Iodinated contrast media Hypersensitivity

Iodinated
contrast media
Hypersensitivity

Outline
Radiocontrast media
Epidemiology and Risk factor of
hypersensitivity
Pathophysiology
Clinical manifestation
Investigation
Management
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 I O D I N A T E D C O N T R A S T M E D I A H Y P E R S E N S I T I V I T Y
2

Introduction
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3
J I N V E S T I G A L L E R G O L C L I N I M M U N O L 2 0 1 6 ; V O L . 2 6 ( 3 ) : 1 4 4 -
1 5 5 3
Iodinated contrast media (ICM) were
introduced into clinical practice in the early
twentieth century.
ICM are iodine salts whose basic chemical
structure comprises a benzene ring with at
least 3 iodine atoms (triiodobenzene).
The number of iodine atoms in each
molecule is responsible for producing
radiopacity.

Classification
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
J
I
N
V
E
S
T
I
G
A
L
L
E
R
G
O
L
C
L
I
N
I
M
M
U
N
O
L
2
0
1
6
;
V
O
L
.
2
6
(
3
)
:
1
4
4
-
1
5
5
4

Osmolarity
5

Classification
E A A C I I N T E R E S T G R O U P O N D R U G H Y P E R S E N S I T I V I T Y . A L L E R G Y .
2 0 0 5 F E B ; 6 0 ( 2 ) : 1 5 0 - 8 . 6
Anaphylactoid

Classification
Anaphylactoid described
later
Non Anaphylactoid : dose
dependent , influenced by
physiochemical properties.
C A N A D I A N A S S O C I A T I O N O F R A D I O L O G I S T S J O U R N A L .
2 0 1 7 ; 6 8 ( 2 ) : 1 8 7 - 1 9 3 . 7

Outline
hypersensitivity
Pathophysiology
Investigation
Management
8

Epidemiology
( 1 ) J A L L E R G Y C L I N I M M U N O L P R A C T 2 0 1 9 ; 7 : 6 1 - 5
( 2 ) P R A C T I C E P A R A M E T E R S F O R D I A G N O S I N G A N D M A N A G I N G I O D I N A T E D C O N T R A S T M E D I A
H Y P E R S E N S I T I V I T Y . 2 0 2 1 M A Y ; 7 6 ( 5 ) : 1 3 2 5 - 1 3 3 9 . 9

Epidemiology :
Comparative Ionic vs non
ionic
 Overall prevalence of ADR
12.66% in ionic patients and
3.13% in non-ionic patients
 Immediate : 3.8-12.7% vs
0.7-3.1%
 Severe reaction : 0.1-0.4%
vs 0.02-0.04%
 Mortality rate not
difference : Mortality rate 1
in 100,000
( 1 ) A L L E R G Y 2 0 0 5 V O L . 6 0 I S S U E 2 P A G E S 1 5 0 - 8
10

Incidence and Risk Factors of Immediate Hypersensitivity Reactions Associated With Low-Osmolar
Iodinated Contrast Media: A Longitudinal Study Based on a Real-Time
Monitoring System
4 5 0 11

Iodine concentration
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
R
A
D
I
O
L
O
G
Y
.
2
0
1
9
O
C
T
;
2
9
3
(
1
)
:
1
1
7
-
1
2
4
.
12

Risk factor of
Hypersensitivity reaction
Controversies in Drug Allergy:
Radiographic Contrast Media
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 J A L L E R G Y C L I N I M M U N O L P R A C T 2 0 1 9 ; 7 : 6 1 - 5 13

Previous RCM
The incidence was the
highest in patients with
previous ADRs to ICMs and
the lowest in those with a
history of ICM usage but no
prior reactions.
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 B R J R A D I O L . 2 0 1 7 F E B ; 9 0 ( 1 0 7 0 ) : 2 0 1 6 0 7 2 9 .
14

Risk factor of Hypersensitivity reaction
Asian Pac J Allergy Immunol. 2013 Dec;31(4):299-306.

Seafood allergy
J E M E R G M E D . 2 0 1 0 N O V ; 3 9 ( 5 ) : 7 0 1 - 7 17

Seafood allergy
A C R M A N U A L O N C O N T R A S T M E D I A , A C R C O M M I T T E E O N
D R U G S A N D C O N T R A S T M E D I A 2 0 2 3 18

Risk factor
4 5 0 19
The incidence of immediate hypersensitivity
to LOCM gradually increased with the
number of previous exposures (P for trend
<.001 )
The cumulative effect of previous repeated
exposures on the incidence of LOCM
hypersensitivity was dependent on the
presence of a history of hypersensitivity to
LOCM.

F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 E U R A N N A L L E R G Y C L I N I M M U N O L . 2 0 2 2 M A R ; 5 4 ( 2 ) : 6 0 - 6 7 .
20
Hypersensitivity reactions to iodinated contrast media in Italy: a
retrospective study. Characteristics of patients and risk factors

21
Risk Factor of Hypersensitivity reaction

Risk factor -> premedication?
A C R M A N U A L O N C O N T R A S T M E D I A , A C R C O M M I T T E E O N
D R U G S A N D C O N T R A S T M E D I A 2 0 2 3 22

23
Risk Factor of Severe Immediate Hypersensitivity reaction

Elevated risk of anaphylactoid reaction from radiographic
contrast media is associated with both beta-blocker exposure
and cardiovascular disorders
The risk of
anaphylactoid
reaction : asthma
OR = 8.74 , P = 0.0012
The risk of
bronchospasm
1.beta-blocker
exposure
OR= 3.73 , P = .025
2. asthma OR = 16.39
P = .0001
The risk of major and
life-threatening reaction
was associated with the
presence of
cardiovascular disorder
OR = 7.71 , P = .046
C U R R E N T O P I N I O N I N A L L E R G Y A N D C L I N I C A L I M M U N O L O G Y
1 1 ( 4 ) : P 3 2 6 - 3 3 1 , A U G U S T 2 0 1 1 . 24

Outline
hypersensitivity
Pathophysiology
Investigation
Management
25

26
Pathophysiology

Skin tests (immediate)
A L L E R G Y . 2 0 0 9 F E B ; 6 4 ( 2 ) : 2 3 4 - 4 1 . 27
0
10
20
30
40
50
60
Category 1
2-6 months other

• Hyperosmolality
and Ionic
Stimulation of
histamine release
from basophils and
mast cells
(mainly calcium and
sodium)
Activation of the
complement system
C3a, C4a and C5a ->
activate mast cell and
basophil
Activation of factor
XII and Coagulation
pathway
Leading to activation of
the kinin system and the
production of
bradykinin
MRGPRX2
MRGPRX2-related
anaphylactic reactions
induced by Iopamidol
(Isovue)
Osmolarity
And Ionic
Immediate non-IgE reactions
J Investig Allergol Clin Immunol 2016; Vol. 26(3): 144-155
Int Immunopharmacol. 2019 Oct;75:105800.
The British Journal of Radiology, 78(2005), 686–693

Immediate IgE reactions
Osmolarity
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
R
I
N
G
J
(
E
D
)
:
A
N
A
P
H
Y
L
A
X
I
S
.
C
H
E
M
I
M
M
U
N
O
L
A
L
L
E
R
G
Y
.
B
A
S
E
L
,
K
A
R
G
E
R
,
2
0
1
0
,
V
O
L
9
5
,
P
P
1
5
7
–
1
6
9
29
0%
20%
40%
60%
80%
Series 1 Series 2 Series 3
Skin test positive in RCM
Immediate HSR
Skin test SPT IDT

R I N G J ( E D ) : A N A P H Y L A X I S . C H E M I M M U N O L A L L E R G Y . B A S E L ,
K A R G E R , 2 0 1 0 , V O L 9 5 , P P 1 5 7 – 1 6 9 30
Non-immediated type reactions

Associations between HLA alleles and iodinated contrast media– induced hypersensitivity
in Korean populations
Pathophysiology - HLA
Transl Clin Pharmacol. 2021 Jun;29(2):107-116
5.06%
6.77%
6.36%
1.55%
0.82%
6.77%

Outline
hypersensitivity
Pathophysiology
Investigation
Management
32

Clinical manifestations
A M E R I C A N C O L L E A G U E O F R A D I O L O G Y , M A N U A L O N
C O N T R A S T M E D I A 2 0 2 1
1 5 5
33

Clinical
manifestations
A M E R I C A N C O L L E A G U E O F R A D I O L O G Y , M A N U A L O N
C O N T R A S T M E D I A 2 0 2 1
C L I N I C A L A N D E X P E R I M E N T A L D E R M A T O L O G Y ( 2 0 1 9 ) 4 4 ,
P P 8 3 9 – 8 4 3 34

INCIDENCE AND SEVERITY
OF ANAPHYLACTOID
REACTIONS TO COLLOID
VOLUME SUBSTITUTES
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
 Grade 1 : generalized cutaneous and/or mucocutaneous symptoms
 Grade 2 : mild systemic reactions
 Grade 3 life-threatening systemic reactions
 Grade 4 cardiac and/or respiratory arrest.
T
H
E
L
A
N
C
E
T
,
V
O
L
U
M
E
3
0
9
,
I
S
S
U
E
8
0
0
9
,
1
9
7
7
,
P
A
G
E
S
4
6
6
-
4
6
9
,
A
L
L
E
R
G
Y
2
0
0
5
V
O
L
.
6
0
I
S
S
U
E
2
P
A
G
E
S
1
5
0
-
8
35

Anaphylaxis
36
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 P L O S O N E . 2 0 1 4 J U N 1 6 ; 9 ( 6 ) : E 1 0 0 1 5 4 .

Anaphylaxis
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 P L O S O N E . 2 0 1 4 J U N 1 6 ; 9 ( 6 ) : E 1 0 0 1 5 4 .
37

non-immediate
type reactions
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
C
L
I
N
E
X
P
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M
A
T
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L
.
2
0
1
9
D
E
C
;
4
4
(
8
)
:
8
4
4
-
8
6
0
.
38

Non-Immediate hypersensitivity
Clin Exp Dermatol. 2019 Dec;44(8):844-860.
Eur Radiol (2011) 21:2305–2310

Non-Immediate hypersensitivity
Practice parameters. Allergy 2021 Vol. 76 Issue 5 Pages 1325-1339

non-immediate
hypersensitivity
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 C L I N E X P D E R M A T O L . 2 0 1 9 D E C ; 4 4 ( 8 ) : 8 4 4 - 8 6 0 .
Disease N Onset ICM Remark
FDE 10 within 24 h over half of cases was a
nonionic monomeric
medium
AGEP 16 Few hours to 3
days
7/16 being triggered by
iodixanol
Higher rate of
iso‐osmolar compared
with low osmolality
DRESS 6 within 1 h to 3 days - The majority (5/6) of
patients had multiple
exposures to ICM
before developing
DRESS
SJS/TEN 11 30 min to 3 days Nonionic monomeric ICM
was the most frequent
culprit
SDRIFE 4 6 h to 2 days -
Vasculitis 5 8 to 48 h -
Iododerma 17 2- 3 days - The majority of cases
(13/17) had renal
insufficiency

Ioderma
A A C E C L I N I C A L C A S E R E P O R T S V O L 4 N O . 2 M A R C H / A P R I L
2 0 1 8
C L I N E X P D E R M A T O L . 2 0 1 9 D E C ; 4 4 ( 8 ) : 8 4 4 - 8 6 0 . 42

Ioderma
H A L O G E N H A L O S : R E P O R T O F A N E A R L Y H I S T O P A T H O L O G I C
F I N D I N G I N I O D O D E R M A . J C U T A N P A T H O L . 2 0 2 3 ; 5 0 ( 9 ) : 8 0 6 -
8 0 9 . 43

Outline
hypersensitivity
Pathophysiology
Investigation
Management
44

Investigation
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 P R A C T I C E P A R A M E T E R - A L L E R G Y . 2 0 2 1 M A Y ; 7 6 ( 5 ) : 1 3 2 5 - 1 3 3 9 .
45

Skin test (Immediate)
1 5 5
P R A C T I C E P A R A M E T E R - A L L E R G Y . 2 0 2 1 M A Y ; 7 6 ( 5 ) : 1 3 2 5 - 1 3 3 9
46

Efficacy
S K I N T E S T I N G I N P A T I E N T S W I T H H Y P E R S E N S I T I V I T Y
R E A C T I O N S T O I O D I N A T E D C O N T R A S T M E D I A - A E U R O P E A N
M U L T I C E N T E R S T U D Y . A L L E R G Y
P R A C T I C E P A R A M E T E R . A L L E R G Y . 2 0 2 1 M A Y ; 7 6 ( 5 ) : 1 3 2 5 - 1 3 3 9
J A L L E R G Y C L I N I M M U N O L P R A C T . 2 0 1 9 J A N ; 7 ( 1 ) : 6 1 - 6 5
47

Skin test
A L L E R G Y . 2 0 1 5 J U N ; 7 0 ( 6 ) : 6 2 5 - 3 7 48

F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 J A L L E R G Y C L I N I M M U N O L P R A C T . 2 0 2 0 J A N ; 8 ( 1 ) : 2 6 7 - 2 7 2 .
49
IDT before performing computed tomography

Tryptase
Practice parameter - Allergy. 2021 May;76(5):1325-1339.
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
I
O
D
I
N
A
T
E
D
C
O
N
T
R
A
S
T
M
E
D
I
A
H
Y
P
E
R
S
E
N
S
I
T
I
V
I
T
Y
50
Clinical practice Guidelines – J Investig Allergol Clin
Immunol 2016; Vol. 26(3): 144-155

Basophil activation test
(weak/low).
P
R
A
C
T
I
C
E
P
A
R
A
M
E
T
E
R
-
A
L
L
E
R
G
Y
.
2
0
2
1
M
A
Y
;
7
6
(
5
)
:
1
3
2
5
-
1
3
3
9
.
51
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3

The diagnostic value of
basophil activation test in
patients with an
immediate
hypersensitivity reaction
to radiocontrast media
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
A
N
N
A
L
S
O
F
A
L
L
E
R
G
Y
,
A
S
T
H
M
A
&
I
M
M
U
N
O
L
O
G
Y
,
2
0
1
1
-
0
5
-
0
1
,
V
O
L
U
M
E
1
0
6
,
I
S
S
U
E
5
,
P
A
G
E
S
3
8
7
-
3
9
3
,
52
• Sensitivity of 46.2% to 61.5% and a
Specificity of 88.4% to 100%,
• Moderate accuracy (area under the
curve 0.70 - 0.90).

Drug provocation test (immediate)
P
R
A
C
T
I
C
E
P
A
R
A
M
E
T
E
R
-
A
L
L
E
R
G
Y
.
2
0
2
1
M
A
Y
;
7
6
(
5
)
:
1
3
2
5
-
1
3
3
9
.
53
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
• Alternative ICM : Skin test
Negative

A
L
L
E
R
G
Y
.
2
0
1
3
S
E
P
;
6
8
(
9
)
:
1
2
0
3
-
6
.
J
A
L
L
E
R
G
Y
C
L
I
N
I
M
M
U
N
O
L
P
R
A
C
T
.
2
0
1
9
S
E
P
-
O
C
T
;
7
(
7
)
:
2
2
1
8
-
2
2
2
4
.
54
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
• 45-min intervals
• using 5 cc, 15 cc, 30 cc
and 50 cc (cumulative
dose = 100 cc)

A
L
L
E
R
G
Y
.
2
0
1
3
S
E
P
;
6
8
(
9
)
:
1
2
0
3
-
6
55
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
DPT Alternative
40% 60%
3%
83%

Cross reactivity
1 5 5 56
Ultravist
Xenetix
Iopamir
omnipaque
visipaque

Classification
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 J A L L E R G Y C L I N I M M U N O L . 2 0 1 6 F E B ; 1 3 7 ( 2 ) : 6 3 3 - 6 3 5
57

Compare Immediate vs Non immediate
( Cross reactivity)
J A L L E R G Y C L I N I M M U N O L P R A C T . J U L - A U G 2 0 1 8 ; 6 ( 4 ) : 1 2 4 6 -
1 2 5 4 . 58

Cross reactivity (All)
Group A : N -(2,3-dihydroxypropyl) carbamoyl
side chain
Iodixanol (Visipaque) , iIohexol (Omnipaque) ,
Iomeprol (Imeron) , Ioversol (Optiray) ,
Iopromide (Ultravist)
Different from classification
1. Include : Iopromide
2.Exclude : Ioxitaglate and Iopamidol (Iopamiro)
J A L L E R G Y C L I N I M M U N O L P R A C T . J U L - A U G 2 0 1 8 ; 6 ( 4 ) : 1 2 4 6 -
1 2 5 4 . 59
Ultravist
Xenetix
Iopamiro
omnipaque
visipaque
• Compare to CPG 2016

Cross reactivity (now)
Group 1 : N -(2,3-dihydroxypropyl) carbamoyl
side chain
Iodixanol (Visipaque) , iIohexol (Omnipaque) ,
Iomeprol (Imeron) , Ioversol (Optiray) ,
Iopromide (Ultravist)
Group 2 : N-(2,3-dihydroxypropyl)-N-
methyl-carbamoyl side chain
Iopromide ( Imeron ) , Iobitridol ( Xenetix )
A L L E R G Y . 2 0 1 5 J U N ; 7 0 ( 6 ) : 6 2 5 - 3 7 .
60
Per-patient cross-reactivity rate
Non immediate > Immediate
1. 39% in immediate HSR
2. 68% in non-immediate HSR

Investigation
61

Skin test (Non immediate)
1 5 5
P R A C T I C E P A R A M E T E R - A L L E R G Y . 2 0 2 1 M A Y ; 7 6 ( 5 ) : 1 3 2 5 - 1 3 3 9
62

DRESS
In DRESS and FDE, patch
tests can be useful and SPT and IDT
should not be used
63

Skin test (Non-immediate) : positive rate
A L L E R G Y . 2 0 1 5 J U N ; 7 0 ( 6 ) : 6 2 5 - 3 7 .
64

Lymphocyte Transformation Test
The LTT can be done as an additional diagnostic tool in selected cases with
contraindications for STs (weak/ low).
Sensitivity ranges from 13% to 75%
LTT can only be considered as an additional tool and taking into account that a negative
LTT cannot rule out a NIHR
It can be positive even 10–20 years after delayed HSR
65

According to limiting value of the skin test and reducing the negative predictive value
The ICM chosen for DPT may be the culprit in patients with non-severe reactions and
negative ST, and a ST negative alternative in patients with confirmed NIHR or with severe
reactions (weak/low). (Practice parameter)
Therefore, in delayed HSRs, the culprit ICM should not be readministered, and a structurally
different ICM should be chosen. (AAIR)
A L L E R G Y A S T H M A I M M U N O L R E S . 2 0 2 2 J U L ; 1 4 ( 4 ) : 3 4 8 - 3 6 0 .
P R A C T I C E P A R A M E T E R - A L L E R G Y . 2 0 2 1 M A Y ; 7 6 ( 5 ) : 1 3 2 5 - 1 3 3 9 . 66
Drug provocation test (non-immediate)

Although various protocols of DPT have been reported, there is still no consensus on
standardized provocation protocols.
The most frequently association has been found between iodixanol and iohexol and
between ioversol and iomeprol.
It has been reported that iobitridol (xenetix) shows low cross reactivity in patients with
NIHR to other ICM
67

A
L
L
E
R
G
Y
.
2
0
2
1
M
A
Y
;
7
6
(
5
)
:
1
3
2
5
-
1
3
3
9
68
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
• 60-min intervals
• using 5 cc, 15 cc, 30 cc and 50 cc (cumulative dose
= 100 cc)
• In the serious nonimmediate reactions
• 2 separate sessions with a gap of at least 1 week
between sessions.
• 5, 10, and 15 cc on the first day (cumulative total of
30 cc) , a week later and 20, 30, and 50 cc on the
second day (cumulative total of 100 cc) (grade of
recommendation, C)

A
L
L
E
R
G
Y
.
2
0
2
1
M
A
Y
;
7
6
(
5
)
:
1
3
2
5
-
1
3
3
9
69
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
• 1/100 of the dose required for radiological
examination and 1-24 hours later 1/10 of the dose
required

Diagnostic evaluation of patients with nonimmediate
cutaneous hypersensitivity reactions to iodinated
contrast media
A
L
L
E
R
G
Y
.
2
0
1
2
J
U
L
;
6
7
(
7
)
:
9
2
9
-
3
5
.
70
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
• Spain
• 1 center trial
• Exanthema and nonimmediate
urticaria
• Patients with severe CM reactions
like Stevens–Johnson syndrome,
acute generalized pustulosis or
drug reaction with eosinophilia
and systemic symptoms were not
included in this study
• In the first run, 5, 10 and 15 cc of
CM were administered and, if this
was well tolerated, 1 week later
CM was administered at 20, 30
and 50 cc (cumulative dose = 100
cc).

Diagnostic evaluation of patients with nonimmediate
cutaneous hypersensitivity reactions to iodinated
contrast media
A
L
L
E
R
G
Y
.
2
0
1
2
J
U
L
;
6
7
(
7
)
:
9
2
9
-
3
5
.
71
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
A skin biopsy was taken from
seven skin-test positive and DPT-
positive patients with similar
results in all cases.
There was a perivascular
mononuclear cell infiltrate, mainly
in the dermis, with higher levels of
CD4 lymphocytes than CD8 T
lymphocytes,

Analysis of cross-reactivity
among radiocontrast media in
97 hypersensitivity reactions
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 J A L L E R G Y C L I N I M M U N O L . 2 0 1 6 F E B ; 1 3 7 ( 2 ) : 6 3 3 - 6 3 5 . E
72

Analysis of cross-reactivity
among radiocontrast media in
97 hypersensitivity reactions
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 J A L L E R G Y C L I N I M M U N O L . 2 0 1 6 F E B ; 1 3 7 ( 2 ) : 6 3 3 - 6 3 5 . E
73

Outline
hypersensitivity
Pathophysiology
Investigation
Management
74

Management to prevent recurrence of
HSR
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
I
O
D
I
N
A
T
E
D
C
O
N
T
R
A
S
T
M
E
D
I
A
H
Y
P
E
R
S
E
N
S
I
T
I
V
I
T
Y
75

Protective effect against repeat adverse
reactions to iodinated contrast medium:
Premedication vs. changing the contrast
media
Iopamidol was used for the CT studies
throughout the entire period.
Iohexol were administered only to the
patients with the breakthrough reactions to
iopamidol.
Premedication prior to contrast for patients
with previous ARs may be protective,
however, changing CM was more effective.
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 E U R R A D I O L . 2 0 1 6 J U L ; 2 6 ( 7 ) : 2 1 4 8 - 5 4 .
76
27.7% 17.3% 5.2% 2.7%

Re-exposure to low osmolar iodinated contrast
media in patients with prior moderate to severe
hypersensitivity reactions : A multicentre
retrospective cohort study
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 E U R R A D I O L . 2 0 1 7 J U L ; 2 7 ( 7 ) : 2 8 8 6 - 2 8 9 3 .
77

Prevent HSR
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
P
R
A
C
T
I
C
E
P
A
R
A
M
E
T
E
R
-
A
L
L
E
R
G
Y
.
2
0
2
1
M
A
Y
;
7
6
(
5
)
:
1
3
2
5
-
1
3
3
9
.
78

F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
I
M
M
E
D
I
A
T
E
T
Y
P
E
79

F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
I
O
D
I
N
A
T
E
D
C
O
N
T
R
A
S
T
M
E
D
I
A
H
Y
P
E
R
S
E
N
S
I
T
I
V
I
T
Y
80

Premedication
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
P
R
A
C
T
I
C
E
P
A
R
A
M
E
T
E
R
-
A
L
L
E
R
G
Y
.
2
0
2
1
M
A
Y
;
7
6
(
5
)
:
1
3
2
5
-
1
3
3
9
.
81

F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 A L L E R G Y . 2 0 2 1 M A Y ; 7 6 ( 5 ) : 1 3 2 5 - 1 3 3 9 .
82
Practice parameters for diagnosing and managing iodinated
contrast media hypersensitivity

83
Premedication
Methylprednisolone-based:
32 mg methylprednisolone by
mouth 12 hours and 2 hours
before contrast
medium administration. 50
mg diphenhydramine may be
added as in option 1
• Methylprednisolone 40 mg IV
or hydrocortisone sodium
succinate 200 mg IV
immediately, and then every 4
hours until contrast medium
administration
• diphenhydramine 50 mg IV 1
hour before contrast medium
administration.

Premedication : Patient risk
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
I
O
D
I
N
A
T
E
D
C
O
N
T
R
A
S
T
M
E
D
I
A
H
Y
P
E
R
S
E
N
S
I
T
I
V
I
T
Y
84

High risk patient
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
J
A
M
C
O
L
L
R
A
D
I
O
L
2
0
1
1
M
A
Y
;
8
(
5
)
:
3
4
5
-
5
4
.
85

Premedication : Duration of treatment
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
I
O
D
I
N
A
T
E
D
C
O
N
T
R
A
S
T
M
E
D
I
A
H
Y
P
E
R
S
E
N
S
I
T
I
V
I
T
Y
86

Summary of Observed
Indirect Harm Associated
with Premedication in the
Inpatient Study Cohort
• Premedicated inpatients had a
• significantly longer median
length of stay (+25 hours;
158 vs 133 hours, P < .001)
• significantly longer median
time to CT (+25 hours, 42
vs 17 hours, respectively; P
< .001)
• significantly greater risk of
hospital acquired infection.
F R I D A Y , S E P T E M B E R 8 , 2 0 2 3 R A D I O L O G Y . 2 0 1 6 M A Y ; 2 7 9 ( 2 ) : 4 9 2 - 5 0 1
87

Practice parameter
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
I
O
D
I
N
A
T
E
D
C
O
N
T
R
A
S
T
M
E
D
I
A
H
Y
P
E
R
S
E
N
S
I
T
I
V
I
T
Y
88

Ending of RCM
hypersensitivity
Pathophysiology
Investigation
Management
89

Gadolinium-based contrast agents
Hypersensitivity

Gadolinium-based
contrast
agents (GBCAs)
Can Assoc Radiol J. 2018 May;69(2):136-150.

Epidemiology
Invest Radiol. 2019 Oct;54(10):633-637.

Risk factor
C U R R E N T O P I N I O N I N A L L E R G Y A N D C L I N I C A L I M M U N O L O G Y
2 3 ( 4 ) : P 3 0 0 - 3 0 6 , A U G U S T 2 0 2 3 . 93

Pathophysiology
94
• Increased levels of C3a and
C4a have been identified in
patients with severe immediate
HSR

Skin test
J Investig Allergol Clin Immunol. 2021 Dec;31(6):504-506.

BAT test
Current Opinion in Allergy and Clinical Immunology 23(4):p
300-306, August 2023.

Cross-Reactivity
Number of patients Culprit Crossreactivity
11 Gadobenate dimeglumine -
1 Gadobenate dimeglumine Gadoteric acid
1 Gadobenate dimeglumine Gadobutrol
2 Gadoteric acid Gadobenate dimeglumine
1 Gadoteric acid Gadobenate dimeglumine
Gadobutrol
3 Gadobutrol -
Cross reactivities seem to affect most
frequently gadoteric acid and gadobutrol
J Allergy Clin Immunol Pract. May-Jun 2017;5(3):846-849.

Can Assoc Radiol J. 2018 May;69(2):136-150.

Cross reactivity
99

Premedication
Front Allergy. 2022 Mar 17;3:813927.
Indeed, for individuals with
evidence of a prior immunologic
reaction, premedication with
antihistamines may inhibit early
signs of anaphylaxis and is
therefore not recommended.
Moreover, premedication did not
provide any additional protection
from recurrence compared with
using a GBCA different from the
one that caused a reaction

Drug provocation test
Int J Immunopathol Pharmacol. Jan-Dec 2021;35:20587384211015061.

Drug provocative
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
A
L
L
E
R
G
Y
.
2
0
2
2
O
C
T
;
7
7
(
1
0
)
:
3
1
5
1
-
3
1
5
3
102

Thank you
F
R
I
D
A
Y
,
S
E
P
T
E
M
B
E
R
8
,
2
0
2
3
I
O
D
I
N
A
T
E
D
C
O
N
T
R
A
S
T
M
E
D
I
A
H
Y
P
E
R
S
E
N
S
I
T
I
V
I
T
Y
103

Iodinated contrast media Hypersensitivity

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