylprednisolone 32 mg PO 12, 2 hours prior ± diphenhydramine (Benadryl) 50 mg PO 1 hour prior
                • Or prednisone 50 mg PO 13, 7, 1 hour prior ± Benadryl 50 mg PO 1 hour prior
                • Or hydrocortisone 200 mg IV 5 hours and 1 hour prior and Benadryl 50 mg IV 1 hour prior (urgent, NPO only, ER, inpatient)
              • Premedication not indicated: Allergic reactions to other substances [including shellfish or contrast media from another class (e.g., gadolinium-based vs. iodinated), asthma, seasonal allergies, or multiple drug and food allergies]

          CLINICAL IMPLICATIONS

          • Reactions to ICM

            • Post-Contrast Acute Kidney Injury

              • Contrast Extravasation

                • Administration of ICM to Pregnant or Potentially Pregnant Patients

                  • Administration of ICM to Lactating Women

                    • Reactions to GBCM

                      • Nephrogenic Systemic Fibrosis

                        • Gadolinium Deposition in Brain

                          Selected References

                          1. McDonald RJ et al: Gadolinium Retention: A Research Roadmap from the 2018 NIH/ACR/RSNA Workshop on Gadolinium Chelates. Radiology. 289(2):517-534, 2018
                          2. Park SJ et al: Immediate mild reactions to CT with iodinated contrast media: Strategy of contrast media readministration without corticosteroids. Radiology. 288(3):710-716, 2018
                          3. Sodagari F et al: Reactions to both nonionic iodinated and gadolinium-based contrast media: Incidence and clinical characteristics. AJR Am J Roentgenol. 210(4):715-719, 2018
                          4. ACR Manual on Contrast Media, version 10.3. https://www.acr.org/Clinical-Resources/Contrast-Manual, 2017
                          5. Kanda T et al: Distribution and chemical forms of gadolinium in the brain: a review. Br J Radiol. 90(1079):20170115, 2017
                          6. Puac P et al: Safety of contrast material use during pregnancy and lactation. Magn Reson Imaging Clin N Am. 25(4):787-797, 2017
                          7. Hatje V et al: Increases in anthropogenic gadolinium anomalies and rare Earth element concentrations in San Francisco Bay over a 20 year record. Environ Sci Technol. 50(8):4159-68, 2016
                          8. Kanda T et al: Gadolinium-based contrast agent accumulates in the brain even in subjects without severe renal dysfunction: Evaluation of autopsy brain specimens with inductively coupled plasma mass spectroscopy. Radiology. 276(1):228-32, 2015
                          9. Errante Y et al: Progressive increase of T1 signal intensity of the dentate nucleus on unenhanced magnetic resonance images is associated with cumulative doses of intravenously administered gadodiamide in patients with normal renal function, suggesting dechelation. Invest Radiol. 49(10):685-90, 2014
                          10. Davenport MS et al: Effect of abrupt substitution of gadobenate dimeglumine for gadopentetate dimeglumine on rate of allergic-like reactions. Radiology. 266(3):773-82, 2013
                          11. Wienbeck S et al: Prospective study of access site complications of automated contrast injection with peripheral venous access in MDCT. AJR Am J Roentgenol. 195(4):825-9, 2010
                          12. Davenport MS et al: Repeat contrast medium reactions in premedicated patients: frequency and severity. Radiology. 253(2):372-9, 2009
                          13. Hunt CH et al: Frequency and severity of adverse effects of iodinated and gadolinium contrast materials: retrospective review of 456,930 doses. AJR Am J Roentgenol. 193(4):1124-7, 2009
                          14. Webb JA et al: Late adverse reactions to intravascular iodinated contrast media. Eur Radiol. 13(1):181-4, 2003
                          15. Caro JJ et al: The risks of death and of severe nonfatal reactions with high- vs low-osmolality contrast media: a meta-analysis. AJR Am J Roentgenol. 156(4):825-32, 1991
                          16. Savill JS et al: Fatal Stevens-Johnson syndrome following urography with iopamidol in systemic lupus erythematosus. Postgrad Med J. 64(751):392-4, 1988
                          17. FDA Drug Safety Communication: FDA identifies no harmful effects to date with brain retention of gadolinium-based contrast agents for MRIs; review to continue
                          18. EMA's final opinion confirms restrictions on use of linear gadolinium agents in body scans
                          19. FDA: New Med Guide for patients receiving gadolinium based contrast agents
                          Related Anatomy
                          Loading...
                          Related Differential Diagnoses
                          Loading...
                          References
                          Tables

                          Tables

                          KEY FACTS

                          • Clinical Implications

                            • Reactions to ICM

                              • Reactions to GBCM

                                • Premedication if Prior Reaction

                                  TERMINOLOGY

                                  • Abbreviations

                                    • Iodinated contrast media (ICM)
                                    • Gadolinium-based contrast media (GBCM)
                                    • Gadolinium-based contrast agent (GBCA)
                                  • Definitions

                                    • Acute allergic-like reactions are known complication of IV contrast
                                    • Acute adverse effects are classified into allergic-like and physiologic reactions
                                      • Although symptoms of allergic-like reactions resemble hypersensitivity reactions, exact mechanism is unknown and does not appear to result from antigen-antibody interaction in most cases; classified as "anaphylactoid," "allergic-like," or "idiosyncratic"
                                    • Frequency of adverse reactions is low
                                      • 0.5-3.0% for low-osmolality ICM (LOCM); recent large analysis: 0.48% (95%CI 0.45 to 0.52)
                                      • 0.004-0.7% for GBCM; recent large analysis: 0.17% (95%CI 0.15 to 0.19)
                                    • Reactions categorized as mild, moderate, or severe
                                      • Mild reactions are most common 0.44% (77-91% of total reactions)
                                        • Usually require only observation, reassurance, &/or supportive measures
                                        • Include wide variety of manifestations; most common is cutaneous (urticaria)
                                        • Other less common mild reactions include hives, pruritus, erythema or rash, scratchy throat, nasal congestion, sneezing, conjunctivitis, localized facial swelling, transient cough, rigors or chills, tachycardia or palpitations, nausea and vomiting
                                      • Moderate nonionic ICM reactions are rare, occurring in only 0.04-0.1% (8-15% of total reactions)
                                        • Diffuse skin urticaria, diffuse erythema
                                        • Shortness of breath, wheezing, mild bronchospasm
                                        • Facial edema, tongue swelling
                                        • Hypotension, hypertension, diaphoresis, vasovagal reaction, cardiac-like symptoms
                                      • Severe, potentially life-threatening adverse reactions are very rare and unpredictable with overall rate of 0.04% (~ 1-3% of all reactions)
                                        • Profound laryngeal edema, cardiopulmonary arrest, anaphylactoid shock, loss of consciousness, seizure
                                        • Nearly all life-threatening contrast reactions occur within first 20 minutes after injection
                                  • Risk Factors for Hypersensitivity Reactions, Premedication

                                    • Risk factors for allergic-like hypersensitivity reactions
                                      • Contrast reactions are sporadic and unpredictable; no known risk factors in vast majority of patients
                                      • Greatest risk with prior allergic-like reaction or unknown-type reaction to same class
                                        • Allergic-like reactions to either LOCM or GBCM extremely rare
                                        • ~ 5x ↑ risk (estimated 10-35%) in high-risk, nonpremedicated patients vs. 10% risk in high-risk premedicated patients
                                      • Severe delayed (up to 1 week after contrast) cutaneous reactions described in individuals with systemic lupus erythematosus (SLE), reported fatality
                                      • History of atopia, asthma ↑ risk; patients are more prone to bronchospasm; however, restriction of ICM is not recommended
                                      • 2-3x ↑ risk in patients with unrelated allergies, but restricting ICM use or premedicating is not recommended on this basis
                                      • Patients with shellfish or povidone-iodine (e.g., Betadine) allergies are at no greater risk from ICM than are patients with other allergies
                                      • No cross-reactivity between different classes of contrast medium; prior reaction to GBCM carries same risk as unrelated allergy to predict future reaction to ICM, or vice versa; institutional variations in premedication policy
                                      • Pheochromocytoma; no evidence that IV administration of modern ICM or GBCM ↑ risk of hypertensive crisis in patients with pheochromocytoma
                                      • Sickle cell trait or sickle cell disease; no evidence of ↑ risk of acute sickle crisis with modern ICM or GBCM
                                      • Myasthenia gravis controversial as relative contraindication for ICM
                                        • Questionable relationship between IV ICM and exacerbations of myasthenic symptoms; myasthenic exacerbation in ~ 6% following CT with ICM vs. 1% after NECT
                                      • Hyperthyroidism; no restrictions in general, but avoid ICM in patients with acute thyroid storm; ICM exposure can potentiate thyrotoxicosis
                                      • ICM can interfere with radioactive iodine therapy or in patients undergoing radioactive iodine thyroid imaging; washout period is suggested to minimize interaction
                                        • Ideally, 3-4 weeks washout for patients with hyperthyroidism; 6 weeks for patients with hypothyroidism
                                    • Premedication
                                      • History of prior severe contrast reaction considered relative contraindication to receiving same class of contrast medium (e.g., ICM vs. GBCM) in future
                                        • Premedication does not prevent all reactions
                                          • No proof of ↓ incidence of moderate or severe reactions or deaths
                                      • History of mild immediate hypersensitivity reaction relative contraindication to receiving same agent
                                        • Rate of recurrent reaction 31% with same agent; ↓ to 12% with change in agent (Park)
                                        • Premedication indicated if receiving same class of agent; antihistamine further ↓ recurrent reaction to 7.6%
                                      • Premedication regimens recommended by ACR
                                        • Methylprednisolone 32 mg PO 12, 2 hours prior ± diphenhydramine (Benadryl) 50 mg PO 1 hour prior
                                        • Or prednisone 50 mg PO 13, 7, 1 hour prior ± Benadryl 50 mg PO 1 hour prior
                                        • Or hydrocortisone 200 mg IV 5 hours and 1 hour prior and Benadryl 50 mg IV 1 hour prior (urgent, NPO only, ER, inpatient)
                                      • Premedication not indicated: Allergic reactions to other substances [including shellfish or contrast media from another class (e.g., gadolinium-based vs. iodinated), asthma, seasonal allergies, or multiple drug and food allergies]

                                  CLINICAL IMPLICATIONS

                                  • Reactions to ICM

                                    • Post-Contrast Acute Kidney Injury

                                      • Contrast Extravasation

                                        • Administration of ICM to Pregnant or Potentially Pregnant Patients

                                          • Administration of ICM to Lactating Women

                                            • Reactions to GBCM

                                              • Nephrogenic Systemic Fibrosis

                                                • Gadolinium Deposition in Brain

                                                  Selected References

                                                  1. McDonald RJ et al: Gadolinium Retention: A Research Roadmap from the 2018 NIH/ACR/RSNA Workshop on Gadolinium Chelates. Radiology. 289(2):517-534, 2018
                                                  2. Park SJ et al: Immediate mild reactions to CT with iodinated contrast media: Strategy of contrast media readministration without corticosteroids. Radiology. 288(3):710-716, 2018
                                                  3. Sodagari F et al: Reactions to both nonionic iodinated and gadolinium-based contrast media: Incidence and clinical characteristics. AJR Am J Roentgenol. 210(4):715-719, 2018
                                                  4. ACR Manual on Contrast Media, version 10.3. https://www.acr.org/Clinical-Resources/Contrast-Manual, 2017
                                                  5. Kanda T et al: Distribution and chemical forms of gadolinium in the brain: a review. Br J Radiol. 90(1079):20170115, 2017
                                                  6. Puac P et al: Safety of contrast material use during pregnancy and lactation. Magn Reson Imaging Clin N Am. 25(4):787-797, 2017
                                                  7. Hatje V et al: Increases in anthropogenic gadolinium anomalies and rare Earth element concentrations in San Francisco Bay over a 20 year record. Environ Sci Technol. 50(8):4159-68, 2016
                                                  8. Kanda T et al: Gadolinium-based contrast agent accumulates in the brain even in subjects without severe renal dysfunction: Evaluation of autopsy brain specimens with inductively coupled plasma mass spectroscopy. Radiology. 276(1):228-32, 2015
                                                  9. Errante Y et al: Progressive increase of T1 signal intensity of the dentate nucleus on unenhanced magnetic resonance images is associated with cumulative doses of intravenously administered gadodiamide in patients with normal renal function, suggesting dechelation. Invest Radiol. 49(10):685-90, 2014
                                                  10. Davenport MS et al: Effect of abrupt substitution of gadobenate dimeglumine for gadopentetate dimeglumine on rate of allergic-like reactions. Radiology. 266(3):773-82, 2013
                                                  11. Wienbeck S et al: Prospective study of access site complications of automated contrast injection with peripheral venous access in MDCT. AJR Am J Roentgenol. 195(4):825-9, 2010
                                                  12. Davenport MS et al: Repeat contrast medium reactions in premedicated patients: frequency and severity. Radiology. 253(2):372-9, 2009
                                                  13. Hunt CH et al: Frequency and severity of adverse effects of iodinated and gadolinium contrast materials: retrospective review of 456,930 doses. AJR Am J Roentgenol. 193(4):1124-7, 2009
                                                  14. Webb JA et al: Late adverse reactions to intravascular iodinated contrast media. Eur Radiol. 13(1):181-4, 2003
                                                  15. Caro JJ et al: The risks of death and of severe nonfatal reactions with high- vs low-osmolality contrast media: a meta-analysis. AJR Am J Roentgenol. 156(4):825-32, 1991
                                                  16. Savill JS et al: Fatal Stevens-Johnson syndrome following urography with iopamidol in systemic lupus erythematosus. Postgrad Med J. 64(751):392-4, 1988
                                                  17. FDA Drug Safety Communication: FDA identifies no harmful effects to date with brain retention of gadolinium-based contrast agents for MRIs; review to continue
                                                  18. EMA's final opinion confirms restrictions on use of linear gadolinium agents in body scans
                                                  19. FDA: New Med Guide for patients receiving gadolinium based contrast agents