Steroid premedication in patients with increased risk of contrast reaction: are you familiar with the latest local and international guidelines?

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1 Steroid premedication in patients with increased risk of contrast reaction: are you familiar with the latest local and international guidelines? Poster No.: C-1369 Congress: ECR 2014 Type: Authors: Keywords: DOI: Scientific Exhibit Y. T. A. Lai, J. S. F. Shum, V. K. P. Fung, C. W. Tam, S. W. Lo; Contrast agents, CT, Contrast agent-intravenous /ecr2014/C-1369 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 11

2 Aims and objectives Background Iodinated contrast agents have been widely used for decades. Although they are generally safe, serious adverse events which are sometimes life-threatening do occur. However, withholding contrast administration may hinder the provision of important diagnostic information and appropriate therapy. Medical evidence, international guidelines and manuals exist to address such issue, such as the ACR Manual on Contrast Media by the American College of Radiology, Standards for intravascular contrast agent administration for adult patients by the Royal College of Radiology, and the European Society of Urogenital Radiology Guidelines on Contrast Media. Local guidelines are also available in different regions and institutes, e.g. in Hong Kong, Guidelines for Use of Steroid Premedication has been issued by the Co-ordinating Committee in Radiology. How familiar are we with the latest evidence, guidelines and manuals? Value of Steroid Premedication in Preventing Adverse Contrast Reactions Steroid premedication has been found to significantly reduce self-limiting mild adverse reactions in patients receiving non-ionic contrast media, but there is no statistically significant difference for moderate and severe reactions, which are potentially lifethreatening [1, 2]. on page No randomized controlled clinical trials have demonstrated premedication protection against severe life-threatening adverse reactions [3]. Table 1: Steroid premedication has been found to significantly reduce self-limiting mild adverse reactions in patients receiving non-ionic contrast media, but there is no statistically significant difference for moderate and severe reactions, which are potentially life-threatening. References: Department of Radiology, Pamela Youde Nethersole Eastern Hospital - Page 2 of 11

3 The European Society of Urogenital Radiology Guidelines on Prevention of Generalized Contrast Medium Reactions in Adults acknowledged that when nonionic agents are used, the opinion is divided about the value of premedication [4]. The second edition of Standards for intravascular contrast agent administration by the Royal College of Radiologists pointed out that there is no conclusive evidence of benefit for the prophylactic use of steroids in the prevention of severe reactions of contrast administration. Instead, in patients at increased risk of adverse contrast reactions, namely those with multiple or severe allergies and asthmatics, the need for contrast administration should be re-examined. If the asthmatic patient is wheezy, or reports the asthma is not currently well-controlled and the examination is not urgent, it should be deferred and the patient referred back for appropriate medical therapy. If injection is deemed necessary, it is advised that a non-ionic low or iso-osmolar agent should be used, close medical supervision should be maintained, and any adverse reaction should be treated readily and promptly [5]. Patients at Risk of Allergic-Type Reactions May Benefit from Steroid Premedication The ACR manual on Contrast Media identified certain groups of patients who are at risk of allergic-type contrast reactions. They may potentially benefit from steroid premedication. The most substantial risk factor is a prior history of allergic-like reaction to iodinated contrast media. Atopic individuals, particularly those with multiple severe allergies, and asthmatics are also at increased risk for allergic-like contrast reactions, and may benefit from premedication. However, predictive value of specific allergies, such as those to shellfish or dairy products, previously thought to be helpful, is now recognized to be unreliable. There is no evidence to continue to inquire specifically into a patient's history of "allergy" to seafood. However, the patient should be questioned further to clarify the type and severity of the reaction. Patients with Prior Physiological Reactions Would Not Require Steroid Premedication The ACR Manual on Contrast Media also stated that patients with prior physiological reactions to contrast media would not require steroid premedication in future iodinated contrast media-enhanced studies. Cardiac arrhythmias, depressed myocardial contractility, cardiogenic pulmonary edema, and seizures are potentially serious physiologic reactions to contrast media, likely related to contrast media-related hyperosmolality and/or calcium binding leading to functional hypocalcemia. Patients with underlying significant cardiac disease are identified to be at increased risk for contrast reactions, because of reduced ability to compensate for the osmotic load and minor negative chronotropic effects of iodinated contrast media. IV administration of a hyperosmolality contrast medium may cause fluid shift and result in cardiac failure and pulmonary oedema. In symptomatic patients and patients with severe aortic stenosis, Page 3 of 11

4 primary pulmonary hypertension, or severe cardiomyopathy, attention should be paid to limiting the volume and osmolality of the contrast media [6]. Risk of Corticosteroids The use of steroids is not entirely without risk. Although the risk of a few doses of oral corticosteroids is extremely low, the ACR Manual on Contrast Media advised that corticosteroids should be used with caution in patients with uncontrolled hypertension, diabetes, tuberculosis, systemic fungal infections, peptic ulcer disease or diverticulitis. Table 2: Opinion is divided about the value of premedication. There is no conclusive evidence of benefit for steroid premedication in the prevention of severe reactions of contrast administration. Patients with prior history of allergic-like reaction to iodinated contrast media, those with multiple or severe allergies, and asthmatic are at-risk individuals who may potentially benefit from steroid premedication. Specific allergies are not reliable in predicting future reactions. Prior physiological reactions, as opposed to allergic-like reactions, to iodinated contrast media would not require future steroid premedication. References: Department of Radiology, Pamela Youde Nethersole Eastern Hospital - Purpose of study We evaluate local radiologists' practices regarding the use of steroid premedication in major Hong Kong government hospitals, the rate of rescheduling appointments for steroid premedication, and the documentation of details of patient's previous allergic reactions. Images for this section: Page 4 of 11

5 Table 1: Steroid premedication has been found to significantly reduce self-limiting mild adverse reactions in patients receiving non-ionic contrast media, but there is no statistically significant difference for moderate and severe reactions, which are potentially life-threatening. Table 2: Opinion is divided about the value of premedication. There is no conclusive evidence of benefit for steroid premedication in the prevention of severe reactions of contrast administration. Patients with prior history of allergic-like reaction to iodinated contrast media, those with multiple or severe allergies, and asthmatic are at-risk individuals who may potentially benefit from steroid premedication. Specific allergies are not reliable in predicting future reactions. Prior physiological reactions, as opposed to allergic-like reactions, to iodinated contrast media would not require future steroid premedication. Page 5 of 11

6 Methods and materials A survey, based on current local and international guidelines, was sent to 25 radiologists from eight government Hong Kong hospitals, asking whether they regarded steroid premedication necessary if the patient had underlying cardiac conditions, seafood allergy, or topical iodine allergy. In two of the hospitals, the rate of rescheduling elective contrast CT cases for steroid premedication was reviewed, and documentation of prior allergy history in the clinical management system (CMS) and electronic patient record (epr) was also assessed. Results 96% (24/25) and 84% (21/25) of the responders believed premedication was necessary if there was a history of mild rash after taking seafood and contact with topical iodine respectively. 88% (22/25) do not render steroid premedication needed in patients with angina or congestive heart failure with minimum exertion. Fig. 1: Most responders believed premedication was necessary if there was history of seafood or topical seafood allergy. Most do not think steroid premedication is needed in patients with angina or congestive heart failure. References: Department of Radiology, Pamela Youde Nethersole Eastern Hospital - Page 6 of 11

7 In two of the hospitals, 1.43% (14/976) and 1.71% (5/292) elective contrast CT cases were rescheduled for steroid premedication over four weeks. 15.8% (3/19) were rescheduled because of mild drug allergy, 21.1% (4/19) mild seafood allergy, and 73.7% (14/19) was undocumented on CMS or epr. There may underestimation of cases, because the reason for rescheduling examinations is not routinely documented. Table 3: Among the elective contrast CT cases which were rescheduled for steroid premedication in two local government hospitals in Hong Kong over four weeks, the prior allergens were mostly not documented in electronic records, and the documented cases were mainly due to minor drug allergies or seafood allergy. References: Department of Radiology, Pamela Youde Nethersole Eastern Hospital - Table 4: Among the elective contrast CT cases which were rescheduled for steroid premedication in two local government hospitals in Hong Kong over four weeks, the majority of prior reactions were not documented in electronic records, and the documented cases were all mild reactions, namely rash and urticaria. References: Department of Radiology, Pamela Youde Nethersole Eastern Hospital - Images for this section: Page 7 of 11

8 Fig. 1: Most responders believed premedication was necessary if there was history of seafood or topical seafood allergy. Most do not think steroid premedication is needed in patients with angina or congestive heart failure. Table 3: Among the elective contrast CT cases which were rescheduled for steroid premedication in two local government hospitals in Hong Kong over four weeks, the prior allergens were mostly not documented in electronic records, and the documented cases were mainly due to minor drug allergies or seafood allergy. Page 8 of 11

9 Table 4: Among the elective contrast CT cases which were rescheduled for steroid premedication in two local government hospitals in Hong Kong over four weeks, the majority of prior reactions were not documented in electronic records, and the documented cases were all mild reactions, namely rash and urticaria. Page 9 of 11

10 Conclusion Many interviewed radiologists were unfamiliar with the latest international evidence and guidelines regarding the role of steroid premedication. Most still believed premedication was necessary if there was a history of seafood or topical iodine allergy, and the majority of the rescheduled cases with documented allergens were due to seafood allergy. Rate of rescheduling appointments may possibly be reduced by increased awareness. Documentation of patients' previous allergic reactions and allergens is also suggested, as the type and severity of reaction may affect the decision of future prescription of steroid premedication. Personal information Yee Tak Alta LAI 1, Sing Fai John SHUM 2, Kai Pong Vincent FUNG 1, Chi Wai Annie TAM 1, Shing Wai Sherwin LO 1 1 Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Hong Kong 2 Radiology Department, Hong Kong Baptist Hospital, Hong Kong References [1] Lasser EC, Berry CC, Mishkin MM, Williamson B, Zheutlin N, Silverman JM. Pretreatment with corticosteroids to prevent adverse reactions to nonionic contrast media. AJR Am J Roentgenol 1994; 162: [2] Morcos SK. Review article: Acute serious and fatal reactions to contrast media: our current understanding. Br J Radiol 2005; 78: [3] Brockow K, Christiansen C, Kanny G, et al. Management of hypersensitivity reactions to iodinated contrast media. Allergy 2005; 60: [4] Morcos SK, Thomsen HS, Webb JA; Contrast Media Safety Committee of the European Society of Urogenital Radiology. Prevention of generalized reactions to contrast media: a consensus report and guidelines. Eur Radiol. 2001;11(9): [5] Standards for intravascular contrast agent administration, second edition. London: The Royal College of Radiologists, ISBN: Page 10 of 11

11 [6] ACR Manual on Contrast Media, Version 9, ACR Committee on Drugs and Contrast Media. American College of Radiology. ISBN: Page 11 of 11