Iodixanol is a parenteral radiographic contrast agent indicated for intra-arterial digital subtraction angiography, angiocardiography (left ventriculography and selective coronary arteriography), peripheral arteriography, visceral arteriography, cerebral arteriography, computed tomography (CT) imaging of the head and body, excretory urography, peripheral venography, and coronary computed tomography angiography (CCTA) to assist diagnostic evaluation of patients with suspected coronary artery disease. Iodinated contrast media can be classified as either ionic or nonionic and high-osmolar or low-osmolar. Iodixanol, a nonionic contrast medium, is considered iso-osmolar with an osmolality of 290 mOsm/kg water. Because osmolality is related to toxicity and adverse events, high-osmolar, ionic contrast media tend to be associated with more adverse events than low or iso-osmolar nonionic contrast media. Limited data indicate that iodixanol may be associated with even less toxicity than low-osmolar contrast media. Radiopaque efficacy of the contrast media depends on the amount of iodine administered to the patient, and there appears to be no major difference in the efficacy of the various agents when equal amounts of iodine are given. Iodixanol is not for intrathecal use. Inadvertent intrathecal administration may cause death, convulsions/seizures, cerebral hemorrhage, coma, paralysis, arachnoiditis, acute renal failure, cardiac arrest, rhabdomyolysis, hyperthermia, and brain edema. Iodixanol can cause life-threatening or fatal hypersensitivity reactions; premedication with antihistamines or corticosteroids may reduce the incidence and severity of hypersensitivity reactions. Life-threatening or fatal cardiovascular reactions, including hypotension, shock, cardiac arrest, and acute kidney injury have also occurred with iodixanol use.
General Administration Information
For storage information, see specific product information within the How Supplied section.
-Patients should be well hydrated prior to and after iodixanol administration. A suggested common regimen in eligible patients (e.g., those patients in which fluid administration would not be contraindicated) is 1 mL/kg/hour of 0.9% Sodium Chloride Injection starting at least 4 hours prior to the procedure or exam and continuing for at least 12 hours after.
-In patients with a history of allergic reaction to contrast media or iodine, those with a history of asthma or allergic reactions to drugs or foods, nonionic contrast media should be used. In addition, consider administering prednisone 50 mg PO (or equivalent dose of other steroids) 13 hours, 7 hours, and 1 hour prior to the exam or procedure plus diphenhydramine 50 mg IM/PO 1 hour prior to the procedure. The administration of prophylactic steroids and antihistamines does not prevent all hypersensitivity reactions, but reduces the likelihood and may decrease the severity of the reaction.
-Use the lowest dose necessary to obtain adequate visualization. Individualize the volume, strength, and rate of administration of iodixanol injection. Consider factors such as age, body weight, vessel size, blood flow rate within the vessel, anticipated pathology, degree and extent of opacification required, structures or area to be examined, disease processes affecting the patient, and equipment and technique to be employed.
Route-Specific Administration
Injectable Administration
-Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
-Use aseptic technique for all handling and administration of iodixanol.
-Warm iodixanol and administer at body or room temperature.
-Do not mix iodixanol with, or inject in intravenous lines containing, other drugs or total nutritional admixtures.
-Avoid extravasation when injecting iodixanol, especially in patients with severe arterial or venous disease.
Intravenous Administration
Coronary computed tomography angiography (CCTA)
-Calibrate the intravenous injection rate so that image acquisition coincides with peak arterial concentration. The time between iodixanol injection and peak arterial concentration varies between patients.
-The main iodixanol volume may be preceded by a test bolus, immediately followed by a 20 mL saline flush, both injected at a rate of 4 to 7 mL/second.
-Iodixanol injection with saline can be either biphasic (without dilution phase) or triphasic (with dilution phase).
Automated contrast injection system
-Iodixanol may be used for computed tomography (CT) of the head and body, including CCTA, with an automated contrast injection system cleared for use with contrast media. See device labeling for information on device indications, instructions for use, and techniques to help assure safe use.
Contrast media management system
-Iodixanol 320 mg iodine/mL in 100 and 150 mL bottles may be used for CT of the head and body, including CCTA, with a contrast media management system cleared for such use. See device labeling for information on device indications, instructions for use, and techniques to help assure safe use.
-Clean the stopper with a pad soaked in sporicidal solution followed by a pad soaked in alcohol, then puncture the stopper. The container closure may be penetrated only 1 time with a suitable sterile component of the contrast media management system.
-Once the container is punctured, do not remove the bottle from the work area during the entire period of use.
-Storage: A maximum use time of 4 hours from initial closure entry is permitted. Each bottle is intended for 1 procedure only. Discard any unused portion.
Other Injectable Administration
Intra-Arterial Administration
-Use injection rates approximately equal to the flow rate of the vessel being injected.
Adverse reactions to contrast media can generally be classified as idiosyncratic (unpredictable, not related to dosage) or chemotoxic (related to dosage, osmolality, viscosity, hydrophilicity, etc.). Idiosyncratic reactions occur more frequently in patients 20 to 40 years old. Severe idiosyncratic reactions are life-threatening, and treatment is urgent and mandatory. Most patients tolerate contrast media injections without sequelae, and 95% of reactions to nonionic contrast media are mild to moderate; however, life-threatening reactions, usually cardiovascular in nature, can occur. The incidence of adverse reactions has been dramatically reduced by the introduction of low osmolar, nonionic contrast media. In a study of over 300,000 patients comparing intravenous administration of ionic vs. nonionic contrast media, adverse reactions were reduced from 12.66% with ionic contrast media to 3.13% (p less than 0.01) with nonionic contrast media. More importantly, the incidence of severe reactions (including shortness of breath, sudden drop in blood pressure, unconsciousness, and cardiopulmonary arrest) was reduced from 0.22% with ionic contrast media to 0.04% with nonionic contrast media (p less than 0.01).
Gastrointestinal adverse events reported in patients receiving iodixanol during clinical trials include diarrhea (0.6%), dyspepsia (0.5% or less), nausea (2.8%), and vomiting (0.8%). During postmarketing use of iodixanol, abdominal pain, pancreatitis, and salivary gland enlargement have been reported.
Regardless of the contrast agent employed, the overall estimated incidence of serious adverse reactions is higher with coronary arteriography than with other procedures. Hemodynamically, when contrast agents are injected intravascularly, arteriolar vasodilation and increases in left ventricular end-diastolic pressure occur secondary to intravascular volume expansion and depressed myocardial function. Also, patients become bradycardic and hypotensive. Electrophysiologic changes associated with the intracoronary injection of contrast media include depressed atrioventricular node conduction and sinoatrial node automaticity. In addition, patients are more susceptible to ventricular fibrillation or tachycardia. During clinical trials of iodixanol, arrhythmias (0.5% or less), chest pain (unspecified) or angina pectoris (2.2%), heart failure (0.5% or less), hypotension (0.5% or less), and myocardial infarction (0.5% or less) have been reported. A total of 3% of women and 0.8% of men reported chest pain. During postmarketing use of iodixanol, palpitations, spasms of the coronary arteries, and hypertension have been reported. In general, nonionic contrast media are associated with a lower incidence of severe cardiac and hemodynamic reactions, although some controversy exists. Not only do nonionic contrast media have fewer cardiac reactions, but the buffer/stabilizer used in iodixanol, edetate calcium disodium, does not bind calcium as avidly as stabilizers used in some ionic contrast media. The use of edetate calcium disodium is an additional factor leading to less cardiovascular toxicity with iodixanol.
Life-threatening or fatal cardiovascular reactions, including hypotension, shock, and cardiac arrest, have occurred with the use of iodixanol. Most deaths occur during injection or 5 to 10 minutes later, with cardiovascular disease as the main aggravating factor. Cardiac decompensation, serious arrhythmias, and myocardial ischemia or infarction can occur during coronary arteriography and ventriculography. If nausea or vomiting occurs during injection, the injection rate should be slowed or stopped. Based on clinical literature, reported deaths from the administration of iodinated contrast agents range from 6.6 per million (0.00066%) to 1 in 10,000 (0.01%). Monitor all patients for severe cardiovascular reactions.
Edema was reported in 0.6% of patients treated with iodixanol during clinical trials. Back pain, fatigue, and malaise were reported in 0.5% or less of iodixanol-treated patients. Chills and fever have been reported during postmarketing use of iodixanol.
Iodixanol can cause life-threatening or fatal hypersensitivity reactions, including anaphylaxis. Manifestations include respiratory arrest, laryngospasm, bronchospasm, angioedema, and shock. Hypersensitivity reactions including anaphylactoid reactions can occur in up to 15% of patients receiving iodixanol similar to other contrast media. The incidence of severe anaphylactoid reactions is 0.04% to 0.22%. Those patients at higher risk for hypersensitivity-type reactions are those with asthma, a history of allergies to drugs or foods, and those with a history of previous contrast media hypersensitivity. Most reactions occur within 1 to 3 minutes, but delayed hypersensitivity reactions can occur as long as 3 days to 1 week after administration of contrast media. Symptoms of hypersensitivity range from mild including nasal congestion, sneezing, itching, pruritus, and rash to severe including urticaria, swelling, laryngeal edema, bronchospasm, wheezing, and anaphylactic shock. The incidence of delayed hypersensitivity is less than 4% with the most common presentation being maculopapular rash; other symptoms such as urticaria and angioedema may also be present. Nonurticarial rash or erythema (2.1%), pruritus (1.6%), and urticaria (0.5%) were reported in patients treated with iodixanol during clinical trials. Pharyngeal edema and flushing were reported in 0.5% or less of iodixanol-treated patients. Hypersensitivity reactions, anaphylactic shock (including life-threatening or fatal anaphylaxis), cough, sneezing, throat irritation or tightness, laryngeal edema, pharyngeal edema, and bronchospasm have been reported during postmarketing use of iodixanol. Premedication with antihistamines or corticosteroids may reduce the incidence and severity of hypersensitivity reactions.
The administration of contrast media is associated with nephrotoxicity. The definition of contrast-induced nephrotoxicity (CIN) varies but is generally recognized as a rise in serum creatine of 25% to 50% or more or more than 0.5 mg/dL over baseline. Symptoms of nephrotoxicity can range from elevations in serum creatinine to oliguria, anuria, and acute renal failure requiring dialysis. The incidence of nephrotoxicity is difficult to estimate as clinical trials have varied with respect to the definition of nephrotoxicity, procedure, volume of contrast media, and patient risk factors. Studies have suggested an incidence of 10% or less in patients with normal renal function; in patients with various risk factors, the incidence rises to anywhere from 12% to 50%. A clinical trial comparing the incidence of nephrotoxicity between iodixanol (an iso-osmolar contrast medium) and iohexol (a low-osmolar contrast medium) in patients at the highest risk of nephrotoxicity (diabetes mellitus with renal insufficiency) undergoing angiography found that the use of iodixanol was associated with a reduced incidence of CIN (defined as a rise in serum creatinine of 0.5 mg/dL or more); the incidence of CIN in the iohexol group was 26% compared to 3% in the iodixanol group (p = 0.002). The mechanism for reduced renal toxicity associated with iodixanol is unknown; however, it may be related to the osmolality. Treatment of acute renal failure from contrast media is supportive; dialysis is indicated only if clinically needed. If a patient requires another procedure or exam requiring contrast media, allow renal function to return to baseline and ensure the patient is well hydrated before reexamination. Abnormal renal function, acute renal failure (unspecified), and hematuria were reported in 0.5% or less of iodixanol-treated patients during clinical trials.
Iodine-containing contrast medium can adversely affect thyroid function, resulting in either hypothyroidism or hyperthyroidism. Hypothyroidism or transient thyroid suppression has been reported in 1% to 15% of young pediatric patients (age birth to 3 years), with the incidence depending on the age of the patient and the dose of the iodinated contrast agent. Monitor young pediatric patients closely for thyroid dysfunction. If thyroid dysfunction is detected, treat and monitor thyroid function as clinically needed. Thyroid storm has occurred after the intravascular use of iodinated contrast agents in patients with hyperthyroidism, or with an autonomously functioning thyroid nodule.
Neurologic adverse events reported in more than 0.5% of patients receiving iodixanol during clinical trials include agitation (0.8%), anxiety (0.8%), insomnia (0.8%), nervousness (0.8%), dizziness (0.7%), headache or migraine (2.5%), paresthesias (1%), sensory disturbance (0.8%), syncope (0.6%), and vertigo (2.4%). Other nervous system adverse events occurring in 0.5% or less of iodixanol-treated patients include cerebral vascular disorder, convulsions or seizures, hypoesthesia, stupor, and confusion. During postmarketing use of iodixanol, coma, loss of consciousness, and transient tremor and have been reported. Extravasation of the contrast media has caused transient contrast-induced encephalopathy, including amnesia, hallucinations, muscle paralysis, paresis, transient speech disorder, aphasia, and dysarthria.
An injection site reaction, including extravasation, has been reported during postmarketing use of iodixanol. Extravasation of iodixanol may cause tissue necrosis and/or compartment syndrome. Iodixanol is often associated with sensations of discomfort, warmth, or pain. In a subgroup of 1,259 patients, 30% who received iodixanol or a comparator had application site discomfort, pain, warmth, or cold. Iodixanol had a trend toward fewer patient reports of moderate or severe pain or warmth. Pain was reported in 2% of patients receiving iodixanol and 10% of patients receiving a comparator. Heat was reported in 29% of patients receiving iodixanol and 51% of patients receiving a comparator. This side effect is thought to be due to peripheral vasodilation and is related to the osmolality of the contrast media. The frequency of such sensations has been reduced with the use of nonionic contrast media. Injection site reaction, including swelling and erythema, is most often due to extravasation of the contrast medium. The symptoms generally diminish rapidly. However, skin necrosis, tissue necrosis, and ulceration have been reported with large volumes of extravasated contrast medium. If extravasation occurs, elevate the affected limb. In addition, heat or cold applied to the affected area has been reported to be successful in relieving extravasation.
Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN), acute generalized exanthematous pustulosis (AGEP), and drug reaction with eosinophilia and systemic symptoms (DRESS) have been reported during postmarketing use of iodixanol. Severe cutaneous adverse reactions may develop from 1 hour to several weeks after intravascular contrast agent administration. Reaction severity may increase and time to onset may decrease with repeat administration of contrast agents; prophylactic medications may not prevent or mitigate severe cutaneous adverse reactions.
Special senses adverse events reported in patients receiving iodixanol during clinical trials include parosmia (0.5%), dysgeusia (3.5%), scotomata (1.1%), tinnitus (0.5% or less), and abnormal vision (0.5% or less). During postmarketing use of iodixanol, transient visual impairment, including cortical blindness, diplopia, and blurred vision, has been reported.
Serious, and potentially fatal, thromboembolism resulting in myocardial infarction and stroke can occur during angiocardiography procedures with both ionic and nonionic contrast media. During these procedures, increased thrombosis and activation of the complement system occurs. Peripheral ischemia was reported in 0.5% or less of patients treated with iodixanol during clinical trials.
Respiratory adverse events occurring in 0.5% or less of patients treated with iodixanol during clinical trials include asthma, bronchitis, dyspnea, pulmonary edema, and rhinitis.
Dermatologic adverse events occurring in 0.5% or less of patients treated with iodixanol during clinical trials include hematoma and hyperhidrosis. During postmarketing use of iodixanol, skin discoloration has been reported.
Hypertensive crisis has occurred after the use of iodinated contrast agents in patients with pheochromocytoma. Monitor patients when administering iodixanol if pheochromocytoma or catecholamine-secreting paragangliomas are suspected. Inject the minimum amount of contrast necessary, assess the blood pressure throughout the procedure, and have measures for treating a hypertensive crisis readily available.
Hypoglycemia has been reported during postmarketing use of iodixanol.
The usefulness of contrast enhancement with iodixanol for the investigation of the retrobulbar space and of low grade or infiltrative glioma has not been demonstrated. Calcified lesions are less likely to enhance. The enhancement of tumors after therapy may decrease. The opacification of the inferior vermis following contrast agent administration has resulted in false-positive diagnosis. Cerebral infarctions of recent onset may be better visualized with contrast enhancement. Older infarctions may be obscured by the contrast agent.
Iodinated contrast media may cross the blood-brain barrier and accumulate in patients where the blood-brain barrier is known or suspected to be disrupted or in patients with a normal blood-brain barrier and renal dysfunction. Caution must be exercised in the use of an iodinated contrast media in these populations as accumulation of contrast media in the brain can cause neurotoxicity. Iodinated contrast media can cause disruption of the blood-brain barrier; properties such as hyperosmolality and chemotoxicity may cause an increase in blood-brain barrier disruption. One study in rats, however, demonstrated that mannitol caused no damage to the blood-brain barrier, while the contrast media (iohexol, iodixanol, ioversol, or iotrolan all of which have osmolalities much lower than mannitol) caused damage to the blood-brain barrier; the authors felt that the damage to the blood-brain barrier was due to a property of the contrast media other than osmolality.
As is recommended with other iodinated contrast media, cerebral arteriography with iodixanol should be undertaken with extreme care in patients in poor clinical condition, of an advanced age, with advanced arteriosclerosis, with severe arterial hypertension, with recent cerebral embolism or thrombosis, and with cardiac decompensation.
As is recommended with other iodinated contrast media, peripheral arteriography with iodixanol should be performed with caution, if at all, in patients with severe ischemia; pulsation should be present in the artery to be injected.
Under conditions of slowed aortic circulation, there is an increased likelihood for aortography to cause muscle spasm. In addition, serious neurologic complications, including paraplegia, have been reported in patients with aortoiliac obstruction, femoral artery obstruction, abdominal compression, hypotension, hypertension, concomitant spinal anesthesia, and injection of vasopressors to increase contrast. As is recommended with other iodinated contrast media, in these patients, the concentration, volume, and number of repeat injections of iodixanol should be minimized with appropriate intervals between injections (to allow for correction of possible hemodynamic disturbances).
Serious, life-threatening, or fatal anaphylactoid or cardiovascular reactions have been reported with the use of contrast media such as iodixanol. The majority of severe reactions occur shortly after the start of the injection (within 3 minutes); however, reactions may develop up to hours later. Diagnostic procedures that involve the use of any radiopaque agent should be carried out under the direction of personnel with prerequisite training and a thorough knowledge of the particular procedure to be performed. Appropriate facilities should be available for coping with any complication of the procedure, as well as for emergency treatment of severe reaction to the contrast agent itself. After parenteral administration of a radiopaque agent, competent personnel and emergency facilities should be available for at least 30 to 60 minutes since severe delayed reactions may occur. Patients at increased risk of anaphylactoid reactions are those with a history of radiopaque contrast media hypersensitivity, iodine hypersensitivity, asthma, atopy (including hay fever, food allergies, and drug allergies), and underlying immune disorders including an autoimmune disease or immunodeficiency that predisposed patients to mediator release. The reported incidence of adverse reactions to contrast media in patients with a history of allergy is twice that of the general population. Patients with a history of a previous reaction to a contrast agent are 3-times more susceptible than other patients. Sensitivity to contrast media does not appear to increase with repeat exposure. Both acute and delayed hypersensitivity reactions have been reported after contrast media exposure. Acute hypersensitivity reactions to contrast media are thought to be mediated by the release of vasoactive substances such as histamine, serotonin and bradykinin; in contrast, delayed-hypersensitivity reactions that can occur as long as 3 to 7 days after contrast media exposure are most likely caused by antigen-antibody reactions. In addition, it appears that the incidence of hypersensitivity reactions is higher with intravenous administration of contrast media. The incidence of hypersensitivity reactions has been reduced with the use of nonionic contrast media. In patients at risk of hypersensitivity (including those patients with previous allergic reaction to contrast media), premedication with corticosteroids and antihistamines has been shown to reduce the incidence and severity of hypersensitivity reactions. Reportedly, 16% to 44% of patients with previous history of hypersensitivity reactions to contrast media will have an allergic reaction upon second exposure; utilizing nonionic contrast media and premedicating at-risk patients reduces the incidence of hypersensitivity during repeat exposure to 10%. Pre-testing patients for the likelihood of an allergic type reaction is not recommended as it is not reliable and it may be dangerous to the patient. Patients with a history of allergy or drug reaction should be observed for several hours after contrast media administration.
Serious, rarely fatal, thromboembolic events causing myocardial infarction and stroke have been reported during angiographic procedures with ionic and nonionic contrast media. Meticulous intravascular administration technique has reduced the incidence of such complications; however, controversy exists as to whether nonionic contrast media such as iodixanol are more thrombogenic than ionic contrast media. The American College of Cardiology has recommended to consider the concomitant administration of heparin to patients when nonionic agents were used; however, this recommendation has been refuted by some authors as they believe the procedure itself is thrombogenic, not the contrast media (i.e., clots forming on the catheters and guidewires, catheter manipulation causing existing plaques to dislodge, or damage/perforation of the vessel wall). Because many factors contribute to thromboembolic events including length of procedure, catheter and syringe material, underlying disease states, and concomitant medications, meticulous intravascular technique is necessary to minimize thromboembolic events. Measures that should be considered to minimize this risk include close attention to guidewire and catheter manipulation, use of manifold systems or 3-way stopcocks, frequent catheter flushing with heparinized saline solutions, and minimizing the length of the procedure. Test injections to ensure proper catheter placement may also be prudent. Clotting has been reported when blood remains in contact with syringes containing nonionic contrast media; the use of plastic syringes in place of glass may minimize in vitro clotting. Special care is necessary when venography is performed in patients with suspected thromboembolic disease such as thrombosis or phlebitis, severe ischemic disease, or a totally obstructed venous system. Because of the increased risk of inducing thrombosis or embolism associated with the procedure, angiography should be avoided whenever possible in patients at increased risk of thromboembolism (including those with a coagulopathy or homocystinuria).
Both ionic and nonionic contrast media can cause nephrotoxicity including acute renal failure sometimes requiring dialysis. The definition of contrast-induced nephrotoxicity (CIN) varies but is generally recognized as a rise in serum creatinine of at least 25% to 50% or more than 0.5 mg/dL over baseline. Risk factors for CIN include advanced age, pre-existing renal impairment (usually defined as a creatinine clearance less than 50 to 60 mL/minute), combined renal disease and hepatic disease, concurrent use of nephrotoxic or diuretic medications, diabetes mellitus, dehydration, ejection fraction 40% or less, females, excretory urography, repeat contrast media exposure within 72 hours, reduced effective arterial volume (i.e., cirrhosis and nephrosis), contrast media type (e.g., ionic contrast media is associated with a higher incidence of CIN than nonionic), and contrast media dose (e.g., higher doses of contrast media are associated with more nephrotoxicity). The patient's risk factors should be taken into consideration before administering contrast during an exam or procedure as the presence of multiple risk factors increases the risk for CIN considerably. The most compelling risk factors for CIN are pre-existing renal impairment, and pre-existing renal impairment plus diabetes mellitus. It may be prudent for all patients with a history of renal insufficiency, diabetes mellitus, or advanced age to have a baseline creatinine clearance calculated prior to the procedure or exam. Preventive measures should be considered in all patients regardless of risk factors. Adequate hydration has repeatedly been the only intervention to show success in reducing the incidence of CIN. In addition to hydration, the use of nonionic contrast media and avoiding the concomitant use of nephrotoxic drugs (i.e., non-steroidal anti-inflammatory drugs, aminoglycosides, etc.), laxatives, and diuretics may be prudent. Patients with diabetes mellitus and renal insufficiency that received iodixanol (an iso-osmolar, nonionic contrast media) had a much lower incidence of CIN when compared to iohexol (a low-osmolar, nonionic contrast media); the incidence of CIN in patients that received iodixanol was 3% compared to 26% in patients that received iohexol (p = 0.002). The reason for the reduced incidence of CIN with iodixanol is unknown; but it is thought to be possibly due to the lower osmolality. Several studies have evaluated the use of n-acetylcysteine (600 mg PO twice daily for 2 days given the day prior to and the day of the procedure or exam); while conflicting data exists, it appears that n-acetylcysteine may provide some benefit in preventing CIN in high-risk patients. Furthermore, some data indicate that the effects of n-acetylcysteine may be dose-dependent. In patients with myocardial infarction undergoing angioplasty, n-acetylcysteine 1,200 mg IV prior to angioplasty followed by 1,200 mg PO twice daily for 48 hours has been reported to be significantly more effective at reducing the incidence of CIN vs. a lower dose or placebo. Other interventions including administration of loop diuretics, calcium antagonists, mannitol, theophylline, or low-dose dopamine have not been successful. Iodinated contrast media may cross the blood-brain barrier and accumulate in patients where the blood-brain barrier is known or suspected to be disrupted or in patients with a normal blood-brain barrier and renal impairment.
Intrathecal administration of iodixanol is contraindicated. Severe and fatal neurotoxic adverse reactions including convulsions or seizures, cerebral hemorrhage, coma, paralysis, arachnoiditis, hyperthermia, brain edema, and death have been reported when inadvertent intrathecal administration of nonionic contrast media occurs. In addition, renal failure, cardiac arrest, and rhabdomyolysis have been reported.
Iodixanol should be used cautiously in patients with multiple myeloma or other paraproteinaceous diseases who are prone to disease-induced renal insufficiency or renal failure; anuria has been reported in this group of patients after receiving contrast media. Although originally thought to be a contraindication to receiving contrast media, it is recognized that the occurrence of anuria or renal impairment in patients with multiple myeloma is probably due to a pre-existing state of dehydration rather than an interaction between the disease itself and the contrast media. If the need arises, patients with multiple myeloma can receive contrast media, but they should be closely monitored and well hydrated prior to the procedure or exam. In addition, partial dehydration may predispose this population of patients to precipitation of the myeloma protein in the renal tubules further increasing the risk of nephrotoxicity. No form of therapy has been effective in reversing this effect.
Use iodixanol in patients with sickle cell disease only if the necessary imaging information cannot be obtained with alternative modalities. If iodixanol use is necessary in these patients, hydrate patients prior to and after iodixanol administration. Intravascular administration of iodinated contrast agents, such as iodixanol, may promote sickling in individuals who are homozygous for sickle cell disease.
Life-threatening and fatal cardiovascular reactions (i.e., hypotension, shock, cardiac arrest) have been reported with the use iodixanol. The majority of fatal reactions occur during injection or within the first 5 to 10 minutes, with cardiovascular disease as the main aggravating factor. In addition, cardiac decompensation, serious arrhythmias, and myocardial ischemia or infarction can occur during coronary arteriography and ventriculography; therefore, use the lowest necessary dose of iodixanol in patients with congestive heart failure. Those patients receiving diuretic therapy may have relative intravascular volume depletion. Furthermore, patients with heart failure are at risk of fluid overload and may not be able to tolerate the recommended hydration regimen used in the prevention of contrast-induced nephropathy (CIN). In addition, while iodixanol is considerably less hyperosmolar when compared to the ionic agents such as diatrizoate, iodixanol can cause a transient increase in circulatory volume; patients receiving diuretic therapy may not have a normal renal response to the osmotic load. In a study evaluating the effects of n-acetylcysteine on the prevention of CIN, patients with left ventricular ejection fractions of 40% or less developed CIN at a rate of almost 3-times that of patients with an ejection fraction of more than 40%. The combination of low ejection fraction and a creatinine clearance 60 mL/minute or less was associated with a 5-times increased incidence of CIN. Diagnostic procedures that involve the use of any radiopaque agent should be carried out under the direction of personnel with prerequisite training and a thorough knowledge of the particular procedure to be performed. Appropriate facilities should be available for coping with any complication of the procedure, as well as for emergency treatment of severe reaction to the contrast agent itself. After parenteral administration of iodixanol, competent personnel and emergency facilities should be available for at least 30 to 60 minutes since severe delayed reactions may occur. Closely monitor patients with congestive heart failure for several hours.
The administration of ionic contrast media has been associated with an unpredictable release of catecholamines and severe hypertensive crisis in patients with pheochromocytoma. If the use of contrast media is determined to be necessary, nonionic contrast media such as iodixanol should be used preferentially and the volume of contrast media used should be minimized. In addition, blood pressure should be measured throughout the procedure with equipment necessary to treat a hypertensive crisis available. In the past, the use of alpha-blockers and potentially even beta-blockers prior to the administration of contrast media in patients with known pheochromocytoma has been recommended by some authors; however recent evidence indicates that such preventive measures may not be necessary when using nonionic contrast media as the risk for hypertensive crisis is lessened.
Administration of iodixanol may result in adverse effects on the thyroid. Reports of thyroid storm have been associated with the use of iodinated radiopaque diagnostic agents in patients with preexisting thyroid disease such as hyperthyroidism, thyrotoxicosis, or an autonomously functioning thyroid nodule. Because the frequency of autonomous thyroid nodules increases with age, older patients may be at increased risk for developing a thyroid storm. Conversely, transient thyroid suppression has been infrequently reported in both adult and pediatric populations. In some cases, drug recipients required treatment for hypothyroidism. Prior to administering iodixanol, evaluate all patients for thyroid-associated risk factors.
Take care to avoid extravasation during administration of iodixanol, especially in those patients with arterial insufficiency, compromised venous drainage, or compromised lymphatic systems. Ensure intravascular placement of the catheter prior to drug administration. Extravasation of nonionic contrast media is better tolerated than ionic contrast media; however, severe reactions have been reported with both types of media. If extravasation occurs, the affected limb should be elevated. In addition, heat or cold applied to the affected area has been reported to be successful in treating extravasation.
Contrast agents are associated with risk and increased radiation exposure. Base the decision to use iodixanol upon a careful evaluation of clinical, other radiological data, and the results of non-contrast computed tomography (CT) findings, taking into account the increased radiation dose and other risks. In addition, use of iodinated contrast media may obscure some lesions which were previously observed on non-contrast CT scans.
Avoid use of iodixanol in patients with a history of contrast-induced serious rash. Iodinated contrast agents have been associated with severe cutaneous adverse reactions, including Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), acute generalized exanthematous pustulosis (AGEP), and drug reaction with eosinophilia and systemic symptoms (DRESS). The reaction onset ranges from 1 hour to several weeks after intravascular drug administration; however, repeat drug exposure may shorten the time to onset and increase the reaction severity. Prophylactic medications may not prevent or mitigate these reactions.
Iodinated contrast agents cause laboratory test interference with certain thyroid function tests. Results of protein-bound iodine (PBI) and radioactive iodine uptake studies, which depend on iodine estimations, will not accurately reflect thyroid function for up to 16 days after administration of iodinated contrast media such as iodixanol. However, thyroid function tests that do not depend on iodine estimations (e.g., T3 resin uptake and total or free thyroxine (T4) assays) are not affected. As reported with other contrast agents, iodixanol may produce a false-positive result for protein in the urine using urine dip tests. However, the Coomassie blue method has been shown to give accurate results for the measurement of urine protein in the presence of iodixanol. Also, take care in interpreting the results of urine specific gravity measurements in the presence of high concentrations of iodixanol and other contrast agents in the urine. Refractometry or urine osmolality may be substituted.
In general, dose selection for a geriatric patient should be cautious usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
Evaluate thyroid function based on underlying risk factors in neonates, infants, and children 3 years or younger after exposure to an iodinated contrast media, especially in term and premature neonates. Hypothyroidism or transient thyroid suppression has been reported in pediatric patients (age birth to 3 years) after both single and multiple exposures to iodinated contrast media, such as iodixanol. Younger age, very low birth weight, prematurity, underlying medical conditions affecting thyroid function, admission to neonatal or pediatric intensive care units, and congenital cardiac conditions are associated with increased risk for hypothyroidism or thyroid suppression. Pediatric patients with congenital cardiac conditions may be at the greatest risk as they often require high doses of contrast during invasive cardiac procedures, such as catheterization and computed tomography (CT). An underactive thyroid during early life may be harmful for cognitive and neurological development and may require thyroid hormone replacement therapy. Pediatric patients at higher risk of experiencing an adverse reaction during and after administration of any contrast agent may include those with asthma, hypersensitivity to other medication and/or allergens, cyanotic and acyanotic heart disease, congestive heart failure, a serum creatinine more than 1.5 mg/dL, immature renal function, dehydration, or those younger than 12 months.
There are no data with iodixanol in pregnant women to inform a drug-associated risk. In animal reproduction studies in rats and rabbits, developmental toxicity was not observed at doses up to 0.24- or 0.48-times the maximum recommended human dose. The American College of Radiology (ACR) manual on contrast media states that iodinated contrast crosses the human placenta and enters the fetus in measurable quantities; however, the risk to the fetus is unknown. Therefore, the ACR recommends iodinated contrast agents be administered during pregnancy only if necessary and only after informed consent is obtained. In contrast, the Guidelines for Computed Tomography and Magnetic Resonance Imaging in Pregnancy and Lactation state that use of iodinated contrasts during pregnancy appears to be safe and should be administered as per usual. It is advised to screen neonates whose mother received iodinated contrast during pregnancy for hypothyroidism.
There are no data on the presence of iodixanol in human milk, the effects on the breast-fed infant, or the effects on milk production. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for iodixanol and any adverse effects on the breast-fed infant from the drug or the underlying maternal condition. Consider interrupting breast-feeding and pumping and discarding breast milk for 10 hours (approximately 5 half-lives) after iodixanol administration to minimize exposure to a breast-fed infant. The Guidelines for Computed Tomography and Magnetic Resonance Imaging Use During Pregnancy and Lactation and the American College of Radiology (ACR) manual on contrast media state that lactating women receiving iodinated contrast can continue breast-feeding without interruption. The reasoning for this recommendation is based on estimates of limited systemic exposure in breast-fed infants and reviews that conclude maternally administered iodinated contrast pose no risk to nursing infants.
Patients should be well hydrated prior to and following iodixanol administration. A suggested common regimen in eligible patients (e.g., those patients in which fluid administration would not be contraindicated) is 1 mL/kg/hour of 0.9% Sodium Chloride Injection starting at least 4 hours prior to the procedure or exam and continuing for at least 12 hours after.
NOTE: In patients with a history of allergic reaction to contrast media or iodine, those with a history of asthma or allergic reactions to drugs or foods, nonionic contrast media should be used. In addition, consider administering prednisone 50 mg PO (or equivalent dose of other steroids) 13 hours, 7 hours, and 1 hour prior to the exam or procedure plus diphenhydramine 50 mg IM/PO 1 hour prior to the procedure. The administration of prophylactic steroids and antihistamines does not prevent all hypersensitivity reactions, but reduces the likelihood and may decrease the severity of the reaction.
NOTE: Only the lowest dose of iodixanol necessary to obtain adequate visualization should be used. Using lower doses reduces the risk of adverse reactions. The dose and concentration of iodixanol, age of the patient, patient's body weight, size of the vessel and its blood flow, pathology and degree and extent of opacification required, area to be examined, the patient's disease states, and equipment or technique to be employed should all be considered when determining the necessary dose.
For use as contrast in angiography:
-for use as a contrast in cerebral arteriography:
Intra-arterial dosage (320 mg iodine/mL):
Adults: 10 to 14 mL/injection intra-arterially for visualization of the carotid arteries and 10 to 12 mL/injection intra-arterially for visualization of the vertebral arteries. Do not exceed a total volume of 175 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Children and Adolescents 12 to 17 years: 10 to 14 mL/injection intra-arterially for visualization of the carotid arteries and 10 to 12 mL/injection intra-arterially for visualization of the vertebral arteries. Do not exceed a total volume of 175 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Infants and Children 1 to 11 years: 1 to 2 mL/kg/dose intra-arterially. Do not exceed a total dose of 4 mL/kg.
Neonates: 1 to 2 mL/kg/dose intra-arterially. Do not exceed a total dose of 4 mL/kg.
-for use as a contrast in angiocardiography including left ventriculography and coronary arteriography:
Intra-arterial dosage (320 mg iodine/mL):
Adults: 3 to 10 mL/injection intra-arterially for visualization of the left coronary artery; 3 to 8 mL/injection intra-arterially for visualization of the right coronary artery; and 20 to 45 mL/injection intra-arterially for visualization of the left ventricle. Do not exceed a total volume of 200 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected. When using large volumes as a single injection (i.e., during ventriculography), allow several minutes to lapse between repeat injections to allow for correction of possible hemodynamic disturbances. Routinely monitor ECG and vital signs during this procedure.
Children and Adolescents 12 to 17 years: 3 to 10 mL/injection intra-arterially for visualization of the left coronary artery; 3 to 8 mL/injection intra-arterially for visualization of the right coronary artery; and 20 to 45 mL/injection intra-arterially for visualization of the left ventricle. Do not exceed a total volume of 200 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected. When using large volumes as a single injection (i.e., during ventriculography), allow several minutes to lapse between repeat injections to allow for correction of possible hemodynamic disturbances. Routinely monitor ECG and vital signs during this procedure.
Infants and Children 1 to 11 years: 1 to 2 mL/kg/dose intra-arterially. Do not exceed a total dose of 4 mL/kg.
Neonates: 1 to 2 mL/kg/dose intra-arterially. Do not exceed a total dose of 4 mL/kg.
-for use as contrast in aortography:
Intra-arterial dosage (320 mg iodine/mL):
Adults: 30 to 70 mL/injection intra-arterially for visualization of the aorta and 10 to 70 mL/injection intra-arterially for visualization of the major branches of the aorta. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected. When using large volumes as a single injection (i.e., during aortography), allow several minutes to lapse between repeat injections to allow for correction of possible hemodynamic disturbances.
Children and Adolescents 12 to 17 years: 30 to 70 mL/injection intra-arterially for visualization of the aorta and 10 to 70 mL/injection intra-arterially for visualization of the major branches of the aorta. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected. When using large volumes as a single injection (i.e., during aortography), allow several minutes to lapse between repeat injections to allow for correction of possible hemodynamic disturbances.
-for use as a contrast in visceral arteriography:
Intra-arterial dosage (320 mg iodine/mL):
Adults: 8 to 18 mL/injection intra-arterially for visualization of the renal arteries. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected. When using large volumes as a single injection (i.e., during ventriculography or aortography), allow several minutes to lapse between repeat injections to allow for correction of possible hemodynamic disturbances.
Children and Adolescents 12 to 17 years: 8 to 18 mL/injection intra-arterially for visualization of the renal arteries. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected. When using large volumes as a single injection (i.e., during ventriculography or aortography), allow several minutes to lapse between repeat injections to allow for correction of possible hemodynamic disturbances.
Infants and Children 1 to 11 years: 1 to 2 mL/kg/dose intra-arterially. Do not exceed a total dose of 4 mL/kg.
Neonates: 1 to 2 mL/kg/dose intra-arterially. Do not exceed a total dose of 4 mL/kg.
-for use as a contrast in peripheral arteriography:
Intra-arterial dosage (320 mg iodine/mL):
Adults: 20 to 90 mL/injection intra-arterially for visualization of the aortofemoral runoffs and 15 to 30 mL/injection intra-arterially for visualization of peripheral arteries. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Children and Adolescents 12 to 17 years: 20 to 90 mL/injection intra-arterially for visualization of the aortofemoral runoffs and 15 to 30 mL/injection intra-arterially for visualization of peripheral arteries. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
-for use as a contrast in peripheral venography:
Intravenous dosage (270 mg iodine/mL):
Adults: 50 to 150 mL IV per lower extremity. Do not exceed a total volume of 250 mL.
Children and Adolescents 12 to 17 years: 50 to 150 mL IV per lower extremity. Do not exceed a total volume of 250 mL.
For use as a contrast in excretory urography:
Intravenous dosage (270 mg iodine/mL):
Adults: 1 mL/kg/dose IV. Do not exceed a total volume of 100 mL/dose.
Children and Adolescents 12 to 17 years: 1 mL/kg/dose IV. Do not exceed a total volume of 100 mL/dose.
Infants and Children 1 to 11 years: 1 to 2 mL/kg/dose IV. Do not exceed 2 mL/kg/dose.
Neonates: 1 to 2 mL/kg/dose IV. Do not exceed 2 mL/kg/dose.
Intravenous dosage (320 mg iodine/mL):
Adults: 1 mL/kg/dose IV. Do not exceed a total volume of 100 mL/dose.
Children and Adolescents 12 to 17 years: 1 mL/kg/dose IV. Do not exceed a total volume of 100 mL/dose.
For use as contrast during computed tomography (CT) imaging of the head and body:
Intravenous dosage (270 mg iodine/mL):
Adults: 75 to 150 mL IV bolus. Alternatively, 100 to 150 mL rapid IV infusion. Do not exceed a total volume of 150 mL/dose.
Children and Adolescents 12 to 17 years: 75 to 150 mL IV bolus. Alternatively, 100 to 150 mL rapid IV infusion. Do not exceed a total volume of 150 mL/dose.
Infants and Children 1 to 11 years: 1 to 2 mL/kg/dose IV. Do not exceed 2 mL/kg/dose.
Neonates: 1 to 2 mL/kg/dose IV. Do not exceed 2 mL/kg/dose.
Intravenous dosage (320 mg iodine/mL):
Adults: 75 to 150 mL IV bolus. Alternatively, 100 to 150 mL rapid IV infusion. Do not exceed a total volume of 150 mL/dose.
Children and Adolescents 12 to 17 years: 75 to 150 mL IV bolus. Alternatively, 100 to 150 mL rapid IV infusion. Do not exceed a total volume of 150 mL/dose.
For use as a contrast in coronary computed tomography angiography (CCTA) to assist in coronary artery disease diagnosis:
Intravenous dosage (320 mg iodine/mL):
Adults: 50 to 150 mL IV bolus with test bolus or bolus tracking. The main dose volume may be preceded by a 20 mL IV test bolus, immediately followed by a 20 mL saline flush, both administered at a rate of 4 to 7 mL/second. Do not exceed a total volume of 150 mL. Injection of iodixanol with saline can be either biphasic (without dilution phase) or triphasic (with dilution phase). Alternatively, 1 mL/kg/dose may be used to calculate total dose (excluding any test bolus). For CCTA acquired at less than 120 kVp, may reduce dose by up to 15% in patients weighing less than 85 kg and with a BMI less than 30 kg/m2. For CCTA acquired on a scanner with more than 64 detector rows, may reduce dose in proportion to the scan duration.
Children and Adolescents 12 to 17 years: 50 to 150 mL IV bolus with test bolus or bolus tracking. The main dose volume may be preceded by a 20 mL IV test bolus, immediately followed by a 20 mL saline flush, both administered at a rate of 4 to 7 mL/second. Do not exceed a total volume of 150 mL. Injection of iodixanol with saline can be either biphasic (without dilution phase) or triphasic (with dilution phase). Alternatively, 1 mL/kg/dose may be used to calculate total dose (excluding any test bolus). For CCTA acquired at less than 120 kVp, may reduce dose by up to 15% in patients weighing less than 85 kg and with a BMI less than 30 kg/m2. For CCTA acquired on a scanner with more than 64 detector rows, may reduce dose in proportion to the scan duration.
For use as a contrast in intra-arterial digital subtraction angiography (DSA):
-for visualization of the carotid or vertebral arteries:
Intra-arterial dosage (320 mg iodine/mL):
Adults: 5 to 8 mL/injection intra-arterially. Do not exceed a total volume of 175 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Children and Adolescents 12 to 17 years: 5 to 8 mL/injection intra-arterially. Do not exceed a total volume of 175 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
-for visualization of the renal arteries:
Intra-arterial dosage (270 mg iodine/mL):
Adults: 10 to 25 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Children and Adolescents 12 to 17 years: 10 to 25 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
-for visualization of the aorta (aortography):
Intra-arterial dosage (270 mg iodine/mL):
Adults: 20 to 50 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Children and Adolescents 12 to 17 years: 20 to 50 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Intra-arterial dosage (320 mg iodine/mL):
Adults: 10 to 50 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Children and Adolescents 12 to 17 years: 10 to 50 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
-for visualization of the major branches of the aorta:
Intra-arterial dosage (270 mg iodine/mL):
Adults: 5 to 30 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Children and Adolescents 12 to 17 years: 5 to 30 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Intra-arterial dosage (320 mg iodine/mL):
Adults: 2 to 10 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Children and Adolescents 12 to 17 years: 2 to 10 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
-for visualization of the aortofemoral runoffs:
Intra-arterial dosage (320 mg iodine/mL):
Adults: 6 to 15 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Children and Adolescents 12 to 17 years: 6 to 15 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
-for visualization of the peripheral arteries:
Intra-arterial dosage (320 mg iodine/mL):
Adults: 3 to 15 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Children and Adolescents 12 to 17 years: 3 to 15 mL/injection intra-arterially. Do not exceed a total volume of 250 mL. Administer at a rate approximately equal to the flow rate in the vessel being injected.
Maximum Dosage Limits:
-Adults
Do not exceed the recommended volume/concentration for the particular intravascular indication; the maximum recommended total dose of iodine per procedure is 80 g.
-Geriatric
Do not exceed the recommended volume/concentration for the particular intravascular indication; the maximum recommended total dose of iodine per procedure is 80 g.
-Adolescents
Do not exceed the recommended volume/concentration for the particular intravascular indication.
-Children
12 years: Do not exceed the recommended volume/concentration for the particular intravascular indication.
1 to 11 years: Do not exceed the recommended volume/concentration for the particular intravascular indication. 2 mL/kg IV of 270 mg iodine/mL; 4 mL/kg intra-arterial of 320 mg iodine/mL.
-Infants
Do not exceed the recommended volume/concentration for the particular intravascular indication. 2 mL/kg IV of 270 mg iodine/mL; 4 mL/kg intra-arterial of 320 mg iodine/mL.
-Neonates
Do not exceed the recommended volume/concentration for the particular intravascular indication. 2 mL/kg IV of 270 mg iodine/mL; 4 mL/kg intra-arterial of 320 mg iodine/mL.
Patients with Hepatic Impairment Dosing
Specific guidelines for dosage adjustment in hepatic impairment are not available; however, it appears no dosage adjustments are needed.
Patients with Renal Impairment Dosing
Specific guidelines for dosage adjustment in renal impairment are not available; however, iodixanol can cause acute renal failure and this risk is higher in patients with underlying renal insufficiency. Patients with renal insufficiency should be well-hydrated and the smallest volume of contrast media should be used.
*non-FDA-approved indication
Acebutolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Acetaminophen; Aspirin, ASA; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Acetaminophen; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Acetaminophen; Caffeine; Dihydrocodeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Acetaminophen; Caffeine; Pyrilamine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acetaminophen; Chlorpheniramine; Phenylephrine : (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acetaminophen; Dextromethorphan; Guaifenesin; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acetaminophen; Dextromethorphan; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acetaminophen; Guaifenesin; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acetaminophen; Ibuprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Acetaminophen; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acyclovir: (Moderate) Concomitant use of acyclovir and contrast agents should be avoided when possible, as use of these drugs together may increase the risk for nephrotoxicity.
Aldesleukin, IL-2: (Moderate) Monitor patients for delayed aldesleukin "recall" reactions in patients receiving iodinated contrast media after aldesleukin therapy. Symptom onset is typically from 1 to 4 hours after administration of iodinated contrast media and may resemble aldesleukin-related infusion reactions including fever, chills, nausea, vomiting, pruritus, rash, diarrhea, hypotension, edema, and oliguria. While most common when contrast media is given within 4 weeks of the last dose of aldesleukin, reports have also occurred when contrast media was administered several months after aldesleukin treatment.
Aliskiren; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Alogliptin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Amikacin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Amiloride: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Amiloride; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Aminoglycosides: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Amiodarone: (Major) When injected directly into coronary arteries, contrast media can cause bradycardia and QT interval prolongation; these reactions tend to be less common with nonionic low-osmolar contrast media. In a retrospective review of 21 patients on amiodarone therapy who underwent cardiac catheterization with iohexol, the QTc interval was significantly prolonged 12-24 hours post catheterization from a baseline QTc interval of 433 msec (95%CI 419-483 msec) to 480 msec (95%CI, 422-483 msec) (p< 0.001). No significant change in the QTc interval was seen in non-amiodarone treated control patients. Until more data are available, clinicians should closely monitor patients taking amiodarone during cardiac catheterization with radiopaque contrast agents; EKG monitoring during intra-coronary artery injection of radiopaque contrast agents is recommended.
Amitriptyline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Amlodipine; Benazepril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Amlodipine; Celecoxib: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Amoxapine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Amoxapine should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Amphetamine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Amphetamines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Amphetamine; Dextroamphetamine Salts: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Amphetamines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Amphetamine; Dextroamphetamine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Amphetamines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Amphotericin B: (Moderate) Because the use of other nephrotoxic drugs, including amphotericin B, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Angiotensin II: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Angiotensin-converting enzyme inhibitors: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Aprotinin: (Moderate) The manufacturer recommends using aprotinin cautiously in patients that are receiving drugs that can affect renal function, such as radiopaque contrast agents, as the risk of renal impairment may be increased.
Aripiprazole: (Major) Aripiprazole lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Articaine; Epinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Asenapine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure. The frequency of seizure activity with asenapine was low during clinical trials; however, seizures have been associated with other antipsychotics and caution is advised.
Aspirin, ASA; Butalbital; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Aspirin, ASA; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Aspirin, ASA; Caffeine; Orphenadrine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Atenolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Atenolol; Chlorthalidone: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Azilsartan; Chlorthalidone: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Barium Sulfate: (Major) Delay the administration of non-ionic contrast media in patients who have recently received an oral cholecystographic contrast agent, such as barium. Renal toxicity has been reported in patients with liver dysfunction who were given an oral cholecystographic agent followed by intravascular iodinated contrast agents.
Benazepril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Benazepril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Benzphetamine: (Major) Sympathomimetics lower the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Beta-blockers: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Betaxolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Bictegravir; Emtricitabine; Tenofovir Alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Bisoprolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Brexpiprazole: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics such as brexpiprazole should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post procedure.
Brimonidine; Timolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Brompheniramine; Dextromethorphan; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Brompheniramine; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Bumetanide: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Bupivacaine; Epinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Bupivacaine; Meloxicam: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Bupropion: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Bupropion should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Bupropion; Naltrexone: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Bupropion should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Butalbital; Acetaminophen; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Butalbital; Acetaminophen; Caffeine; Codeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Butalbital; Aspirin; Caffeine; Codeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure. (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Caffeine; Sodium Benzoate: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Calcium, Magnesium, Potassium, Sodium Oxybates: (Major) Sodium oxybate lowers seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Canagliflozin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Candesartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Capreomycin: (Major) Because the use of other nephrotoxic drugs, including capreomycin, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible. Monitor patients for changes in renal function if these drugs are coadministered.
Captopril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Captopril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Carteolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Carvedilol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Celecoxib: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Celecoxib; Tramadol: (Major) Tramadol lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure. (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Chlordiazepoxide; Amitriptyline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Chlorothiazide: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Chlorpheniramine; Dextromethorphan; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Chlorpheniramine; Ibuprofen; Pseudoephedrine: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Chlorpheniramine; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Chlorpromazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Chlorthalidone: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Cisplatin: (Moderate) Closely monitor renal function if concomitant use with cisplatin and non-ionic contrast media is necessary. Both drugs can cause nephrotoxicity, which may be additive when used together.
Clindamycin: (Moderate) Concomitant use of non-ionic contrast media and clindamycin may result in additive nephrotoxicity. Monitor for renal toxicity if concomitant use is required.
Clomipramine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Clozapine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Cocaine: (Major) Use of medications that lower the seizure threshold, such as cocaine, should be carefully evaluated when considering intrathecal radiopaque contrast agentsl. While the contributory role of such medications has not been established, some physicians discontinue these drugs at least 48 hours before and for at least 24 hours after intrathecal use.
Codeine; Phenylephrine; Promethazine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects. (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Codeine; Promethazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Colistimethate, Colistin, Polymyxin E: (Major) Because the use of other nephrotoxic drugs, including colistimethate sodium, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible. Monitor patients for changes in renal function if these drugs are coadministered.
Colistin: (Major) Because the use of other nephrotoxic drugs, including colistimethate sodium, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible. Monitor patients for changes in renal function if these drugs are coadministered.
Cyclobenzaprine: (Major) Use of medications that lower the seizure threshold, such as cyclobenzaprine, should be carefully evaluated when considering intrathecal radiopaque contrast agents. Cyclobenzaprine should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Cyclosporine: (Moderate) Because the use of other nephrotoxic drugs, including cyclosporine, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, when possible, cyclosporine should be withheld during radiopaque contrast agent administration.
Dapagliflozin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Deferasirox: (Moderate) Acute renal failure has been reported during treatment with deferasirox. Coadministration of deferasirox with other potentially nephrotoxic drugs, including radiopaque contrast agents, may increase the risk of this toxicity. Monitor serum creatinine and/or creatinine clearance in patients who are receiving deferasirox and nephrotoxic drugs concomitantly.
Desipramine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Dexmethylphenidate: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Methylphenidate derivatives should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Dextroamphetamine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Amphetamines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Dextromethorphan; Bupropion: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Bupropion should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Dextromethorphan; Diphenhydramine; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Dextromethorphan; Guaifenesin; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Diclofenac: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Diclofenac; Misoprostol: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Diethylpropion: (Major) Use of medications that lower the seizure threshold, such as diethylpropion, should be carefully evaluated when considering non-ionic contrast media. Such medications should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Diflunisal: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Diphenhydramine; Ibuprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Diphenhydramine; Naproxen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Diphenhydramine; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Dopamine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Doravirine; Lamivudine; Tenofovir disoproxil fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Dorzolamide; Timolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Doxepin: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Droxidopa: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Efavirenz; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Empagliflozin; Linagliptin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Empagliflozin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Emtricitabine; Rilpivirine; Tenofovir alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Emtricitabine; Rilpivirine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Emtricitabine; Tenofovir alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Enalapril, Enalaprilat: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Enalapril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Entecavir: (Moderate) Because entecavir is primarily eliminated by the kidneys and radiopaque contrast agents can affect renal function, concurrent administration with radiopaque contrast agents may increase the serum concentrations of entecavir and adverse events. The manufacturer of entecavir recommends monitoring for adverse effects when these drugs are coadministered.
Ephedrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Ephedrine; Guaifenesin: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Epinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Eprosartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Ergotamine; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Ertugliflozin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Esmolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Ethacrynic Acid: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Etodolac: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Fenoprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Fluphenazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Flurbiprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Fosinopril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Fosinopril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Furosemide: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Gentamicin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Glipizide; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Glyburide; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Green Tea: (Major) Some, but not all, green tea products contain caffeine. Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products including green tea should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Guaifenesin; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Haloperidol: (Major) Haloperidol lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Hydrochlorothiazide, HCTZ; Moexipril: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Hydrocodone; Ibuprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Ibandronate: (Moderate) Theoretically, coadministration of intravenous ibandronate with other potentially nephrotoxic drugs, such as radiopaque contrast agents, may increase the risk of developing nephrotoxicity.
Ibuprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Ibuprofen; Famotidine: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Ibuprofen; Oxycodone: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Ibuprofen; Pseudoephedrine: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Iloperidone: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure. Iloperidone has not been associated with seizure activity more frequently than placebo in clinical trials; however, lowering of the seizure threshold is generally a class effect among antipsychotics and caution is advised.
Imipramine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Indomethacin: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Irbesartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Ketoprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Ketorolac: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Labetalol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Levobunolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Lidocaine; Epinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Linagliptin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Lisdexamfetamine: (Major) Use of medications that lower the seizure threshold, such as lisdexamfetamine, should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Lisinopril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Lisinopril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Loop diuretics: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Losartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Loxapine: (Major) Loxapine lower the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Lurasidone: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Maprotiline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Maprotiline should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Meclofenamate Sodium: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Mefenamic Acid: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Meloxicam: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Metformin; Repaglinide: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Metformin; Saxagliptin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Metformin; Sitagliptin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Methamphetamine: (Major) Methamphetamine lowers the seizure threshold and should be discontinued at least 48 hours before and for at least 24 hours after intrathecal use of contrast media.
Methylphenidate Derivatives: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Methylphenidate derivatives should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Methylphenidate: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Methylphenidate derivatives should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Metolazone: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Metoprolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Metoprolol; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Midodrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Moexipril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Molindone: (Major) Molindone lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Nabumetone: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Nadolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Naproxen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Naproxen; Esomeprazole: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Naproxen; Pseudoephedrine: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Nebivolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Nebivolol; Valsartan: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Nonsteroidal antiinflammatory drugs: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Norepinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Nortriptyline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Olanzapine: (Major) Atypical antipsychotics may lower the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Olanzapine; Fluoxetine: (Major) Atypical antipsychotics may lower the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Olanzapine; Samidorphan: (Major) Atypical antipsychotics may lower the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Olmesartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Oxaliplatin: (Major) Avoid coadministration of oxaliplatin with non-ionic contrast media due to the risk of increased oxaliplatin-related adverse reactions. Non-ionic contrast media is known to be potentially nephrotoxic; because platinum-containing drugs like oxaliplatin are eliminated primarily through the kidney, oxaliplatin clearance may be decreased by coadministration with nephrotoxic agents.
Oxaprozin: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Pamidronate: (Moderate) Coadministration of pamidronate with other nephrotoxic drugs may increase the risk of developing nephrotoxicity following pamidronate administration, even in patients who have normal renal function.
Paromomycin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Perindopril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Perindopril; Amlodipine: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Perphenazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Perphenazine; Amitriptyline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure. (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Phendimetrazine: (Major) Phendimetrazine lowers the seizure threshold and should be discontinued at least 48 hours before and for at least 24 hours after intrathecal use of contrast media.
Phenothiazines: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Phentermine: (Major) Phentermine lowers the seizure threshold and should be discontinued at least 48 hours before and for at least 24 hours after intrathecal use of contrast media.
Phentermine; Topiramate: (Major) Phentermine lowers the seizure threshold and should be discontinued at least 48 hours before and for at least 24 hours after intrathecal use of contrast media.
Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Pimozide: (Major) Pimozide lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Pindolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Pioglitazone; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Piroxicam: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Plazomicin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Potassium-sparing diuretics: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Prilocaine; Epinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Prochlorperazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Promethazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Promethazine; Dextromethorphan: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Promethazine; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects. (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Propranolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Protriptyline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Quetiapine: (Major) Quetiapine lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Quinapril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Quinapril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Ramipril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Risperidone: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Serdexmethylphenidate; Dexmethylphenidate: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Methylphenidate derivatives should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Sodium Iodide: (Moderate) Administration of non-ionic contrast media may interfere with thyroid uptake of radioactive sodium iodide (I-131) and decrease therapeutic and diagnostic efficacy in patients with carcinoma of the thyroid. The decrease in efficacy lasts for 6 to 8 weeks.
Sodium Oxybate: (Major) Sodium oxybate lowers seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Sotalol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Spironolactone: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Spironolactone; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Streptomycin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Sulindac: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Sumatriptan; Naproxen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Telmisartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Tenofovir Alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Tenofovir Alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Thiazide diuretics: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Thioridazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Thiothixene: (Major) Use of medications that lower the seizure threshold, such as thiothixene, should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Timolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Tobramycin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Tolmetin: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Torsemide: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Tramadol: (Major) Tramadol lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Tramadol; Acetaminophen: (Major) Tramadol lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Trandolapril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Trandolapril; Verapamil: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Triamterene: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Triamterene; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Tricyclic antidepressants: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Trifluoperazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Trimipramine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Valacyclovir: (Moderate) Concomitant use of valacyclovir and contrast agents should be avoided when possible, as use of these drugs together may increase the risk for nephrotoxicity.
Valsartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Vasopressin, ADH: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Vasopressors: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Voclosporin: (Moderate) Concomitant use of voclosporin and non-ionic contrast media may result in additive nephrotoxicity. Monitor for renal toxicity if concomitant use is required.
Ziprasidone: (Major) Use of medications that lower the seizure threshold, such as ziprasidone, should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Zoledronic Acid: (Moderate) Theoretically, the chronic coadministration of zoledronic acid with other nephrotoxic drugs, such as radiopaque contrast agents, may increase the risk of developing nephrotoxicity, even in patients who have normal renal function.
Iodixanol is an iodinated contrast media used to visualize the internal structures of the body including blood vessels, tissues, and organs. Iodine is the radiopaque component of iodixanol, allowing for opacification of vessels in the path of the blood flow of contrast media during angiography and urography. After iodixanol injection, internal structures of the human body can be visualized until significant hemodilution occurs.
Iodixanol enhances computed tomographic (CT) imaging through augmentation of radiographic efficiency. The degree of enhancement is directly related to the iodine content in the administered dose; peak iodine blood levels usually occur immediately and dramatically decrease within 5-10 minutes. During computed tomographic brain imaging, a lag between contrast media administration and maximum contrast enhancement of up to one hour occurs most likely because accumulation of iodine within the lesion and the outside blood pool is necessary for visualization; the mechanism by which this occurs is not clear. Because contrast media does not cross the blood-brain barrier, contrast media does not accumulate in normal brain tissue; contrast enhancement of normal brain tissue is most likely secondary to iodine accumulation within the blood pool. In the presence of a break in the blood-brain barrier, however, contrast media does accumulate within the interstitial spaces of the brain. In addition, iodixanol itself can cause blood-brain barrier disruption and accumulate in the central nervous system in patients with previously normal blood-brain barriers and renal impairment. During computed tomographic imaging of the body, enhancement is related to blood flow, concentration of the contrast medium, and extraction of the contrast medium by various interstitial tissues since no barrier exists. In contrast to brain imaging, contrast enhancement of the body is due to the relative differences in extravascular diffusion of contrast media between normal and abnormal tissue
Pharmacokinetics:
Iodixanol is administered by intravenous or intra-arterial injection. Care should be taken to avoid intrathecal administration of iodixanol. Iodixanol demonstrates 2-compartment model pharmacokinetics. Peak plasma concentrations occur rapidly allowing for quick visualization of the blood, liver, spleen, and other organs followed by slower urinary excretion. Following intravascular injection, iodixanol is immediately distributed into circulating blood volume (the vascular phase). Iodixanol then distributes into the interstitial space; after equilibrium, distribution into extracellular space occurs. Enhancement of visualization of tissues by contrast media is directly related to the vascularization of the specific tissue. Iodixanol is not significantly bound to to serum or plasma proteins and normally does not cross the blood-brain barrier. However, in patients with a disrupted blood-brain barrier or in some patients with normal blood-brain barriers but renal impairment, iodixanol can accumulate in the brain. Iodixanol does not undergo any significant metabolism, deiodination, or biotransformation, but is primarily eliminated via glomerular filtration through the kidneys. The biological half-life of iodixanol is 2.1 hours in healthy volunteers. Greater than 97% of the administered dose is excreted in the first 24 hours. Fecal elimination is negligible.
-Route-Specific Pharmacokinetics
Intravenous Route
Visualization of the renal parenchyma occurs within 30-60 seconds following rapid intravenous injection of iodixanol. The calyces and pelves in patients can be visualized within 1-3 minutes, but optimal visualization occurs after 5-15 minutes. Maximum contrast enhancement during computed tomography brain imaging can occur up to one hour after injection depending on the type of lesion to be visualized. Contrast enhancement during computed tomography of the body appears to be greatest soon after bolus administration of the contrast medium (15-120 seconds). The greatest enhancement can be detected by a series of consecutive 2-3 second scans (e.g., dynamic computed tomography imaging) performed within 30-90 seconds after injection.
-Special Populations
Renal Impairment
In patients with renal impairment, the clearance of all iodinated contrast media, including iodixanol, is reduced; the reduction in iodixanol clearance correlates to the degree of renal impairment. Depending on the degree of impairment, the half-life of contrast media in patients with renal insufficiency can approach 30 hours. In patients with a mean creatinine clearance of 13.61 ml/min, iodixanol has been detected in the plasma 5 days after injection. It appears that iodixanol is readily dialyzable; in vitro, approximately 36% of iodixanol was removed from the plasma after 4 hours of dialysis with a cellulose membrane and approximately 49% of iodixanol was removed after 4 hours of dialysis with a polysulfone membrane. It is possible that in patients with severely impaired renal function or in infants with immature kidneys, nonrenal excretion such as biliary elimination or hepatic metabolism is increased. Iodixanol does not normally cross the blood-brain barrier; however, disruption of the blood-brain barrier and accumulation of iodixanol in the brain has been reported in patients with normal blood-brain barriers and renal insufficiency.
Pediatrics
Forty pediatric patients <= 12 years old, with normal renal function received multiple intra-arterial administrations of iodixanol injection in doses of 0.32-3.2 grams Iodine/kg body weight. The mean elimination half-life in these patients, calculated from the elimination rate constant, was 4.1 hours for patients <= 2 months of age, 2.8 hours for patients aged 2-6 months, 2.4 hours for patients aged 6-12 months, and 2.3 hours for patients aged 1-12 years. Actual clearance and volume of distribution was not measured.