Late adverse reactions to intravascular iodine based contrast media: an update

Late adverse events to iodinated contrast media in patients treated with IL-2: a safety report from the Danish Renal Carcinoma Group (DaRenCa) study - 1

BACKGROUND

A higher incidence of late adverse events (LAEs) to iodinated contrast media in interleukin-2 (IL-2)-treated patients has been reported.

PURPOSE

To assess the incidence of LAEs after administration of iodinated contrast media in patients with metastatic renal cell carcinoma (mRCC) treated with IL-2.

MATERIAL AND METHODS

Patients were randomized to treatment with IL-2 and interferon-α with/without bevacizumab in the Danish Renal Carcinoma Group study - 1. Patients underwent a computed tomography (CT) scan at baseline, at one month, at three months, and every third month until RECIST 1.1 defined progression. LAEs due to iodinated contrast media were systematically registered according to the Common Terminology Criteria for Adverse Events classification.

RESULTS

In total, 89 patients were included and underwent a total of 507 contrast-enhanced CT scans. An overall incidence of 46 (9.1%) LAEs was observed in 38 of 89 (42.7%) patients; 3 LAEs at baseline (3.4% of all baseline scans), 39 (13.9%) LAEs during IL-2-based therapies, and 4 (2.9%) LAEs after termination of IL-based therapies. There was no difference in progression-free survival, overall survival, and treatment response in patients experiencing LAEs compared to patients without LAEs (P = 0.2, P = 0.5, and P = 0.6, respectively).

CONCLUSION

Patients with mRCC demonstrated a higher incidence of LAEs after administration of iodinated contrast during ongoing IL-2 therapy, indicating that iodinated contrast media may cause a recall phenomenon of IL-2 toxicities in patients with mRCC. Treatment with IL-2 should not be a contraindication for contrast-enhanced scans in patients with mRCC but expertise and vigilance are required.

Factors influencing the safety of outpatient coronary CT angiography: a clinical registry study

OBJECTIVES

Since the safety of coronary CT angiography (CTA) is of great importance, especially with regard to widening indications and increasing morbidity, the aim of this study was to assess influencing factors.

METHODS

Patients undergoing coronary CTA in a third-generation dual-source CT in a radiological centre were included in a clinical registry. Up to 20 mg metoprolol was administered intravenously to attain a heart rate ≤65/min. Glyceryl trinitrate (GTN) was administered in doses of 0.8 mg and 0.4 mg. Blood pressure was measured before the administration and after the CTA.

RESULTS

Out of 5500 consecutive patients (3194 men, 62.3 (54.9-70.0) years), adverse events occurred in 68 patients (1.2%) with mild anaphylactoid reactions (0.4%), vasovagal symptoms (0.3%) and extravasation (0.3%) being most frequent. Anti-allergic drugs were given in 17 patients, atropine in 3 patients and volume in 1 patient. Drug administration resulted in a significant mean arterial pressure decline (96.0 (88.3-106.0) vs 108.7 (99.7-117.3) mmHg; p<0.001). Patients who suffered systolic blood pressure drops >20 mmHg or >40 mmHg were older (66.5 (58.6-73.3) vs 60.5 (53.6-68.3) years; 70.2 (63.3-76.5) vs 62.1 (54.7-69.6) years), more often male (65.1% vs 54.4%; 68.9% vs 57.3%) and had higher Agatston score equivalents (83.0 (2.0-432.0) vs 15.0 (0.0-172.0); 163.0 (16.3-830.8) vs 25.0 (0.0-220.0); all p<0.001). GTN dose reduction lowered the fraction of patients suffering from blood pressure drops >20 mmHg or >40 mmHg from 34.5% to 27.4% and from 6.1% to 3.5% (both p<0.001), respectively. The proportion of coronary segments with impaired image quality did not differ significantly.

CONCLUSIONS

Coronary CTA with intravenous beta-blocker administration is a safe procedure in an outpatient setting as adverse events are rare and mostly mild. Reduced GTN doses can further improve safety by lowering the rate of significant blood pressure drops, which occurred especially in elderly men with increased plaque burden.

TRIAL REGISTRATION NUMBER

NCT03815123.

Incidence and risk factors of late adverse reactions to low-osmolar contrast media: A prospective observational study of 10,540 exposures

PURPOSE

To evaluate the incidence and risk factors of late adverse reactions (ARs) to non-ionic low-osmolar contrast media (LOCM).

METHODS

The occurrence of late AR was monitored on day 1 and from day 7 to day 28 in all patients who received enhanced computed tomography using LOCM during a 5-week study period in a single tertiary hospital. Patients who experienced late AR were followed up for three years.

RESULTS

Among the total 10,540 LOCM exposures, 315 ARs (3.0%) were reported; acute ARs occurred in 108 LOCM exposures (1.0%) and late ARs occurred in 207 LOCM exposures (2.0%) (90.9% within one week, 9.1% developed afterwards by day 20). Previous history of drug allergy (odds ratio [OR] = 4.59; 95% confidence interval [CI] 2.17-9.71) and allergic diseases (OR = 2.54; 95% CI 1.32-4.91) were risk factors of late ARs to LOCM. Although the recurrence rate was lowered with premedication from 8.5% to 1.7% (8/94 vs. 3/178; p = 0.016), LOCM change did not make difference compared to reuse of the culprit LOCM (2/38 vs. 9/234; p = 0.655). In patients with a history of late AR to LOCM, the risk of recurrent reactions decreased with longer time intervals between exposures (OR = 0.86; 95% CI: 0.77-0.97; p = 0.025) and with the use of antihistamine premedication (OR = 0.27; 95% CI: 0.06-0.99; p = 0.049).

CONCLUSIONS

Late ARs to LOCM occurred mostly within one week. The use of premedication may be helpful in reducing the recurrence of late ARs.

Pharmacological prevention of delayed hypersensitivity reactions caused by iodinated contrast media

Background

Delayed hypersensitivity reactions (DHRs) to radiocontrast media (RCM) occur in approximately 0.5–23.0% of patients and are thought to be caused by T cell-mediated mechanisms. However, an optimal pharmacological preventive strategy is not yet established in patients with histories of delayed reactions to RCM.

Objective

We aimed to evaluate the efficacy of pharmacological prevention in patients with histories of delayed reactions to non-ionic low-osmolar RCM when re-exposed to RCM.

Methods

A retrospective review of electronic medical records of 117 patients with previous histories of DHRs to RCM who visited an allergy clinic for the prevention of reactions after the re-exposure to RCM was conducted. The effects of pharmacological prevention were compared according to the symptom scores of previous reactions based on their intensities and durations with electronic medical records (EMRs).

Results

Of the 117 patients who experienced DHRs after RCM injection, we confirmed the outcomes of RCM re-exposure in 101 patients. For pharmacological prevention, 92 patients (91.1%) received steroids before RCM injection and among them, 50 patients (49.5%) received additional steroids after RCM injection. With this pharmacological prevention, patients of symptoms improved or no recurrence, recurrence of similar previous symptoms, and recurrence of worse symptoms were 98 (97.0%), 2 (2.0%), and 1 (1.0%), respectively. The proportions of no recurrence after pharmacological prevention were lower in patients with severe reactions and higher symptom scores.

Conclusion

Pharmacological prevention showed a beneficial effect in most patients with delayed hypersensitivity to RCM. Further investigations are needed to establish an effective protocol for the prevention of delayed reactions to RCM.

Nonrenal Complications of Contrast Media

Injection of contrast media is the foundation of invasive and interventional cardiovascular practice. Iodine-based contrast was first used in the 1920s for urologic procedures and examinations. The initially used agents had high ionic and osmolar concentrations, which led to significant side effects, namely nausea, vomiting, and hypotension. Newer contrast agents had lower ionic concentrations and lower osmolarity. Modifications to the ionic structure and iodine content led to the development of ionic low-osmolar, nonionic low-osmolar, and nonionic iso-osmolar contrast media. Contemporary contrast agents are better tolerated and produce fewer major side effects.

Immediate and delayed hypersensitivity after intra-arterial injection of iodinated contrast media: a prospective study in patients with coronary angiography

OBJECTIVES

While hypersensitivity reactions (HSR) to intravenously administered iodinated contrast media (ICM) have been well studied, not much is known about HSR to intra-arterially administered ICM.

METHODS

A prospective observational study was performed to evaluate coronary angiography (CAG)-induced ICM hypersensitivity in patients who underwent CAG using ICM including ioversol, a low-osmolar non-ionic monomer, and iodixanol, an iso-osmolar non-ionic dimer. The HSR were investigated through in-patient monitoring after CAG and telephone interview after discharge.

RESULTS

A total of 714 patients were enrolled during the observation period, of whom 26 (3.6%) showed immediate HSR and 108 (15.1%) showed delayed HSR. With regard to severity, proportion of immediate HSR grades 1, 2, and 3 was 57.7%, 38.5%, and 3.8%, respectively, whereas that of delayed HSR grades 1, 2, and 3 was 85.2%, 13.9%, and 0.9%, respectively. Multivariate analysis revealed that previous intra-arterial exposure to ICM was an independent risk factor for immediate HSR (odds ratio (OR) 2.92, 95% confidence interval (CI) 1.22-6.96; p = 0.015). Iodixanol was a significant risk factor for delayed HSR (OR 1.61, 95% CI 1.07-2.43; p = 0.024) and correlated with a higher incidence of delayed HSR within 24-h post-ICM administration compared to ioversol.

CONCLUSION

The incidence rate of immediate and delayed HSR in intra-arterially administered ICM was 3.6% and 15.1%, respectively. Previous exposure to intra-arterially administered contrast media was a significant risk factor for immediate HSR. Compared to ioversol, iodixanol was associated with relatively earlier and more frequent delayed HSR.

KEY POINTS

• In this prospective study, the incidence of immediate and delayed hypersensitivity in intra-arterial injection of contrast media during coronary angiography was 3.6% and 15.1%, respectively. • Delayed hypersensitivity reactions were more common but less severe than immediate hypersensitivity reactions during coronary angiography. • Previous exposure to ICM via intra-arterial route was a significant risk factor for immediate hypersensitivity to intra-arterial contrast medium.

Patients with a history of hypersensitivity reaction to iodinated contrast medium and given iodinated contrast during an interventional pain procedure

In patients with a history of a hypersensitivity reaction to iodinated contrast medium, iodinated contrast medium is avoided, antihistamine and steroid premedication are given, or a gadolinium-based contrast agent is employed. Six patients with a history of a hypersensitivity reaction to iodinated contrast medium and who were not premedicated had an unintentional injection of iodinated contrast. None of the patients developed a moderate or severe reaction. All patients had gadopentetate dimeglumine in one of their injections; three had repeated injections of the gadopentetate. The lack of a significant reaction may be due to any or all of the following: questionable history of iodinated contrast reaction, low dose of iodinated contrast given, concomitant injection of (epidural) steroid, and slower absorption from epidural compared with intravenous injection. While it is reassuring to know that there is a low possibility of a moderate to severe reaction in these patients, every effort should be made to avoid this scenario, appropriate drugs and resuscitation equipment should be immediately available, and the patients should be observed adequately and followed for the possibility of late reactions. Recent publications have called for caution in the use of gadolinium-based contrast agents.

Outcomes of corticosteroid prophylaxis for hypersensitivity reactions to low osmolar contrast media in high-risk patients

BACKGROUND

Corticosteroid prophylaxis has been widely adopted for the prevention of acute allergic-like reactions to iodinated contrast media, but its use is still controversial because there is no strong evidence supporting its efficacy before administration of nonionic low osmolar contrast media (LOCM).

OBJECTIVE

To assess the outcomes of premedication in patients with previous acute allergic-like reactions to LOCM in clinical practice.

METHODS

A retrospective study was performed on 322 high-risk patients who were reexposed to LOCM after premedication composed of antihistamines and/or systemic corticosteroids because of a previous history of acute allergic-like reactions to LOCM.

RESULTS

After premedication, 275 patients (85.4%) did not experience any reaction, but 47 patients (14.6%) still experienced a breakthrough reaction. The premedication rate and amount of corticosteroid administered were significantly higher in the nonrecurrence group than in the recurrence group (P = .04 and P = .04, respectively), and a linear trend was observed in the use of corticosteroid premedication and the efficacy of prevention (P for trend = .02). Multivariate binary logistic regression revealed that corticosteroid premedication was effective in preventing recurrence (odds ratio, 0.284; 95% confidence interval, 0.103-0.784). Nonetheless, despite corticosteroid premedication, 3.4% of high-risk patients still experienced moderate to severe reactions, and 14.3% of patients with a severe index reaction again had a severe reaction.

CONCLUSION

Premedication with corticosteroids seems to be helpful in reducing the overall rate of recurrence of acute allergic-like reactions to LOCM in high-risk patients, but patients with severe index reactions are still at risk of developing severe reactions despite corticosteroid premedication.

Should patients with risk factors be tested for hypersensitivity to contrast media: a prospective study

BACKGROUND

Previous hypersensitivity reactions to contrast media (CM), atopy, atopic disease, drug allergy, and age (20-29 or >55) are risk factors for CM hypersensitivity reactions. Our aim was to evaluate whether these risk factors should prompt skin testing for diagnosing CM allergy.

METHODS

The study was conducted among patients referred for allergy testing with CM. Skin tests were performed with non ionic or gadolinium CM, recommended by a radiologist. After completion of tests patients were telephonically queried on their symptoms of reactions.

RESULTS

151 risk patients (53 men, 98 women; mean age 55.2) were included in the study. Only 13 (9 %) had a history of hypersensitivity reaction to CM. Compared with the other patients, atopy was significantly more common in patients with a history of CM hypersensitivity reactions. Female gender and mean age were also higher, but not significant. All of the tests with CMs were negative. Only one patient reported urticaria within 1-2 min after administration of CM (telephonically).

CONCLUSIONS

Atopy can increase the risk of CM allergy. However, skin tests with CMs may be inefficient, unnecessary, and time-consuming, except in cases with a history of CM allergy. Premedication protocols appear to be beneficial in patients with a history of CM allergy and cannot be recommended for patients with well-controlled asthma, rhinitis, atopic dermatitis or history of drug allergy.

Acute pyelonephritis in transplanted kidneys: can diffusion-weighted magnetic resonance imaging be useful for diagnosis and follow-up?

PURPOSE

To assess reliability of diffusion-weighted magnetic resonance imaging (DW-MRI) in the management of acute pyelonephritis (APN) foci in transplanted kidneys.

MATERIALS AND METHODS

In the 2012-2014 period, 24 kidney-transplanted patients underwent MR screening for clinical suspicion of APN. Two readers independently analyzed all images, establishing presence and location of APN foci. The 22 patients who were positive at the MR exam constituted the study population. For each patient the apparent diffusion coefficient (ADC) was measured in the APN foci and in three sites of the healthy parenchyma (case-control comparison). The data were matched to the laboratory measurements for white blood cell, C-reactive protein, and serum creatinine.

RESULTS

Forty-six APN foci were found in 22/24 patients. At the acute stage, the difference in ADC between healthy parenchyma and APN foci was significant (2.06 ± 0.16 vs. 1.43 ± 0.32 × 10(-3) mm(2)/s; p < 0.0001). The performance of ADC as APN indicator was tested by the receiving operating characteristics (ROC) curve: the area under curve AUC = 0.99 witnessed an excellent discriminatory ability, with threshold APN/normal parenchyma 1.9 × 10(-3) mm(2)/s. At the 1-month follow-up 43/46 APN foci were no longer visible, with ADC values significantly higher than at the acute stage; all laboratory data were physiological, with WBC significantly reduced from the acute phase (5.2 ± 1.6 × 10(9)/L vs. 10.6 ± 4.8 × 10(9)/L; p < 0.0001). The other 3 patients underwent further therapy and exams, including a third MR.

CONCLUSIONS

DW-MRI with ADC measurement seems to be a reliable tool in diagnosing and monitoring APN foci in transplanted kidneys, with clinical impact on patient management.

Intra-arterial and intravenous applications of Iosimenol 340 injection, a new non-ionic, dimeric, iso-osmolar radiographic contrast medium: phase 2 experience

BACKGROUND

Iosimenol 340 injection is a new, dimeric, iso-osmolar, iodinated contrast medium for X-ray angiography.

PURPOSE

To compare the safety and efficacy of iosimenol injection to iodixanol injection in two randomized, controlled phase 2 trials.

MATERIAL AND METHODS

One hundred and forty-four adult patients were enrolled in the two trials, one for evaluation during arteriography and the other for evaluation during computed tomography. Safety was compared by assessing adverse events, vital signs, ECGs, and laboratory parameters. Efficacy was assessed as X-ray attenuation in the computed tomography (CT) trial and as the quality of contrast enhancement in the arteriography trial.

RESULTS

There were no statistically significant differences in terms of safety or efficacy between the two contrast media. Both were well tolerated upon intravenous as well as intra-arterial injection. The most common adverse event was a feeling of warmth (observed in 35.1% of the patients with Iosimenol injection and 44.3% with iodixanol injection).

CONCLUSION

Iosimenol upon intravenous as well as upon intra-arterial injection exhibits a safety profile and shows an efficacy similar to that of iodixanol.

Transthoracic echocardiography as an alternative major guidance to angiography during transcatheter closure of patent ductus arteriosus: technical feasibility and clinical relevance

The conventional transcatheter closure of patent ductus arteriosus (PDA) requires femoral artery puncture and angiography for duct anatomic and shunting estimation. If such estimation can be replaced by transthoracic echocardiography (TTE), the procedure will be further simplified, with fewer invasions. This study aimed to examine whether TTE can serve as an alternative to aorta angiography and as a major guidance for transcatheter duct closure. The study enrolled 298 consecutive patients (71 males and 227 females) with PDA. In the study, TTE with combined two-dimensional echocardiography (2DE) imaging and color-coded flow imaging (CDFI) was performed to measure the minimal shunting width (MSW) as the estimated minimal duct size for selection of an Amplatzer duct occluder (ADO) and to monitor the transcatheter duct closure intraprocedurally. The MSW was validated against the duct-stretched diameter (SDD), against the minimal waist diameter of the conical part of a released occluder measured by X-ray spot picture after successful duct closure (SDC), and against the size of the finally used ADO (SADO). Good correlation was found between MSW and SDD [SDD (mm) = 1.31 MSW; r = 0.89; p < 0.01] and between MSW and SADO [SADO (mm) = 1.71 MSW; r = 0.88; p < 0.01]. Of 296 patients who received occlusion using MSW as the reference for selection of the occluder, SDC was attained in 288 (97.3%), 5 (1.7%), and 2 (0.7%) patients, respectively, at the first, second (1 ADO replacement), and third (2 ADO replacements) occluding attempt. Acute occluder dislodgement occurred in one patient (0.3%). At the 12-month follow-up assessment, no major complications were found, and the total immediate or 12-month SDC was 99.7%. Echocardiography as an alternative major guidance to angiography for transcatheter duct closure is technically feasible, and TTE guidance can further simplify the procedure, with fewer invasions and potential complications.

[Iodinated contrast agents used in Radiology]

Iodinated contrast media are widely used in Radiology practices with a very low rate of adverse effects, being contrast-induced nephropathy the most serious one. In the majority of cases it is temporary and reversible, even though it can increase the inhospital morbidity and mortality in patients with risk factors. We will describe the various measures of prevention, being hydration and use of non-ionic contrast low osmolality those which have demonstrated greater effectiveness. Precautions to be taken in some risk situations, as patients treated with metformin or with impaired renal function, are also discussed.

Nonrenal Complications of Contrast Media

Nonrenal complications of contrast media are caused by chemotoxic or anaphylactoid reactions related to the contrast agent used. Chemotoxicity is mainly attributed to ionic concentration and osmolality. Anaphylactoid reactions are typically caused by direct activation of basophils, mast cells, and complement rather than an observable antigen-antibody interaction, and may be acute or delayed. History of an adverse reaction following prior exposure is the strongest predictor of a subsequent adverse reaction to contrast. Premedication regimens of corticosteroids or antihistamines can lower the risk of repeat adverse reactions. Treatment of anaphylactoid reactions depends on the severity of symptoms.

Safety of contrast-enhanced ultrasonography in dogs and cats: 488 cases (2002-2011)

OBJECTIVE

To determine the incidence of adverse events within 24 hours after contrast-enhanced ultrasonography (CEUS) in dogs and cats and compare the risk of death within 24 hours after imaging for animals that underwent ultrasonography with and without injection of a contrast agent.

DESIGN

Retrospective case-control study.

ANIMALS

750 animals (411 case dogs, 238 control dogs, 77 case cats, and 24 control cats).

PROCEDURES

At 11 institutions, medical records were reviewed of dogs and cats that had CEUS performed (cases) as were medical records of dogs and cats with clinical signs similar to those of case animals that had ultrasonography performed without injection of a contrast agent (controls). Information regarding signalment; preexisting disease; type, dose, and administration route of contrast agent used; immediate (within 1 hour after CEUS) and delayed (> 1 and ≤ 24 hours after CEUS) adverse events; and occurrence and cause of death (when available) was extracted from each medical record. Risk of death within 24 hours after ultrasonography was compared between case and control animals.

RESULTS

Of the 411 case dogs, 3 had immediate adverse events (vomiting or syncope) and 1 had a delayed adverse event (vomiting). No adverse events were recorded for case cats. Twenty-three of 357 (6.4%) clinically ill case animals and 14 of 262 (5.3%) clinically ill control animals died within 24 hours after ultrasonography; risk of death did not differ between cases and controls.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that CEUS was safe in dogs and cats.

A delayed, unusual non-cardiogenic pulmonary edema after intravascular administration of non-ionic, low osmolar radiocontrast media for coronary angiography

Non-cardiogenic pulmonary edema (NCPE) is a rare adverse reaction to iodinated radiocontrast media (RCM), in which all previous cases were immediate reactions. A 56-year-old male was given iopamidol, a non-ionic, low osmolar RCM, during coronary artery angiography. He developed pulmonary edema and fever a day after the procedure. Despite diuretic therapy, the patient's pulmonary edema worsened and his high fever persisted. The patient's pulmonary edema was eventually resolved with intravenous steroid treatment. We interpreted the patient's condition as NCPE manifesting as a delayed reaction to RCM. To our knowledge, our case is the first to show NCPE as a delayed hypersensitivity reaction.

[Contrast agents in radiology: current agents approved, recommendations, and safety aspects]

The manuscript summarizes current approved contrast media and their indications. Contrast agents that are discussed include iodinated contrast agents, magnetic resonance (MR) contrast agents, and ultrasound contrast agents. Allergic and non-allergic renal adverse events are described. The clinical issue of metformin and the administration of contrast agents are updated. Nephrogenic systemic fibrosis (NSF) is discussed and safety issues of available MR contrast agents are analyzed. The most recent changes in European Society of Urogenital Radiology (ESUR) guidelines are also presented.

Nonallergic drug hypersensitivity reactions

BACKGROUND

Nonallergic drug hypersensitivities, also referred to as pseudoallergic or anaphylactoid reactions, have clinical manifestations that are often indistinguishable from allergic reactions.

METHODS

We performed a PubMed search using the terms 'drug allergy, drug hypersensitivity, pseudoallergies, anaphylaxis and nonallergic drug reactions' and reviewed 511 publications dated between 1970 and 2012. A total of 160 papers that were relevant to the most common nonallergic drug hypersensitivity reactions were selected for discussion.

RESULTS

Nonallergic drug hypersensitivities do not involve either IgE-mediated (type 1) or delayed (type 4) hypersensitivity. Nonallergic hypersensitivities are commonly referred to as pseudoallergic or idiosyncratic reactions. The common nonallergic drug hypersensitivities are secondary to chemotherapeutic drugs, radiocontrast agents, vancomycin, nonsteroidal anti-inflammatory agents, local anesthetic reactions and opiates. Protocols for skin testing of radiocontrast, nonsteroidal anti-inflammatory agents, local anesthetics and chemotherapeutic agents have been developed, though most have not been validated or standardized. Other diagnostic tests include in vitro-specific IgE tests, and the current 'gold' standard is usually an oral challenge or bronchoprovocation test. In the case of aspirin, even though it is not believed to be IgE-mediated, a 'desensitization' protocol has been developed and utilized successfully, although the mechanism of this desensitization is unclear.

CONCLUSIONS

Diagnostic methods exist to distinguish allergic from nonallergic drug hypersensitivity reactions. The best option in nonallergic drug hypersensitivity is avoidance. If that is not possible, premedication protocols have been developed, although the success of premedication varies amongst drugs and patients.