Contrast Medium Reactions Guidelines

Updated: Jan 25, 2023
  • Author: Nasir H Siddiqi, MD; Chief Editor: Eugene C Lin, MD  more...
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Guidelines Summary

ACR guidelines

The American College of Radiology (ACR) Committee on Drugs and Contrast Media has created a guide for radiologists to promote safe and effective practices concerning the use of contrast media, including patient screening, premedication, adverse reactions, and emergency-related treatment of adverse reactions. [1]

The ACR Committee published the following recommendations for imaging patients at risk for NSF [1] :

  • Group II agents (gadobenate dimeglumine, gadobutrol, gadoterate acid, gadoteridol) are strongly preferred in patients at risk for NSF (nephrogenic systemic fibrosis). Given the very low, if any, risk of NSF development with group II agents, regardless of renal function or dialysis status, informed consent is not recommended prior to GBCA (gadolinium-based contrast agent) group II injection, but deference is made to local practice preferences.
  • If use of a group I agent (gadodiamide, gadopentetate dimeglumine, gadoversetamide) or group III agent (gadoxetate disodium) is being considered in a patient with a risk of NSF, if the potential benefits of a GBCA-enhanced MRI exam are felt to outweigh the risk of NSF in an individual patient, and if there is no suitable alternative, the referring physician and patient should be informed of the risks of GBCA administration, and both should agree with the decision to proceed with GBCA injection. Group I agents, the GBCAs that have been most often associated with NSF, have been contraindicated by the FDA for use in these patients.
  • The lowest dose of GBCA required to obtain the needed clinical information should be used in at-risk patients, and it should generally not exceed the recommended single dose.

ETA guidelines

The European Thyroid Association (ETA) has published the following guidelines regarding thyroid dysfunction (TD) resulting from iodine contrast media (ICM) [14] :

  • Recommend baseline thyroid function testing of the general population before radiologic exam using ICM administration.
  • Before ICM exposure, suggest a thorough case-finding approach, based on identifying persons most likely to have undiagnosed thyroid dysfunction.
  • Suggest measurement of baseline serum TSH in high-risk patients for ICM-induced TD, especially in the elderly and persons at risk for cardiovascular disease. If serum TSH is abnormal, thyroid hormones (T3 and/or T4) should be measured. 
  • Do not recommend radiologic exam using ICM in patients with overt hyperthyroidism. Alternative imaging procedures such as ultrasound, MRI, and noncontrast CT should be considered. 
  • Patients on thyroid hormone replacement are not at risk for ICM-induced TD and do not require specific management.
  • Suggest considering prophylactic treatment with methimazole and/or perchlorate before emergency radiologic exam in selected patients who are less tolerant of the effects of ICM-induced hyperthyroidism, such as elderly patients with persistent endogenous subclinical hypertension and/or nodular goiter, and/or concomitant cardiovascular disease, especially in areas of iodine deficiency. 
  • Suggest measuring thyroid function 3-4 wk after ICM exposure in high-risk patients for ICM-induced hyperthyroidism, especially in the elderly and/or those with an underlying unstable cardiovascular disease.
  • Recommend avoiding isotope imaging of the thyroid and radioactive iodine treatment for 1-2 mo after ICM injection. 
  • In severe cases, recommend initiation of treatment with ATD (methimazole, carbimazole, or propylthiouracil). In cases of partial response to ATD, a combination with perchlorate is helpful to control hyperthyroidism. 
  • Recommend that even mild ICM-induced hyperthyroidism should be treated in patients older than 65 yr, particularly in the presence of comorbidity. 
  • Recommend that serum TSH should be measured as an initial screening test in patients with suspicion of ICM-induced hypothyroidism. If serum TSH is high, serum T4 levels should be measured. 
  • Recommend measurement of serum thyroid peroxidase antibodies if the etiology of ICM-induced hypothyroidism is unclear.

ESUR guidelines

The following guidelines were published by the European Society of Urogenital Radiology (ESUR) [15] :

  • When an acute reaction occurs, check for skin erythema, urticaria (undress the patient to inspect the whole body), nausea, vomiting, decreased blood pressure, abnormal heart rate, dyspnea, and bronchospasm (requires auscultation for reliable diagnosis).
  • Patients who have had a previous contrast medium reaction or who are on interleukin-2 treatment should be advised that a late skin reaction is possible and that they should contact a physician if a problem arises.  
  • Patch and delayed-reading intradermal tests may be useful to confirm a late skin reaction to contrast medium and to study cross-reactivity patterns with other agents. To reduce the risk of repeat reaction, use a contrast medium other than the one that precipitated the first reaction. Avoid agents that have shown cross-reactivity on skin testing. Drug prophylaxis is generally not recommended
  • Iodine-based contrast media should not be given to patients with manifest hyperthyroidism. 
  • In patients suspected of being at risk of thyrotoxicosis, TSH measurement may be helpful. 
  • In selected high-risk patients, prophylactic treatment may be given by an endocrinologist. 
  • Patients at risk should be closely monitored by endocrinologists after iodine-based contrast medium injection. 
  • Intravenous cholangiographic contrast media should not be given to patients at risk.
  • Estimated glomerular filtration rate (eGFR), calculated from the serum creatinine, is the recommended method to estimate renal function before contrast agent administration. •In adults 18 yr or older, the CKD-EPI formula is recommended to calculate eGFR.