Iopamidol is an iodinated nonionic, low-osmolar contrast medium used for visualization during angiography and excretory urography. In addition, an intrathecal formulation is available for use during myelography and to enhance myelographic computed tomography imaging (cisternography and ventriculography). Iopamidol is used to enhance computed tomography head and body imaging and to investigate the presence of cerebral infarctions, active infections, arteriovenous malformations, aneurysms and lesions or tumors (both malignant and nonneoplastic) in the liver, kidneys, pancreas, aorta, abdominal cavity, pelvis, retroperitoneal space, and the mediastinum. Iopamidol was approved by the FDA on December 31, 1985.
Iodinated contrast media can be classified as either ionic or nonionic and high-osmolar or low-osmolar. In general, ionic contrast media (diatrizoate and iothalamate) have a high osmolality (1400 mOsm/kg water or higher) when compared to plasma (285 mOsm/kg water) and cerebrospinal fluid (301 mOsm/kg water). One ionic agent, ioxaglate, is considered to be low-osmolar with an osmolality of 600 mOsm/kg water. Nonionic contrast media such as iopamidol, iohexol, iopromide, and ioversol are considered low-osmolar with osmolalities ranging from approximately 600 mOsm/kg water to 900 mOsm/kg water. Iodixanol, a nonionic contrast medium, is considered to be iso-osmolar with an osmolality of 290 mOsm/kg water. Because one of the properties related to toxicity and adverse events is the osmolality of the contrast media, ionic contrast media tend to be associated with more adverse events than nonionic. Less toxicity is reported with the low-osmolar ionic contrast media ioxaglate than high-osmolar contrast media; however, the incidence of adverse events is slightly higher with ioxaglate when compared to low-osmolar nonionic contrast media. In addition, recent, limited data indicate that iodixanol, the iso-osmolar contrast medium, may be associated with even less toxicity than low-osmolar. Radiopaque efficacy of the contrast media depend 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.
Overall, most people tolerate contrast media injections without adverse reactions. However, severe, life-threatening reactions do occur. Acute renal failure can occur in up to 50% of patients with risk factors (i.e., renal insufficiency, diabetes mellitus, dehydration etc.). Using the smallest volume and concentration of nonionic contrast media and adequate hydration before and after the procedure or exam is recommended to minimize the risk of nephrotoxicity. Hypersensitivity reactions can occur in up to 15% of patients and tend to be more common with the use of ionic contrast media in at-risk patients (i.e., atopy, asthma, previous reaction to contrast media, etc.); anaphylaxis is rare (0.04-0.22% incidence). In patients with risk factors for hypersensitivity, the incidence and severity of reactions can be minimized with the use of nonionic contrast media and/or prophylactic corticosteroids/antihistamines. Cardiovascular toxicity can occur but is more prevalent with coronary arteriography and the use of ionic contrast media. Cardiovascular shock, unconsciousness and death occur very rarely; these life-threatening reactions are unpredictable; they can occur with any contrast media and are not related to the route of administration or patient risk factors. Major motor seizures are rare but have been associated with the use of contrast media; however, seizures are more commonly associated with intrathecal use. Prior to the administration of contrast media, patients should be evaluated for risk factors of toxicity. In those patients with risk factors, the benefits of the procedure or exam should be carefully evaluated and preventive measures should be taken when possible.
General Administration Information
For storage information, see specific product information within the How Supplied section.
NOTE: Patients should be well-hydrated prior to and following iopamidol injection 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, 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 one 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 iopamidol necessary to obtain adequate visualization should be used. Using lower doses reduces the risk of adverse reactions. The dose and concentration of iopamidol, age of the patient, patient's body size, 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 technique to be employed should all be considered when determining the necessary dose.
Route-Specific Administration
Injectable Administration
-As recommended with other contrast media, if a reaction occurs during administration, the injection should be stopped until the reaction has subsided.
-In order to decrease the viscosity, iopamidol should be at body temperature prior to injection.
-Sterile technique must be used in all injections involving contrast media. If non-disposable equipment is used, scrupulous care should be taken to prevent residual contamination with traces of cleansing agents.
-Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit. The solution should be clear and colorless to pale yellow. If the vial contents are crystallized or if there are signs of damage to the container closure system, discard the unused vial.
-Per the manufacturer, iopamidol should not be mixed with any other drugs.
-Iopamidol can be administered via intravenous or intra-arterial injection. NOTE: Care should be taken to avoid inadvertent intrathecal administration of iopamidol injections not intended for intrathecal use. Only iopamidol for intrathecal administration (Isovue-M) should be administered intrathecally.
-When using iopamidol for coronary arteriography, ventriculography, or pediatric angiocardiography, EKG monitoring is mandatory; in addition, vital signs should be routinely monitored throughout the procedure.
Preparation of multiple doses using bulk packaging
-Multiple single doses for multiple patients may be prepared from the Isovue Imaging Bulk Package.
-In a room designated for intravenous radiological procedures, aseptically transfer iopamidol from the Isovue Imaging Bulk Package using an automated contrast injection system or contrast management system approved for use with Isovue Imaging Bulk Package.
-Prior to penetrating the bulk packaging container closure, swab the stopper with 70% isopropyl alcohol. Puncture the stopper with a suitable-sterile component of the automated contrast injection system or contrast management system. NOTE: The stopper may be penetrated only once.
-Once the bulk package stopper has been penetrated, it should not be removed from the work area for the entire period of use, and the bottle must remain inverted so the contents are in constant contact with the dispensing set. A storage temperature of 25 degrees C (77 degrees F) should not be exceeded during the transfer process.
-Transfer must be complete within 10 hours of the initial closure entry. Discard any unused product after 10 hours. In addition, the bulk package and all the disposables for the delivery system should be discarded if the integrity of the product or delivery system cannot be assured through direct continuous supervision.
-If using 0.9% Sodium Chloride Injection in 500 mL or 1000 mL flexible bags, prepare the intravenous port by swabbing with 70% isopropyl alcohol. Using a suitable sterile component of the contrast management system, aseptically penetrate the port of the 0.9% Sodium Chloride Injection container. NOTE: The port may be penetrated only once. Strap the saline tag provided with the Isovue Imaging Bulk Package on the 0.9% Sodium Chloride Injection container. The maximum use time is 10 hours from initial closure entry. Discard any unused 0.9% Sodium Chloride Injection after 10 hours.
Management of patients during procedure
-The patient should remain still during the procedure and not move unless instructed. Abrupt activity can cause excessive mixing of iopamidol with cerebrospinal fluid. If the patient must be moved, it is preferable for trained personnel to move the patient slowly.
-Avoid early and high cephalad dispersion of iopamidol and an intracranial bolus. To maintain iopamidol solution as a bolus, the medium can be moved distally very slowly under fluoroscopic control. The patient's head should remain elevated above the highest level of the spine. The head of the table should not should not be lowered more than 15 degrees during thoraco-cervical procedures. In patient's with excessive curvature of the lumbar spine, consider a lateral position for the injection and movement of the medium cephalad.
-At completion of direct cervical or lumbo-cervical procedures, raise head of table steeply (45 degree angle) for about 2 minutes to restore iopamidol to lower levels of the spine.
Management of patients post-procedure
-Patients should remain in a bed with the head raised (30 to 45 degree angle) for 12 to 24 hours post procedure. Patients should be advised to remain quite and still for the first 24 hours with their head in the up position. Additionally, the patient should be kept under close observation during this time period.
-Alternatively, recent evidence suggests that maintaining patients in an upright position post myelography (via a wheelchair or ambulation) may help minimize adverse effects.
Intravenous Administration
-When using iopamidol intravenously, it may be prudent to use a short needle catheter assembly that can be left in place for venous access if a major reaction occurs.
-As is recommended with other contrast media, to facilitate clearing the contrast medium from the extremity and to minimize the risk of extravasation during peripheral intravenous administration, the vein should be flushed with an adequate volume of 0.9% Sodium Chloride Injection or 5% Dextrose Injection immediately following the iopamidol administration.
Intrathecal Administration
-NOTE: Care should be taken to avoid inadvertent intrathecal administration of iopamidol. Only iopamidol for intrathecal administration (Isovue-M) should be administered intrathecally.
-Lumbar puncture should be performed under sterile conditions. Lumbar puncture is usually placed between L3 and L4; however, if the pathology is suspected to be in this area, the interspace immediately above or below can be used. A lateral cervical puncture may also be used.
-Intrathecal iopamidol should be injected slowly, over 1 to 2 minutes, to minimize mixing of the solution with cerebrospinal fluid. In addition, slow injection will minimize premature cephalad (cranial) dispersion of iopamidol. Once injected, the needle can be removed.
-Consider holding neuroleptic drugs (including phenothiazines) for at least 48 hours before and 24 hours after the procedure.
Because measurable plasma concentrations of iopamidol are attained following intrathecal administration, adverse reactions associated with intravascular administration of iopamidol are theoretically possible when used intrathecally.
Adverse reactions to contrast media (e.g., iopamidol) 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. 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 contrast media. In a study of over 300,000 patients comparing intravenous administration of ionic versus nonionic contrast media, adverse reactions were reduced from 12.66% with ionic contrast media to 3.13% (p < 0.01) with nonionic contrast media. More importantly, the incidence of severe reactions (including shortness of breath, sudden drop in blood pressure, loss of consciousness, and cardiopulmonary arrest) were reduced from 0.22% with ionic contrast media to 0.04% with nonionic contrast media (p < 0.01).
In vitro studies with animal blood showed that many radiopaque contrast agents, including iopamidol, may produce transient changes in red cell and leukocyte counts, serum calcium, serum creatinine, serum aspartate aminotransferase (AST), and uric acid in urine; transient albuminuria may occur. These findings have not been associated with clinical manifestations.
Severe reactions including cardiovascular collapse, cardiac arrest, unconsciousness, shock, and death have been reported with iopamidol use. These life-threatening reactions tend to be unpredictable. The estimated incidence of shock after the administration of iodinated contrast media such as iopamidol is 1 per 20,000 patients (0.005%) and the reported incidence of death ranges from 6.6 per 1 million patients (0.00066%) to 1 in 10,000 patients (0.01%). Most deaths occur during injection or the first 5 to 10 minutes. Nausea and vomiting may be the first sign of a severe reaction. If nausea or vomiting occurs during injection, the injection rate should be slowed or stopped.
Hypersensitivity reactions including anaphylactoid reactions can occur in up to 15% of patients receiving contrast media such as iopamidol. 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 radiopaque 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 post administration of contrast media. Symptoms of hypersensitivity range from mild including nasal congestion, sneezing, itching, pruritus, skin discoloration, and rash (unspecified) to severe including urticaria, swelling, laryngeal edema, bronchospasm, wheezing, and anaphylactic shock. The incidence of delayed hypersensitivity is < 4% with the most common presentation being maculopapular rash; other symptoms such as urticaria and angioedema may also be present.
The administration of contrast media such as iopamidol is associated with nephrotoxicity. 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. Symptoms of nephrotoxicity can range from elevations in serum creatinine to oliguria, anuria, and acute renal failure (unspecified) requiring dialysis. The incidence of nephrotoxicity is difficult to estimate as clinical trials have varied with respect to definition of nephrotoxicity, procedure, volume of contrast media, and patient risk factors. Studies have suggested an incidence of up to 10% in patients with normal renal function; in patients with various risk factors, the incidence rises to anywhere from 12% to 50%. 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, renal function should return to baseline, and the patient should be well hydrated prior to re-examination.
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.
Adverse Reactions reported with Intravascular Use:
Isovue-M is specifically indicated for intrathecal administration. Care should be taken not to administer other Isovue products intrathecally. Severe and fatal neurotoxic adverse reactions including convulsions, cerebral hemorrhage, unconsciousness, paralysis, arachnoiditis, hyperthermia, and brain edema have been reported when inadvertent intrathecal administration of ionic and nonionic contrast media such as iopamidol occurs. In addition, renal failure, cardiac arrest, and rhabdomyolysis 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 can occur secondary to intravascular volume expansion and depressed myocardial function; in addition, patients may 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. Cardiac arrest, serious arrhythmias, sinus bradycardia, EKG changes, hypotension, angina pectoris, myocardial ischemia or myocardial infarction have been reported when iopamidol is used intravascularly, but these reactions occur more frequently during cardioarteriography and ventriculography. In general, nonionic contrast media are associated with a lower incidence of severe cardiac reactions, although some controversy exists. Not only do nonionic contrast media have fewer cardiac reactions, but the buffer/stabilizer used in iopamidol, 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 iopamidol.
Adverse reactions that occur more commonly during cerebral arteriography with iopamidol include convulsions, somnolence, paresis, and visual changes. In addition, cardiovascular reactions, specifically bradycardia and blood pressure fluctuations might also be more common during cerebral arteriography than during other procedures.
Intravascular injection of iopamidol is associated with the sensation of warmth (1.1%) and pain (2.8%) and flushing/hot flashes (1.5%) especially in peripheral arteriography and venography; 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. During angiocardiography, the incidence of hot flashes was 3.4% and flushing was 1.8%.
Injection site reaction, including swelling and erythema, is most often due to extravasation of iopamidol. 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, the affected limb should be elevated. In addition, heat or cold applied to the affected area have been reported to be successful in treating extravasation.
Some adverse reactions that occur may be a consequence of the procedure; bleeding, pseudoaneurysm at the puncture site, brachial plexus palsy after axillary artery injections are possible. During aortography, the risks of the procedure itself include injury to the aorta and neighboring organs, pleural puncture, renal damage including infarction and renal tubular necrosis, accidental selective filling of the right renal artery during the translumbar procedure in the presence of preexisting renal disease, retroperitoneal bleeding from the translumbar approach, and spinal cord injury and pathology associated with the syndrome of transverse myelitis. Thromboembolism, venous thrombosis, displacement of arterial plaques, stroke, dissection of the coronary vessels, and transient sinus arrest are rare complications. In vitro studies with animal blood show that many radiopaque contrast agents, including iopamidol, produce a slight decrease of plasma coagulation factors including prothrombin time, partial thromboplastin time, and fibrinogen, as well as a slight tendency to cause platelet and/or red blood cell aggregation.
Adverse reactions reported with Intrathecal Use:
The incidence of adverse reactions in 61 patients aged 24 days to 17 years receiving intrathecal iopamidol was 10%. The symptoms reported included headache, low back pain, leg pain, injection site pain, irritability, vomiting, and ataxia. All of the adverse reactions were mild and resolved without treatment. It should be noted that the incidence of headache in children after lumbar puncture alone has been reported to be as high as 20%. The most commonly reported adverse reactions associated with intrathecal iopamidol in adults include headache (16.4%), nausea or vomiting (7.3%), and musculoskeletal pain (2.2%) including back pain, leg pain/sciatica, and neck pain. The reactions usually occur from 1 to 10 hours after injection. Most are usually mild to moderate and disappear within 24 hours. Headaches may be severe or persist for several days and are often accompanied by nausea and vomiting. Headaches tend to be more frequent and persistent in patients that are not adequately hydrated. If a patient experiences nausea and vomiting, intravenous fluids should be initiated to prevent dehydration, In addition, because of the increased risk of seizure activity associated with intrathecal iopamidol, drugs from the phenothiazine class (i.e., prochlorperazine) should not be used to treat nausea and vomiting.
Major motor seizures have been reported in the medical literature and since market introduction of intrathecal iopamidol in the United States. Transitory EEG changes occur and usually take the form of slow wave activity. Early onset of seizures (less than 2 hours) is indicative of early substantial intracranial entry. If such intracranial entry of the medium occurs, prophylactic anticonvulsant treatment with diazepam or barbiturates orally for 24 to 48 hours should be considered. In most reported cases of seizures with nonionic contrast media used during myelography, 1 or more of the following is usually present: deviations from recommended procedure in myelographic management; use in patients with a history of epilepsy; overdosage; intracranial entry of a bolus or premature diffusion of a high concentration of the medium; medication with neuroleptic drugs or phenothiazine antinauseants; failure to maintain elevation of the head during the procedure, on the stretcher, or in bed; or excessive and particularly active patient movement or straining.
Neurological adverse events that have been associated with intrathecal contrast media including iopamidol are ataxia, weakness (including muscle weakness), emotional distress, syncope, vertigo, irritability, hallucinations, fever, fatigue, transient perceptual aberrations (depersonalization, anxiety, depression, hyperesthesia, speech or hearing disturbances, visual impairment, disorientation), hyperreflexia or areflexia, hypertonia or flaccidity, restlessness, asterixis, and dysphasia. Rare, severe mental disturbances (various forms of aphasia and disorientation) usually appear 8 to 10 hours post injection and last for up to 24 hours. However, apprehension, agitation, or progressive withdrawal to stupor or coma has been reported. In some cases, transient auditory and visual disturbances (believed subjective or delusional) have accompanied these severe mental disturbances. Persistent cortical loss of vision in association with convulsions and ventricular block has been reported. Rarely, persistent though transitory weakness in the leg or ocular muscles has been reported. Peripheral neuropathy has been rare and transitory; specific neuropathies include sensory and/or motor or nerve root disturbances, myelitis, persistent leg muscle pain or weakness, sixth nerve palsy, or cauda equina syndrome. Muscle cramps, fasciculation or myoclonia, spinal convulsion, paralysis, or spasticity are unusual. In addition to the above mentioned adverse reactions, bacterial meningitis, aseptic meningitis syndrome, and Guillain-Barre syndrome have been reported.
Nonionic contrast media are associated with fewer adverse reactions than ionic in children; the majority of adverse reactions in children are minor in nature. In a study comparing ionic and nonionic contrast media for CT studies in children, minor side effects were detected in 85% of children that received meglumine diatrizoate, 18% of children receiving iohexol, and 36% of children receiving iopamidol. The most common adverse reactions in this study were nausea, vomiting, warmth, flushing, abnormal taste, dizziness, additional movements, itching and local discomfort. All adverse reactions occurred with a much lower frequency in the iopamidol and iohexol groups.
Adverse Reactions associated with iopamidol and other iodinated contrast media use in general:
Adverse reactions have been reported with iopamidol or other iodinated contrast media in the medical literature. It is expected that adverse reactions reported with one iodinated contrast medium are possible with any other water soluble iodinated contrast media. Cardiovascular type reactions such as vasodilation (feeling of warmth), flushing, cerebral hematoma, hemodynamic disturbance, chest pain (unspecified), sinus bradycardia, transient electrocardiographic abnormalities, arrhythmias, conduction defects, cardiopulmonary arrest, arterial spasms, sinus tachycardia, hypertension, hypertensive crisis, transient ischemic attack, thrombophlebitis, petechiae, peripheral edema, false aneurysm, disseminated intravascular coagulation (DIC), and vasovagal reactions have been reported. Digestive system reactions including nausea, vomiting, severe unilateral or bilateral swelling of the parotid and submaxillary glands, dry mouth (xerostomia), anorexia, retching, choking, and abdominal cramps have been reported. Dyspepsia and diarrhea have been associated with intrathecal iopamidol. In addition, nervous system reactions including headache, confusion, paresthesias, dizziness, involuntary movements, tremor, convulsions, paralysis, coma, temporary cortical blindness, and temporary amnesia have been reported. Respiratory-related adverse effects have been reported and include increased cough, sneezing, asthma, wheezing, hypoxia, apnea, dyspnea, laryngeal edema, pulmonary edema, bronchospasm or laryngospasm, nasal congestion, rhinitis, throat constriction, and cyanosis. Other reported adverse effects include periorbital edema, facial edema, malaise, pallor, fever, chills, diaphoresis, increased sweating (hyperhidrosis), rash, urticaria, ecchymosis, osmotic nephrosis of proximal tubular cells, polyuria, renal failure, urinary retention, hematuria, dysgeusia (perversion of taste), visual disturbances, bilateral ocular irritation; lacrimation; itching; conjunctival chemosis, infection, and conjunctivitis. Neutropenia has been reported with other contrast media and is possible with iopamidol.
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.
Peripheral angiography with iopamidol should be performed with caution, if at all, in patients with severe ischemia; pulsation should be present in the artery to be injected.
Serious, life-threatening, or fatal anaphylactoid or cardiovascular reactions have been reported with the use of contrast media (e.g. iopamidol). The majority of fatal reactions occur during injection or the first 5 to 10 minutes after injection with cardiac arrest being the most prevalent feature; cardiovascular disease is the main aggravating factor. Patients at increased risk of anaphylactoid reactions are those with a history of radiopaque contrast media hypersensitivity, iodine hypersensitivity, asthma, and atopy (including hay fever, food allergies, and drug allergies). 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%. Pretesting 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. 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.
Serious, rarely fatal, thromboembolic events causing myocardial infarction and stroke have been reported during angiographic procedures with ionic and nonionic contrast media. Controversy exists as to whether nonionic contrast media such as iopamidol are more thrombogenic than ionic contrast media. In 1993, the American College of Cardiology 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 angioplasty procedure itself is thrombogenic, not the contrast media. Because many factors contribute to thromboembolic events including length of procedure, catheter and syringe material, underlying disease state, 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 and/or three way stopcocks, frequent catheter flushing with heparinized saline solutions, and minimizing the length of the procedure. 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. In addition, the possibility of dislodging plaques or damaging or perforating the vessel wall can occur during catheter manipulations and contrast medium injection. Test injections to ensure proper catheter placement may be prudent. Special care is necessary when venography is performed in patients with suspected thromboembolic disease such as thrombosis, 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, 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 iopamidol 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.) may be prudent. 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 1200 mg IV prior to angioplasty followed by 1200 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.
Contrast media should such as iopamidol be used cautiously in patients with multiple myeloma; 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 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 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.
Contrast media such as iopamidol may promote sickling in individuals who are homozygous for sickle cell disease. Patients with sickle cell disease tend to be dehydrated during an acute sickle cell crisis. If contrast media is used in this population, patients should be adequately hydrated.
Contrast media such as iopamidol should be used cautiously in patients with congestive heart failure. 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 iopamidol is considerably less hyper-osmolar when compared to the ionic agents such as diatrizoate, iopamidol can cause a transient increase in circulatory volume. In a study evaluating the effects of n-acetylcysteine on the prevention of CIN, patients with left ventricular ejection fractions <= 40% developed CIN at a rate of almost 3 times that of patients with an ejection fraction of > 40%. The combination of low ejection fraction and a creatinine clearance <= 60 mL/min was associated with a 5 times increased incidence of CIN. Following contrast media administration, patients with congestive heart failure should be observed closely 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 iopamidol 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.
The exacerbation of myasthenia gravis has been reported after the use of contrast media. It has been suggested that contrast media such as iopamidol can increase neuromuscular blockage and that those patients with bulbar signs and requiring high doses of contrast media are at higher risk for this complication.
Administration of iopamidol 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 a 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 iopamidol, evaluate all patients for thyroid-associated risk factors.
Selective coronary arteriography should be performed only in selected patients where the expected benefits outweigh the procedural risk. Monitor EKG during this procedure. Contrast media injected directly into coronary arteries or chambers of the heart may cause EKG changes such as a transient prolongation of the RR and QT intervals. Selective coronary arteriography should be used with caution in patients with congenital or acquired QT prolongation syndromes as QT prolongation can predispose patients to serious arrhythmias including torsades de pointes. In addition, contrast media injected directly into coronary arteries or chambers of the heart causes myocardial contraction depression and is associated with bradycardia and hypotension lasting 5 to 10 seconds. Most patients recover from this effect without treatment; however, in select patients including those with severe cardiac disease (i.e., coronary artery obstruction, heart failure, ischemic heart disease, valvular heart disease, pulmonary hypertension, etc.), these hemodynamic effects can cause ischemia and profound hypotension possibly leading to myocardial infarction or death. The risk of cardiovascular reactions is less with nonionic contrast media (i.e., iopamidol) than ionic. In terms of overall cardiovascular safety, nonionic contrast media such as iopamidol tend to be less arrhythmogenic and cause less hemodynamic and electrophysiologic changes than their ionic counterparts. Administer intrathecal iopamidol with caution in patients with severe cardiovascular disease. Particular attention must be given to state of hydration, concentration of medium, dose, and technique used in these patients.
Angiocardiography using iopamidol should proceed with caution in patients with chronic pulmonary emphysema. Reported effects of iodinated contrast media on lung function include bronchospasm, pulmonary edema, increased pulmonary vascular resistance, and histamine release from lung mast cells and basophils and these effects can contribute to adverse effects in patients with pulmonary disease including emphysema and asthma.
Cerebral arteriography with iopamidol 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.
Care should be taken to avoid extravasation of contrast media such as iopamidol, especially in those patients with arterial insufficiency, compromised venous drainage, or compromised lymphatic systems. Fluoroscopy is recommended. 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 have been reported to be successful in treating extravasation.
Avoid use of iopamidol 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 iopamidol. 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. Perform any test which might be affected by contrast media before administration of the contrast medium.
Isovue is not indicated for intrathecal administration; however, iopamidol is also available as Isovue-M, which is indicated for intrathecal administration. Severe and fatal neurotoxic adverse reactions including convulsions, cerebral hemorrhage, unconsciousness, paralysis, inflammation of the arachnoid membrane, hyperthermia, and brain edema have been reported when inadvertent intrathecal administration of nonionic contrast media occurs. In addition, renal failure, cardiac arrest, and rhabdomyolysis have been reported.
Concomitant use of intrathecal corticosteroid therapy with intrathecal iopamidol is contraindicated. Do not perform myelography in the presence of significant local or systemic infection where bacteremia is likely. Always consider the possibility of inducing bacterial meningitis in patients during intrathecal procedures. To avoid bacterial contamination during spinal puncture, maintain a sterile field at all times.
Administer intrathecal iopamidol with caution in patients with increased intracranial pressure or suspicion of intracranial mass or tumor, abscess or hematoma, chronic alcoholism, or multiple sclerosis. Particular attention must be given to state of hydration, concentration of medium, dose, and technique used in these patients.
Because of overdosage considerations and the increased risk of neurotoxicity, immediate repeat myelography in the event of technical failure is contraindicated. Allow at least 48 hours to elapse between procedures with 5 to 7 days preferred. Direct intracisternal or ventricular administration for standard radiography (without computerized tomographic enhancement) is not recommended. Inadvertent intracranial entry of a large or concentrated bolus of the contrast medium, which increases the risk of neurotoxicity, can be prevented by careful patient management. Also, avoid rapid dispersion of iopamidol causing inadvertent rise to intracranial concentrations (e.g., by active patient movement). If such intracranial entry of the medium occurs, consider prophylactic anticonvulsant treatment with diazepam or barbiturates orally for 24 to 48 hours. Administer intrathecal iopamidol with caution in patients with a history of seizure disorder. Particular attention must be given to state of hydration, concentration of medium, dose, and technique used in these patients. Maintain patients receiving anticonvulsants on these medications. Furthermore, in patients with a history of a seizure disorder not on anticonvulsant therapy, consider prophylactic diazepam or barbiturates. In order to minimize the risk of overdosage and neurotoxicity, follow the recommended dosage guidelines, neuroradiographic procedures, and patient management strategies.
Preparatory dehydration is dangerous and may contribute to acute renal failure in susceptible nondiabetic patients (often geriatric patients with pre-existing renal disease). Ensure patients are well hydrated prior to and after iopamidol administration. Use iopamidol for myelographic examination with caution in geriatric patients; particular attention must be given to state of hydration, concentration of medium, dose, and technique used in these patients.
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 iopamidol. 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.
Use iopamidol during pregnancy only if clearly needed. There are no adequate and well-controlled studies in pregnant women. 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 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. Reproduction studies have been performed in rats and rabbits at doses up to 2.7 and 1.4 times the maximum recommended human dose (1.48 gI/kg in a 50 kg individual), respectively, and have revealed no evidence of impaired fertility or harm to the fetus due to iopamidol.
It is not known whether iopamidol is excreted in human milk. Because many drugs are excreted in human milk, use caution when iopamidol is administered to a breast-feeding woman. 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 to breast-feed 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 iopamidol injection administration. A suggested common regimen in eligible patients (e.g., those patients in which fluid administration would not be contraindicated) is 1ml/kg/hr of 0.9% saline 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, 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 one 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 iopamidol necessary to obtain adequate visualization should be used. Using lower doses reduces the risk of adverse reactions. The dose and concentration of iopamidol, age of the patient, patient's body size, 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 technique to be employed should all be considered when determining the necessary dose.
For use in angiography via intravascular administration:
-for use as a contrast in cerebral arteriography:
Intra-arterial dosage:
Adults: 8 to 12 mL of 300 mg iodine/mL injection (Isovue-300) as a single injection via carotid puncture or transfemoral catheterization. If multiple injections are necessary, up to 90 mL can be used.
-for use as a contrast in peripheral arteriography:
Intra-arterial dosage:
Adults: 5 to 40 mL of 300 mg iodine/mL injection (Isovue-300) as a single injection via the femoral artery or subclavian artery. Alternatively, 25 to 50 mL of 300 mg iodine/mL injection (Isovue-300) as a single injection via the aorta for a distal runoff. If multiple injections are necessary, up to 250 mL can be used.
-for use as a contrast in peripheral venography:
Intravenous dosage:
Adults: 25 to 150 mL per lower extremity of 200 mg iodine/mL injection (Isovue-200) as a single injection. If multiple injections are necessary, up to a combined dose of 350 mL can be used. NOTE: Following the procedure, the venous system should be flushed with normal saline or 5% dextrose in water. Massage and elevation of the affected limb may help in clearing the contrast medium from the extremity.
-for use as a contrast in selective visceral arteriography and aortography:
Intra-arterial dosage:
Adults: Iopamidol 370 mg iodine/mL injection (Isovue-370) should be used. The volume used depends on the vessel to be visualized. For larger vessels, such as the aorta or celiac artery, single injections as high as 50 mL may be necessary; For visualization of the renal arteries, single injections of up to 10 mL may be sufficient. Lower doses will often provide acceptable visualization. If multiple injections are necessary, up to 225 mL can be used. NOTE: When using large volumes as a single injection (i.e., during ventriculography or aortography), several minutes between repeat injections should lapse to allow for correction of hemodynamic disturbances.
-for use as a contrast in adult angiocardiography including ventriculography and coronary arteriography:
Intra-arterial dosage:
Adults: Iopamidol 370 mg iodine/mL injection (Isovue-370) should be used. For selective coronary artery visualization, the usual dose is 2 to 10 mL. For ventriculography or visualization of multiple coronary arteries, the usual dose is 25 to 50 mL injected into the aortic root. If multiple injections are necessary, up to 200 mL can be used. NOTE: When using large volumes as a single injection (i.e., during ventriculography or aortography), several minutes between repeat injections should lapse to allow for correction of hemodynamic disturbances. EKGs and vital signs should be routinely monitored during this procedure.
-for use as a contrast in pediatric angiocardiography:
NOTE: Iopamidol can be injected into a large peripheral vein or by direct catheterization of the heart. The dosages are the same for either method of administration.
NOTE: When using large volumes as a single injection, several minutes between repeat injections should lapse to allow for correction of hemodynamic disturbances. EKGs and vital signs should be routinely monitored during this procedure.
Intravascular dosage:
Children and Adolescents 10 to 18 years: 20 to 50 mL of 370 mg iodine/mL injection (Isovue-370). Maximum dosage for multiple injections: 125 mL.
Children 5 to 9 years: 15 to 30 mL of 370 mg iodine/mL injection (Isovue-370). Maximum dosage for multiple injections: 100 mL.
Children 2 to 4 years: 15 to 30 mL of 370 mg iodine/mL injection (Isovue-370). Maximum dosage for multiple injections: 50 mL.
Children and Infants < 2 years: 10 to 15 mL of 370 mg iodine/mL injection (Isovue-370). Maximum dosage for multiple injections: 40 mL.
For use as a contrast in excretory urography:
Intravenous dosage:
Adults: Iopamidol should be administered by rapid intravenous injection. 50 to 100 mL of 250 mg iodine/mL injection (Isovue-250) OR 50 mL of 300 mg iodine/mL injection (Isovue-300) OR 40 mL of 370 mg iodine/mL (Isovue-370).
Children: 1.2 to 3.6 mL/kg of 250 mg iodine/mL injection (Isovue-250) OR 1 to 3 mL iodine/kg of 300 mg iodine/mL injection (Isovue-300) by rapid intravenous injection. It should not be necessary to exceed a total dose of 30 g of iodine.
For use as contrast enhancement during computed tomography (CT) imaging of the head or body:
Intravenous dosage:
Adults: 130 to 240 mL of 250 mg iodine/mL injection (Isovue-250) OR 100 to 200 mL of 300 mg iodine/mL injection (Isovue-300). Imaging may be performed immediately after completion of administration. Equivalent doses of 370 mg iodine/mL injection (Isovue-370) based on organically bound iodine content may also be used for CT imaging of the body. Total dose of iodine should not exceed 60 g for either procedure.
Children: 1.2 to 3.6 mL/kg of 250 mg iodine/mL injection (Isovue-250) OR 1 to 3 mL/kg of 300 mg iodine/mL injection (Isovue-300) by rapid intravenous injection. It should not be necessary to exceed a total dose of 30 g of iodine.
For use in neuroradiology including myelography:
NOTE: Only iopamidol for intrathecal administration (Isovue-M) should be used for intrathecal administration.
NOTE: A minimum interval of 48 hours should pass between repeat examinations; however, 5 to 7 days between examinations is preferable when possible. Only one injection of iopamidol should be given per procedure when used intrathecally.
NOTE: Consider holding neuroleptic drugs (including phenothiazines) for at least 48 hours before and 24 hours after the procedure.
NOTE: The pediatric dosages listed are based on age rather than weight because the brain and CSF volume are independent of weight. However, dosage may vary based on individual factors such as patient height, suspected pathology, patient condition, and technique.
-for use as a contrast in lumbar or thoracic myelogram:
Intrathecal dosage:
Adults: 10 to 15 mL of 200 mg iodine/mL injection (Isovue-M 200).
Adolescents: Per the manufacturer, 10 to 12 mL of 200 mg iodine/mL injection (Isovue-M 200); others have suggested doses up to 15 mL may be used.
Children 8 to 12 years: Per the manufacturer, 8 to 11 mL of 200 mg iodine/mL injection (Isovue- 200); others have suggested doses up to 15 mL may be used.
Children 2 to 7 years: Per the manufacturer, 7 to 9 mL of 200 mg iodine/mL injection (Isovue-M 200); others have suggested doses up to 10 mL may be used.
Infants 2-24 months* and Children < 2years*: Safety and efficacy have not been established. A dose of 4 to 6 mL of 200 mg iodine/mLinjection (Isovue-M 200) has been suggested.
Infants < 2 months*: Safety and efficacy have not been established. A dose of 3 to 5 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
-for use as a contrast in cervical myelogram (via lumbar injection):
Intrathecal dosage:
Adults: 10 to 15 mL of 200 mg iodine/mL injection (Isovue-M 200) OR 10 mL of 300 mg iodine/mL injection (Isovue-M 300).
Adolescents*: Safety and efficacy have not been established. A dose of 8 to 12 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Children 8-12 years*: Safety and efficacy have not been established. A dose of 7 to 10 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Children 2-7 years*: Safety and efficacy have not been established. A dose of 6 to 10 mL of 200 mg iodine/mL injection (Isovue-M) 200 has been suggested.
Infants 2-24 months* and Children < 2 years*: Safety and efficacy have not been established. A dose of 4 to 6 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Infants < 2 months*: Safety and efficacy have not been established. A dose of 3 to 5 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
-for use as a contrast in cervical myelogram (via lateral cervical injection):
Intrathecal dosage:
Adults: 10 mL of 200 mg iodine/mL injection (Isovue-M 200).
Adolescents*: Safety and efficacy have not been established. A dose of 5 to 10 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Children 8 to 12 years*: Safety and efficacy have not been established. A dose of 5 to 10 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Children 2 to 7 years*: Safety and efficacy have not been established. A dose of 4 to 8 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Infants 2-24 months* and Children < 2years*: Safety and efficacy have not been established. A dose of 3 to 4 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Infants < 2 months*: Safety and efficacy have not been established. A dose of 2 to 3 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
-for use as a contrast in total columnar myelography:
Intrathecal dosage:
Adults: 10 mL of 300 mg iodine/mL injection (Isovue-M 300).
Adolescents*: Safety and efficacy have not been established. A dose of 10 to 15 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Children 8 to 12 years*: Safety and efficacy have not been established. A dose of 10 to 15 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Children 2 to 7 years*: Safety and efficacy have not been established. A dose of 8 to 12 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Infants 2 to 24 months* and Children < 2 years*: Safety and efficacy have not been established. A dose of 4 to 8 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Infants < 2 months*: Safety and efficacy have not been established. A dose of 3 to 6 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
-for use as a contrast in computed tomography cisternography via lumbar injection:
NOTE: Direct intracisternal administration of iopamidol for standard radiography (without computed tomography enhancement) is not recommended.
Intrathecal dosage:
Adults: 4 to 6 mL: of 200 mg iodine/mL: injection (Isovue-M 200).
Adolescents*: Safety and efficacy have not been established. A dose of 3 to 6 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Children 8 to 12 years*: Safety and efficacy have not been established. A dose of 3 to 6 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Children 2 to 7 years*: Safety and efficacy have not been established. A dose of 2 to 5 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Infants 2 to 24 months* and Children < 2 years*: Safety and efficacy have not been established. A dose of 2 to 4 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.[28693
Infants < 2 months*: Safety and efficacy have not been established. A dose of 1 to 2 mL of 200 mg iodine/mL injection (Isovue-M 200) has been suggested.
Maximum Dosage Limits:
-Adults
Do not exceed recommended volume/concentration for the particular intravascular indication; 15 mL of 200 mg iodine/mL injection or 10 mL of 300 mg iodine/mL injection per procedure intrathecally.
-Adolescents
Do not exceed recommended volume/concentration for the particular intravascular indication; per the manufacturer, 12 mL of 200 mg iodine/mL injection per procedure intrathecally. Others have suggested up to 15 mL of 200 mg iodine/mL injection per procedure intrathecally.
-Children
8-12 years: Do not exceed recommended volume/concentration for the particular intravascular indication; per the manufacturer, 11 mL of 200 mg iodine/mL injection per procedure intrathecally. Others have suggested up to 15 mL of 200 mg iodine/mL injection per procedure intrathecally.
2-7 years: Do not exceed recommended volume/concentration for the particular intravascular indication; per the manufacturer, 9 mL of 200 mg iodine/mL injection per procedure intrathecally. Others have suggested up to 12 mL of 200 mg iodine/mL injection per procedure intrathecally
12-24 months: Do not exceed recommended volume/concentration for the particular intravascular indication. Safe and effective use has not been established for myelography; a dose of 8 mL of 200 mg iodine/mL injection per procedure intrathecally has been suggested.
-Infants
>= 2 months: Do not exceed recommended volume/concentration for the particular intravascular indication. Safe and effective use has not been established for myelography; a dose of 8 mL of 200 mg iodine/mL injection per procedure intrathecally has been suggested.
< 2 months: Do not exceed recommended volume/concentration for the particular intravascular indication. Safe and effective use has not been established for myelography; a dose up to 6 mL of 200 mg iodine/mL injection per procedure intrathecally has been suggested.
Patients with Hepatic Impairment Dosing
Specific guidelines for dosage adjustment in hepatic impairment are not available; it appears no dosage adjustments are needed.
Patients with Renal Impairment Dosing
Specific guidelines for dosage adjustment in renal impairment are not available; however, iopamidol 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.
Betamethasone: (Contraindicated) Because both intrathecal corticosteroids (i.e., betamethasone) and intrathecal radiopaque contrast agents (i.e., iopamidoll) can increase the risk of seizures, the intrathecal administration of corticosteroids with intrathecal radiopaque contrast agents is contraindicated.
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.
Clonazepam: (Moderate) The use of intrathecal radiopaque contrast agents is associated with a risk of seizures. Patients should be instructed to continue using benzodiazepines during procedures or exams that require the use of intrathecal radiopaque contrast agents as abrupt discontinuation of benzodiazepines may also increase seizure risk.
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.
Dexamethasone: (Contraindicated) Because both intrathecal corticosteroids (i.e., dexamethasone) and intrathecal radiopaque contrast agents (i.e., iopamidoll) can increase the risk of seizures, the intrathecal administration of corticosteroids with intrathecal radiopaque contrast agents is contraindicated.
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.
Hydrocortisone: (Contraindicated) Because both intrathecal corticosteroids (i.e., hydrocortisone) and intrathecal radiopaque contrast agents (i.e., iopamidoll) can increase the risk of seizures, the intrathecal administration of corticosteroids with intrathecal radiopaque contrast agents is contraindicated.
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.
Isocarboxazid: (Major) Discontinue monoamine oxidase inhibitors (MAOIs) at least 48 hours before myelography with iopamidol and do not resume for at least 24 hours post procedure due to increased seizure risk. In non-elective procedures in patients on these drugs, consider prophylactic use of anticonvulsants.
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.
Linezolid: (Major) Discontinue linezolid at least 48 hours before myelography with iopamidol and do not resume for at least 24 hours post procedure due to increased seizure risk. In non-elective procedures in patients on these drugs, consider prophylactic use of anticonvulsants.
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.
Lorazepam: (Moderate) The use of intrathecal radiopaque contrast agents is associated with a risk of seizures. Patients should be instructed to continue using benzodiazepines during procedures or exams that require the use of intrathecal radiopaque contrast agents as abrupt discontinuation of benzodiazepines may also increase seizure risk.
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.
Methylprednisolone: (Contraindicated) Because both intrathecal corticosteroids (i.e., methylprednisolone) and intrathecal radiopaque contrast agents (i.e., iopamidoll) can increase the risk of seizures, the intrathecal administration of corticosteroids with intrathecal radiopaque contrast agents is contraindicated.
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.
Monoamine oxidase inhibitors: (Major) Discontinue monoamine oxidase inhibitors (MAOIs) at least 48 hours before myelography with iopamidol and do not resume for at least 24 hours post procedure due to increased seizure risk. In non-elective procedures in patients on these drugs, consider prophylactic use of anticonvulsants.
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.
Phenelzine: (Major) Discontinue monoamine oxidase inhibitors (MAOIs) at least 48 hours before myelography with iopamidol and do not resume for at least 24 hours post procedure due to increased seizure risk. In non-elective procedures in patients on these drugs, consider prophylactic use of anticonvulsants.
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.
Prednisolone: (Contraindicated) Because both intrathecal corticosteroids (i.e., prednisolone) and intrathecal radiopaque contrast agents (i.e., iopamidoll) can increase the risk of seizures, the intrathecal administration of corticosteroids with intrathecal radiopaque contrast agents is contraindicated.
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.
Theophylline, Aminophylline: (Major) Use of medications that lower the seizure threshold, such as aminophylline, should be carefully evaluated when considering intrathecal iopamidol. Some physicians discontinue these drugs at least 48 hours before and for at least 24 hours after intrathecal use. (Major) Use of medications that lower the seizure threshold, such as theophylline, should be carefully evaluated when considering intrathecal iopamidol. Some physicians discontinue these drugs at least 48 hours before and for at least 24 hours after intrathecal use.
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.
Tranylcypromine: (Major) Discontinue monoamine oxidase inhibitors (MAOIs) at least 48 hours before myelography with iopamidol and do not resume for at least 24 hours post procedure due to increased seizure risk. In non-elective procedures in patients on these drugs, consider prophylactic use of anticonvulsants.
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.
Iopamidol is an iodinated contrast media used to visualize the anatomical structures of the body including blood vessels, tissues, and organs. Iodine is the radiopaque component of iopamidol, allowing for opacification of vessels in the path of the blood flow of contrast media during angiography and urography. After iopamidol injection, internal structures of the human body can be visualized until significant hemodilution occurs.
For enhancement of computed tomographic (CT) imaging, the degree of visualization is directly related to the iodine content of an administered dose; peak iodine blood concentrations 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 5-40 minutes occurs most likely because the accumulation of iodine within the lesion and the outside blood pool is necessary for visualization; the mechanism by which this occurs is not clear. The radiographic enhancement of nontumoral lesions, such as arteriovenous malformations and aneurysms, is probably dependent on the iodine content of the circulating blood pool. 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 iopamidol accumulation within the blood pool. If the presence of a malignant tumor causes a break in the blood-brain barrier, contrast media does accumulate within the interstitial tissues of the tumor; however, adjacent normal brain tissue does not contain contrast medium. During computed tomography of the body, enhancement is related to blood flow, concentration of the contrast medium, and extraction of the contrast medium by interstitial tissue of tumors since no barrier exists. In contrast to brain imaging, contrast enhancement is due to the relative differences in extravascular diffusion of contrast media between normal and abnormal tissue.
Iopamidol is administered by intravascular (intravenous or intra-arterial) or intrathecal injection. Care should be taken to administer only iopamidol for intrathecal administration (Isovue-M) intrathecally. Iopamidol demonstrates 2-compartment model pharmacokinetics. Peak plasma concentrations occur rapidly allowing for quick visualization of the blood, liver, spleen and other organs followed by slow urinary excretion. Following intravascular injection, iopamidol is immediately distributed into circulating blood volume (the vascular phase). Iopamidol 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; it does not appear that iopamidol is significantly deposited into normal tissue. Iopamidol is not significantly bound to plasma or serum proteins and does not cross the blood-brain barrier. Iopamidol does not undergo any significant metabolism, deiodination, or biotransformation but is primarily eliminated through the kidneys via glomerular filtration. The elimination half-life is approximately 2 hours in patients with normal renal function. 35-40% of the dose of iopamidol is recovered in the urine at 60 minutes, 80-90% at 8 hours, and 90% or more at 72-96 hours. Less than one percent of the administered dose is recovered in the feces.
-Route-Specific Pharmacokinetics
Intravenous Route
Visualization of the renal parenchyma occurs within 30-60 seconds after intravenous injection of iopamidol. The calyces and pelves in patients can be visualized within 1-3 minutes, but optimal visualization occurs after 5-15 minutes. In patients with renal impairment, visualization may be delayed. Maximum contrast enhancement during computed tomography brain imaging ranges from 5-40 minutes 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 administration of the contrast medium, and following intra-arterial rather than intravenous administration. 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.
Other Route(s)
Intrathecal Route
Intrathecally administered iopamidol is rapidly absorbed into the bloodstream from the cerebrospinal fluid (CSF). Iopamidol appears in plasma within one hour after intrathecal administration and almost all drug reaches systemic circulation within 24 hours. After intrathecal injection, contrast enhancement will be visualized for up to 30 minutes using conventional radiography; after one hour, contrast enhancement is usually negligible. Sufficient contrast for computed tomography myelography, will be available for several hours post administration.
Intra-arterial Route
Contrast enhancement during computed tomography of the body appears to be greatest soon after administration of the contrast medium, and following intra-arterial rather than intravenous administration. 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 iopamidol, is reduced; the reduction in contrast media 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. Both hemodialysis and continuous ambulatory peritoneal dialysis (CAPD) are effective in removing contrast media from the body. Approximately 73% of iopamidol is removed after 4 hours of hemodialysis. In patients undergoing CAPD (4 two-liter exchanges per day), an average of 75% of iopamidol (range 60 to 93%) was recovered in the urine plus dialysate after 7 days. The half-life of iopamidol in CAPD patients in this study was 37.9 hours. 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.
Pediatrics
It is possible that in infants with immature kidneys, nonrenal excretion of iopamidol such as biliary elimination or hepatic metabolism is increased.