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contrast agent

Classification: 1st generation agents: a) iodinated, ionic b) very hyperosmolar (1500-1800 mOsm/kg of water). 2nd generation agents: (i.e. iohexol) a) non-ionic b) lower osmolarity (780 mOsm/kg of water) 3rd generation agent: (iodixanol) a) iso-osmolar to blood (290 mOsm/kg of water) b) least nephrotoxic agent Indications: - for use in conjunction with diagnostic imaging Contraindications: (cautions) 1) sensitivity to contrast 2) allergies to shellfish? [3] - no reliable evidence that seafood allergy increases risk for allergic reaction to contrast media* [10] 3) renal failure * contrast-enhanced CTs can be performed using the standard contrast medium without premedication in patients with seafood allergies [10] Adverse effects: 1) anaphylactoid a) occur with 2-6% of procedures b) may have the clinical appearance of anaphylaxis, but are more appropriately termed anaphylactoid, because they do not involve IgE c) complement activation d) low ionic strength contrast agents are less likely to result in an adverse reaction e) previously, patients with a history of contrast reaction could be pretreated with the following protocol: 1] 50 mg of prednisone every 6h for 3 doses, or 30 mg every 6 hours for 4 doses [3] 2] last dose 1 hour before procedure 3] 50 mg of diphenhydramine (Benadryl) at time of last dose f) current guidelines (2023) recommend proceeding with non-ionic, low ionic or iso-osmolar contrast with consideration of premedication with glucocorticoid & antihistamine [11] 2) nephrotoxicity (see contrast nephropathy) a) selection of alternative diagnostic procedure 1] radionuclide scintigraphy 2] ultrasonography b) generally low morbidity & mortality c) contrast-enhanced CT not associated with contrast nephropathy in the emergency department [6,7] d) safe when GFR > 30 mL/min [9] 3) iodinated contrast agents are associated with a) hypothyroidism (HR=1.6) b) hyperthyroidism (HR=3.0) [4] - patients with underlying thyroid disease, most commonly multinodular goiter [11] 4) extravasation of iodinated contrast* [12] * image Management: - patients with previous adverse reactions to contrast typically receive prednisone (50 mg) at 13 hours, 7 hours, & 1 hour before intravenous low-osmolality contrast material plus diphenhydramine (50 mg) at 1-hour prior [5] - > 500 patients need pretreatment to prevent 1 severe reaction - patients with seafood allergy (shellfish allergy) should receive standard contrast agent [10]

Interactions

drug adverse effects of contrast agents

Related

contrast contrast nephropathy (contrast-induced nephropathy, CIN)

Specific

barium sulfate (BaSO4, Baricon, Barite) contrast for evaluation of gastrostomy/duodenostomy/jejunostomy/cecostomy contrast for laryngography/bronchography diatrizoate ethiodized oil (Ethiodol) ferumoxides (Feridex) ferumoxsil (Gastromark) ferumoxytol (Feraheme, ferrosoferric oxide) flutemetamol F18 gadolinium contrast (Omniscan) hippuran indigotindisulfonate (Indigo Carmine) iodamide meglumine (Renovue-65, Renovue-DIP) iodixanol (Visipaque) iohexol (Omnipaque) iopamidol (Isovue) iopanoic acid (Telepaque) iothalamate (Conray, Conray-400) ioversol (Optiray) ioxaglate (Hexabrix) ioxilan (Oxilan) ipodate (Oragrafin) iso-sulfan blue (Lymphazurin) mangafodipir (Teslascan) micro-bubble contrast agent sulfur hexafluoride (SonoVue, Lumason) tyropanoate (Bilopaque)

General

pharmaceutical agent

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 31, 598, 625
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
  3. Veterans Administration, Dept. of Radiology
  4. Rhee CM et al. Association between iodinated contrast media exposure and incident hyperthyroidism and hypothyroidism. Arch Intern Med 2012 Jan 23; 172:153. PMID: 22271121
  5. Mervak BM et al. Rates of breakthrough reactions in inpatients at high risk receiving premedication before contrast-enhanced CT. AJR Am J Roentgenol 2015 Jul; 205:77 PMID: 26102383
  6. Hinson JS, Ehmann MR, Fine DM et al. Risk of acute kidney injury after intravenous contrast media administration. Ann Emerg Med 2017 Jan 19 PMID: 28131489
  7. Aycock RD et al. Acute kidney injury after computed tomography: A meta-analysis. Ann Emerg Med 2017 Aug 12 PMID: 28811122
  8. American College of Radiology Manual on Contrast Media. v 10.3 https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf
  9. Davenport MS, Perazella MA, Yee J, et al. Use of intravenous iodinated contrast media in patients with kidney disease: Consensus statements from the American College of Radiology and the National Kidney Foundation. Radiology 2020 Mar; 294:660. PMID: 31961246 https://pubs.rsna.org/doi/10.1148/radiol.2019192094
  10. NEJM Knowledge+ Question of the Week. Nov. 29, 2022 https://knowledgeplus.nejm.org/question-of-week/1239/
  11. NEJM Knowledge+ Endocrinology
  12. Corbella-Bagot L, Luque-Luna M Images in Dermatology Extravasation of Iodine Contrast JAMA Dermatol. 2023;159(11):1268-1269. PMID: 37792372 https://jamanetwork.com/journals/jamadermatology/fullarticle/2810089