Ioversol is an iodinated nonionic, low-osmolar contrast medium used for visualization of the internal structures of the body during angiography including digital subtraction angiography and excretory urography. Ioversol is used to enhance computed tomography imaging of the head and body. Ioversol was approved by the FDA on December 30, 1988.
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 plus antihistamines. Cardiovascular toxicity can occur but is more prevalent in coronary arteriography and when using 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 and have been associated with the use of intravascular 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 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% 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 necessary to obtain adequate visualization should be used. Using lower doses reduces the risk of adverse reactions. The dose and concentration of ioversol, 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
-Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit; do not use if particulate matter or discoloration are present or if container is damaged.
Preparation
-Use sterile technique for all handling and administration of ioversol.
-Single use containers: Discard unused portion after use.
-Bulk vials: Penetrate the container closure only 1 time using a suitable transfer device or dispensing set; a maximum time of 4 hours from initial closure entry is permitted to complete fluid transfer.
-Do not mix with other drugs or solutions.
Administration
-Ioversol is for intravascular use only (via intravenous or intra-arterial injection). Do NOT administer intrathecally and use care to avoid inadvertent intrathecal administration. Avoid extravasation, particularly in patients with severe arterial or venous disease.
-Warm ioversol and administer at body or room temperature.
-Use the lowest dose necessary to obtain adequate visualization.
Intravenous Administration
-When using intravenously, it may be prudent to use a short needle catheter assembly that can be left in place for venous access in case a major reaction occurs.
Adverse reactions to contrast media can generally be classified as idiosyncratic (unpredictable, not related to dosage) or chemotoxic (related to dosage, osmolality, viscosity, hydrophilicity, etc.). Idiosyncratic reactions occur more frequently in patients 20 to 40 years old. Most patients tolerate contrast media injections without sequelae and 95% of reactions to nonionic contrast media are mild to moderate; however, life-threatening reactions, usually cardiovascular in nature, can occur. The incidence of adverse reactions has been dramatically reduced by the introduction of low osmolar, nonionic contrast media. In a study of over 300,000 patients comparing intravenous administration of ionic versus nonionic contrast media, adverse reactions were reduced from 12.66% with ionic contrast media to 3.13% with nonionic contrast media (p < 0.01). 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 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 decompensation, cardiac arrest, unconsciousness, shock, and death have been reported with ioversol use. Most deaths occur during injection or within the first 5 to 10 minutes. The reported incidence of death ranges from 6.6 per 1 million patients (0.00066%) to 1 in 10,000 patients (0.01%). 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. The incidence of severe anaphylactoid reactions is 0.04% to 0.22%. Those patients at higher risk for hypersensitivity-type reactions are those with asthma, a history of allergies to drugs or foods, and those with a history of previous contrast media hypersensitivity. Most reactions occur within 1 to 3 minutes, but delayed hypersensitivity reactions can occur as long as 3 days to 1 week post administration of contrast media. Symptoms of hypersensitivity range from mild including nasal congestion, sneezing, pruritus, and rash (unspecified) to severe including urticaria, swelling, laryngeal edema, laryngospasm, bronchospasm, wheezing, and anaphylactic shock. The incidence of delayed hypersensitivity is less than 4% with the most common presentation being maculopapular rash; other symptoms such as urticaria and angioedema may also be present.
The administration of contrast media such as ioversol is associated with nephrotoxicity. The definition of contrast-induced nephrotoxicity (CIN) varies but is generally recognized as a rise in serum creatine 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.
Care should be taken not to administer ioversol 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 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 (ST segment depression, AV block, nodal rhythm), palpitations, hypotension, angina pectoris, myocardial ischemia or myocardial infarction have been reported when iodinated contrast media are 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 and hemodynamic reactions, although some controversy exists. Not only do nonionic contrast media have fewer cardiac reactions, but the buffer/stabilizer used in ioversol, 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 ioversol.
Seizures, drowsiness, paresis, and visual impairment occur more commonly during cerebral arteriography using ioversol. 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 ioversol is associated with the sensation of warmth, pain, and flushing/hot flashes 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.
Injection site reaction (including pain, swelling, induration, pruritus, erythema, rash, and nerve injury) is most often due to extravasation of the contrast medium such as ioversol. 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 has been reported to be successful in relieving extravasation.
In controlled clinical trials involving 159 patients for pediatric angiocardiography, contrast enhanced computed tomographic imaging of the head and body, and intravenous excretory urography using ioversol, adverse reactions reported were as follows: fever (1.3%), nausea (0.6%), muscle spasm (0.6%) and LV pressure changes (0.6%). 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 have been reported with ioversol or other 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 include vasodilation (feeling of warmth), flushing, cerebral hematoma, hemodynamic disturbances, sinus bradycardia, transient electrocardiographic abnormalities, conduction defects, arrhythmias, sinus tachycardia, hypertension, hypertensive crisis, transient ischemic attack, thrombo-phlebitis, petechiae, vasovagal reactions, peripheral edema, arterial spasms, vasospasms, pseudoaneurysm, chest pain (unspecified), and disseminated intravascular coagulation (DIC). Gastrointestinal system reactions including dysphagia, nausea, vomiting, abdominal pain, dry mouth (xerostomia), and choking have been reported. In addition, nervous system reactions and special senses disorders including anxiety, blurred vision, vertigo, cerebral infarct, dizziness, headache, visual hallucinations, confusion or disorientation, paresthesias, dysphasia, muscle spasms, muscle weakness, syncope, convulsions or seizures, tremor, aphasia, paralysis, transient cortical blindness, visual impairment, tinnitus, and coma have been reported. Respiratory-related adverse events have been reported and include respiratory arrest, laryngeal edema, laryngospasm and bronchospasm, asthma, pulmonary edema, dyspnea, hypoxia, and hyperventilation. These symptoms may be the initial manifestations of severe but infrequent allergic-type reactions and can progress into anaphylaxis, apnea, or cyanosis. Increased cough, sneezing, nasal congestion, and rhinitis have also been reported. Other reported adverse events include metabolic acidosis, erythema multiforme, periorbital or facial edema, fever, chills, back pain, asthenia, malaise, fatigue, increased sweating (hyperhidrosis), dysgeusia (bad taste), conjunctivitis, ecchymosis, polyuria, urinary retention, nephrosis of the proximal tubular cells, and renal failure.
Some adverse reactions that occur may be as consequence of the procedure, such as bleeding, pseudoaneurysms at the puncture site, brachial plexus palsy following axillary artery injections, are possible. During aortography, the risks include injury to the aorta and neighboring organs, pleural puncture, renal damage including infarction and renal tubular necrosis, retroperitoneal bleeding from the translumbar approach, and spinal cord injury and pathology associated with the syndrome of transverse myelitis. Under conditions of slowed aortic circulation, there is an increased likelihood of muscle spasms. Thromboembolism, venous thrombosis, displacement of arterial plaques, stroke, dissection of the coronary vessels and transient sinus arrest are rare complications. While clinical manifestations have not been noted, in vitro studies with animal blood show that many radiopaque contrast agents produce a slight depression 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.
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.
Cerebral arteriography 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.
Peripheral arteriography, with agents like ioversol, should be performed with caution, if at all, in patients with severe ischemia; pulsation should be present in the artery to be injected.
Under conditions of slowed aortic circulation, there is an increased likelihood for aortography to cause muscle spasm. In addition, serious neurologic complications, including paraplegia, have been reported in patients with aortoiliac obstruction, femoral artery obstruction, abdominal compression, hypotension, hypertension, concomitant spinal anesthesia, and injection of vasopressors to increase contrast. In these patients, the concentration, volume, and number of repeat injections of contrast media should be minimized with appropriate intervals between injections (to allow for correction of possible hemodynamic disturbances).
Serious, life-threatening, or fatal anaphylactoid or cardiovascular reactions have been reported with the use of contrast media such as ioversol. 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 such as ioversol. Meticulous intravascular administration technique has reduced the incidence of such complications; however, controversy exists as to whether nonionic contrast media such as ioversol 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 procedure itself is thrombogenic, not the contrast media (i.e., clots forming on the catheters and guidewires, catheter manipulation causing existing plaques to dislodge, or damage/perforation of the vessel wall). Because many factors contribute to thromboembolic events including length of procedure, catheter and syringe material, underlying disease 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. Test injections to ensure proper catheter placement may also be prudent. Clotting has been reported when blood remains in contact with syringes containing nonionic contrast media; the use of plastic syringes in place of glass may minimize in vitro clotting. Special care is necessary when venography is performed in patients with suspected thromboembolic disease such as thrombosis, 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 creatine 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, repeat contrast media exposure within 72 hours, reduced effective arterial volume (i.e., cirrhosis and nephrosis), contrast media type (e.g., ionic contrast media is associated with a higher incidence of CIN than nonionic), and contrast media dose (e.g., higher doses of contrast media are associated with more nephrotoxicity). The patient's risk factors should be taken into consideration before administering contrast such as ioversol 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.
Ioversol is not indicated for intrathecal administration. 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 nonionic contrast media occurs. In addition, renal failure, cardiac arrest, and rhabdomyolysis have been reported.
Contrast media such as ioversol should 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 pre-existing state of dehydration rather than an interaction between the disease itself and the contrast media. If the need arises, patients with multiple myeloma can receive contrast media, but they should be 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 ioversol 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 ioversol 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 ioversol is considerably less hyper-osmolar when compared to the ionic agents such as diatrizoate, ioversol 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 ioversol 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 such as ioversol. It has been suggested that contrast media 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 ioversol 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 ioversol, 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., ioversol) than ionic. In terms of overall cardiovascular safety, nonionic contrast media such as ioversol tend to be less arrhythmogenic and cause less hemodynamic and electrophysiologic changes than their ionic counterparts.
Angiocardiography using ioversol should proceed with caution in patients with chronic pulmonary emphysema as instructed by the manufacturer. 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.
Care should be taken to avoid extravasation of contrast media such as ioversol, 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 ioversol 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 ioversol. 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.
Ioversol is nearly completely excreted as parent drug by the kidney, and the risk of adverse reactions may be greater in patients with impaired renal function. Because geriatric patients are more likely to have decreased renal function, dose selection should be cautious usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy.
Evaluate thyroid function based on underlying risk factors in neonates, infants, and children 3 years or younger after exposure to an iodinated contrast media, especially in term and premature neonates. Hypothyroidism or transient thyroid suppression has been reported in pediatric patients (age birth to 3 years) after both single and multiple exposures to iodinated contrast media, such as ioversol. 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.
Postmarketing data with ioversol use in human pregnancy are insufficient to inform a drug-associated risk. Limited data show that ioversol crosses the placenta and is visualized in the digestive tract of exposed infants. In animal reproduction studies, no adverse effects were noted after daily intravenous administration of ioversol to pregnant rats (gestation day 7 to 17) and rabbits (gestation day 6 to 18) at doses 0.35 and 0.71 times, respectively, the maximum recommended human dose. Due to the potential risks to the fetus, the American College of Radiology (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 contrast during pregnancy appears to be safe and should be administered as per usual. It is advised to screen a neonate whose mother received iodinated contrast during pregnancy for hypothyroidism.
There are no data available on the presence of ioversol in human milk, the effects on the breast-fed infant, or the effects on milk production. However, iodinated contrast agents are excreted unchanged in human milk in very minimal amounts with poor absorption from the gastrointestinal tract of the breast-fed infant. Interruption of breast-feeding is not necessary after exposure to ioversol because the potential exposure to the breast-fed infant to iodine is small. A lactating woman may consider interrupting breast-feeding and pumping and discarding breast milk for 8 hours (approximately 5 elimination half-lives) after ioversol administration in order to minimize drug exposure to the infant. The Guidelines for Computed Tomography and Magnetic Resonance Imaging Use During Pregnancy and Lactation and the American College of Radiology (ACR) manual on contrast media also state that lactating women receiving iodinated contrast can continue to breast-feed without interruption. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for ioversol and any potential adverse effects on the breast-fed infant from ioversol or the underlying maternal condition.
Patients should be well-hydrated prior to and following ioversol 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 ioversol necessary to obtain adequate visualization should be used. Using lower doses reduces the risk of adverse reactions. The dose and concentration of ioversol, 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: 2 to 12 mL intra-arterial of ioversol 240 mg iodine/mL (Optiray 240), 300 mg iodine/mL (Optiray 300), or 320 mg iodine/mL (Optiray 320) repeated as necessary for visualization of the carotid or vertebral arteries. 20 to 50 mL injected through the aortic arch is necessary for a simultaneous 4-vessel study. If multiple injections are necessary, up to 200 mL can be used.
-for use as a contrast in peripheral arteriography:
Intra-arterial dosage:
Adults: 60 mL (range: 20 to 90 mL) intra-arterial for visualization of the aorto-iliac runoff; 40 mL (range: 10 to 50 mL) intra-arterial for visualization of the common iliac/femoral artery; 20 mL (range: 15 to 30 mL) intra-arterial for visualization of the subclavian/brachial artery of ioversol 300 mg iodine/mL (Optiray 300), 320 mg iodine/mL (Optiray 320), or 350 mg iodine/mL (Optiray 350). If multiple injections are necessary, up to 250 mL can be used.
-for use as a contrast in peripheral venography:
Intravenous dosage:
Adults: 50 to 100 mL IV per extremity of ioversol 240 mg iodine/mL (Optiray 240), 300 mg iodine/mL (Optiray 300), 320 mg iodine/mL (Optiray 320), or 350 mg iodine/mL (Optiray 350). The maximum total dosage is 250 mL.
-for use as a contrast in selective visceral arteriography and aortography:
Intra-arterial dosage:
Adults: 45 mL (range: 10 to 80 mL) intra-arterial for visualization of the aorta; 45 mL (range: 12 to 60 mL) intra-arterial for visualization of the celiac artery; 45 mL (range: 15 to 60 mL) intra-arterial for visualization of the superior mesenteric artery; 9 mL (range: 6 to 15 mL) intra-arterial for visualization of the renal artery or the inferior mesenteric artery of ioversol 320 mg iodine/mL (Optiray 320). If multiple injections are necessary, up to 250 mL can be used.
-for use as a contrast in adult angiocardiography including left ventriculography and coronary arteriography:
Intra-arterial dosage:
Adults: 8 mL (range: 2 to 10 mL) intra-arterial for visualization of the left coronary artery; 6 mL (range: 1 to 10 mL) intra-arterial for visualization of the right coronary artery; 40 mL (range: 30 to 50 mL) intra-arterial for visualization of the left ventricle of ioversol 320 mg iodine/mL (Optiray 320) or 350 mg iodine/mL (Optiray 350). If multiple injections are necessary, up to 250 mL can be used.
-for use as a contrast in pediatric angiocardiography:
NOTE: When using large volumes as a single injection, several minutes between repeat injections should lapse to allow for correction of possible hemodynamic disturbances. EKGs and vital signs should be routinely monitored during this procedure.
Intra-arterial dosage:
Infants, Children, and Adolescents: 1.25 mL/kg (range: 1 to 1.5 mL/kg) intra-arterial of ioversol 320 mg iodine/mL (Optiray 320) or 350 mg iodine/mL (Optiray 350). When multiple injections are given, the total administered dose should not exceed 5 mL/kg up to a total volume of 250 mL.
-for use as a contrast in digital subtraction angiography (DSA):
Intravenous dosage:
Adults: 30 to 50 mL IV of ioversol 350 mg iodine/mL (Optiray 350). Injections may be repeated as necessary; the total dosage should not exceed 250 mL. The rate of injection should be 10 to 30 mL/second for central injections and 12 to 20 mL/second following peripheral injections.
For use as a contrast in excretory urography:
Intravenous dosage:
Adults: 50 to 75 mL IV of ioversol 350 mg iodine/mL (Optiray 350), 320 mg iodine/mL (Optiray 320), or 300 mg iodine/mL (Optiray 300) is the usual dose. Alternatively, 75 to 100 mL IV of ioversol 240 mg iodine/mL (Optiray 240) can be used. Regimens for high-dose urography include ioversol 350 mg iodine/mL (Optiray 350) at a dosage of 1.4 mL/kg IV (Max: 140 mL), ioversol 320 mg iodine/mL (Optiray 320) at a dose of 1.5 to 2 mL/kg IV (Max: 150 mL), ioversol 300 mg iodine/mL (Optiray 300) at a dose of 1.6 mL/kg IV (Max: 150 mL), or ioversol 240 mg iodine/mL (Optiray 240) at a dose of 2 mL/kg IV (Max: 200 mL).
Infants, Children, and Adolescents: 1 to 1.5 mL/kg (range: 0.5 to 3 mL/kg) IV of ioversol 320 mg iodine/mL (Optiray 320). The total administered dose should not exceed 3 mL/kg.
For use during computed tomography (CT) imaging of the head and body:
-for use as a contrast enhancement during CT imaging of the head:
Intravenous dosage:
Adults: 50 to 150 mL IV infusion of ioversol 300 mg iodine/mL (Optiray 300), 320 mg iodine/mL (Optiray 320), or 350 mg iodine/mL (Optiray 350) or 100 to 250 mL IV infusion of ioversol 240 mg iodine/mL (Optiray 240).
Infants, Children, and Adolescents: 1.5 to 2 mL/kg (range: 1 to 3 mL/kg) IV of ioversol 320 mg iodine/mL (Optiray 320).
-for use as a contrast enhancement during CT imaging of the body:
Intravenous dosage:
Adults: 25 to 75 mL IV bolus or 50 to 150 mL IV infusion of ioversol 300 mg iodine/mL (Optiray 300), 320 mg iodine/mL (Optiray 320), or 350 mg iodine/mL (Optiray 350) or 35 to 100 mL IV bolus or 70 to 250 mL IV infusion of ioversol 240 mg iodine/mL (Optiray 240). May administer by bolus injection, rapid infusion, or a combination of both.
Infants, Children, and Adolescents: 1.5 to 2 mL/kg (range: 1 to 3 mL/kg) IV of ioversol 320 mg iodine/mL (Optiray 320).
Maximum Dosage Limits:
-Adults
Do not exceed the recommended volume/concentration for the particular intravascular indication; 250 mL total volume of ioversol.
-Geriatric
Do not exceed the recommended volume/concentration for the particular intravascular indication; 250 mL total volume of ioversol.
-Adolescents
Do not exceed the recommended volume/concentration for the particular intravascular indication; 5 mL/kg up to 250 mL total volume of ioversol.
-Children
Do not exceed the recommended volume/concentration for the particular intravascular indication; 5 mL/kg up to 250 mL total volume of ioversol.
-Infants
Do not exceed the recommended volume/concentration for the particular intravascular indication; 5 mL/kg total volume of ioversol.
-Neonates
Safety and efficacy have not been established.
Patients with Hepatic Impairment Dosing
Specific guidelines for dosage adjustment in hepatic impairment are not available; however, it appears no dosage adjustments are needed.
Patients with Renal Impairment Dosing
Specific guidelines for dosage adjustment in renal impairment are not available; however, ioversol can cause acute renal failure and this risk is higher in patients with underlying renal insufficiency. Patients with renal insufficiency should be well-hydrated and the smallest volume of contrast media should be used.
*non-FDA-approved indication
Acebutolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Acetaminophen; Aspirin, ASA; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Acetaminophen; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Acetaminophen; Caffeine; Dihydrocodeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Acetaminophen; Caffeine; Pyrilamine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acetaminophen; Chlorpheniramine; Phenylephrine : (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acetaminophen; Dextromethorphan; Guaifenesin; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acetaminophen; Dextromethorphan; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acetaminophen; Guaifenesin; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acetaminophen; Ibuprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Acetaminophen; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Acyclovir: (Moderate) Concomitant use of acyclovir and contrast agents should be avoided when possible, as use of these drugs together may increase the risk for nephrotoxicity.
Aldesleukin, IL-2: (Moderate) Monitor patients for delayed aldesleukin "recall" reactions in patients receiving iodinated contrast media after aldesleukin therapy. Symptom onset is typically from 1 to 4 hours after administration of iodinated contrast media and may resemble aldesleukin-related infusion reactions including fever, chills, nausea, vomiting, pruritus, rash, diarrhea, hypotension, edema, and oliguria. While most common when contrast media is given within 4 weeks of the last dose of aldesleukin, reports have also occurred when contrast media was administered several months after aldesleukin treatment.
Aliskiren; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Alogliptin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Amikacin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Amiloride: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Amiloride; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Aminoglycosides: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Amiodarone: (Major) When injected directly into coronary arteries, contrast media can cause bradycardia and QT interval prolongation; these reactions tend to be less common with nonionic low-osmolar contrast media. In a retrospective review of 21 patients on amiodarone therapy who underwent cardiac catheterization with iohexol, the QTc interval was significantly prolonged 12-24 hours post catheterization from a baseline QTc interval of 433 msec (95%CI 419-483 msec) to 480 msec (95%CI, 422-483 msec) (p< 0.001). No significant change in the QTc interval was seen in non-amiodarone treated control patients. Until more data are available, clinicians should closely monitor patients taking amiodarone during cardiac catheterization with radiopaque contrast agents; EKG monitoring during intra-coronary artery injection of radiopaque contrast agents is recommended.
Amitriptyline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Amlodipine; Benazepril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Amlodipine; Celecoxib: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Amoxapine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Amoxapine should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Amphetamine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Amphetamines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Amphetamine; Dextroamphetamine Salts: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Amphetamines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Amphetamine; Dextroamphetamine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Amphetamines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Amphotericin B: (Moderate) Because the use of other nephrotoxic drugs, including amphotericin B, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Angiotensin II: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Angiotensin-converting enzyme inhibitors: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Aprotinin: (Moderate) The manufacturer recommends using aprotinin cautiously in patients that are receiving drugs that can affect renal function, such as radiopaque contrast agents, as the risk of renal impairment may be increased.
Aripiprazole: (Major) Aripiprazole lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Articaine; Epinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Asenapine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure. The frequency of seizure activity with asenapine was low during clinical trials; however, seizures have been associated with other antipsychotics and caution is advised.
Aspirin, ASA; Butalbital; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Aspirin, ASA; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Aspirin, ASA; Caffeine; Orphenadrine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Atenolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Atenolol; Chlorthalidone: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Azilsartan; Chlorthalidone: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Barium Sulfate: (Major) Delay the administration of non-ionic contrast media in patients who have recently received an oral cholecystographic contrast agent, such as barium. Renal toxicity has been reported in patients with liver dysfunction who were given an oral cholecystographic agent followed by intravascular iodinated contrast agents.
Benazepril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Benazepril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Benzphetamine: (Major) Sympathomimetics lower the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Beta-blockers: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Betaxolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Bictegravir; Emtricitabine; Tenofovir Alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Bisoprolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Brexpiprazole: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics such as brexpiprazole should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post procedure.
Brimonidine; Timolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Brompheniramine; Dextromethorphan; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Brompheniramine; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Bumetanide: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Bupivacaine; Epinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Bupivacaine; Meloxicam: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Bupropion: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Bupropion should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Bupropion; Naltrexone: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Bupropion should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Butalbital; Acetaminophen; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Butalbital; Acetaminophen; Caffeine; Codeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Butalbital; Aspirin; Caffeine; Codeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure. (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Caffeine; Sodium Benzoate: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Calcium, Magnesium, Potassium, Sodium Oxybates: (Major) Sodium oxybate lowers seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Canagliflozin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Candesartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Capreomycin: (Major) Because the use of other nephrotoxic drugs, including capreomycin, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible. Monitor patients for changes in renal function if these drugs are coadministered.
Captopril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Captopril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Carteolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Carvedilol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Celecoxib: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Celecoxib; Tramadol: (Major) Tramadol lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure. (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Chlordiazepoxide; Amitriptyline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Chlorothiazide: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Chlorpheniramine; Dextromethorphan; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Chlorpheniramine; Ibuprofen; Pseudoephedrine: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Chlorpheniramine; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Chlorpromazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Chlorthalidone: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Cisplatin: (Moderate) Closely monitor renal function if concomitant use with cisplatin and non-ionic contrast media is necessary. Both drugs can cause nephrotoxicity, which may be additive when used together.
Clindamycin: (Moderate) Concomitant use of non-ionic contrast media and clindamycin may result in additive nephrotoxicity. Monitor for renal toxicity if concomitant use is required.
Clomipramine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Clozapine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Cocaine: (Major) Use of medications that lower the seizure threshold, such as cocaine, should be carefully evaluated when considering intrathecal radiopaque contrast agentsl. While the contributory role of such medications has not been established, some physicians discontinue these drugs at least 48 hours before and for at least 24 hours after intrathecal use.
Codeine; Phenylephrine; Promethazine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects. (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Codeine; Promethazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Colistimethate, Colistin, Polymyxin E: (Major) Because the use of other nephrotoxic drugs, including colistimethate sodium, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible. Monitor patients for changes in renal function if these drugs are coadministered.
Colistin: (Major) Because the use of other nephrotoxic drugs, including colistimethate sodium, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible. Monitor patients for changes in renal function if these drugs are coadministered.
Cyclobenzaprine: (Major) Use of medications that lower the seizure threshold, such as cyclobenzaprine, should be carefully evaluated when considering intrathecal radiopaque contrast agents. Cyclobenzaprine should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Cyclosporine: (Moderate) Because the use of other nephrotoxic drugs, including cyclosporine, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, when possible, cyclosporine should be withheld during radiopaque contrast agent administration.
Dapagliflozin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Darunavir; Cobicistat; Emtricitabine; Tenofovir alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Deferasirox: (Moderate) Acute renal failure has been reported during treatment with deferasirox. Coadministration of deferasirox with other potentially nephrotoxic drugs, including radiopaque contrast agents, may increase the risk of this toxicity. Monitor serum creatinine and/or creatinine clearance in patients who are receiving deferasirox and nephrotoxic drugs concomitantly.
Desipramine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Dexmethylphenidate: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Methylphenidate derivatives should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Dextroamphetamine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Amphetamines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Dextromethorphan; Bupropion: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Bupropion should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Dextromethorphan; Diphenhydramine; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Dextromethorphan; Guaifenesin; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Diclofenac: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Diclofenac; Misoprostol: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Diethylpropion: (Major) Use of medications that lower the seizure threshold, such as diethylpropion, should be carefully evaluated when considering non-ionic contrast media. Such medications should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Diflunisal: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Diphenhydramine; Ibuprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Diphenhydramine; Naproxen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Diphenhydramine; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Dopamine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Doravirine; Lamivudine; Tenofovir disoproxil fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Dorzolamide; Timolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Doxepin: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Droxidopa: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Efavirenz; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Empagliflozin; Linagliptin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Empagliflozin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Emtricitabine; Rilpivirine; Tenofovir alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Emtricitabine; Rilpivirine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Emtricitabine; Tenofovir alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Enalapril, Enalaprilat: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Enalapril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Entecavir: (Moderate) Because entecavir is primarily eliminated by the kidneys and radiopaque contrast agents can affect renal function, concurrent administration with radiopaque contrast agents may increase the serum concentrations of entecavir and adverse events. The manufacturer of entecavir recommends monitoring for adverse effects when these drugs are coadministered.
Ephedrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Ephedrine; Guaifenesin: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Epinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Eprosartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Ergotamine; Caffeine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Ertugliflozin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Esmolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Ethacrynic Acid: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Etodolac: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Fenoprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Fluphenazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Flurbiprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Fosinopril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Fosinopril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Furosemide: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Gentamicin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Glipizide; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Glyburide; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Green Tea: (Major) Some, but not all, green tea products contain caffeine. Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine containing products including green tea should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Guaifenesin; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Haloperidol: (Major) Haloperidol lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Hydrochlorothiazide, HCTZ; Moexipril: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Hydrocodone; Ibuprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Ibandronate: (Moderate) Theoretically, coadministration of intravenous ibandronate with other potentially nephrotoxic drugs, such as radiopaque contrast agents, may increase the risk of developing nephrotoxicity.
Ibuprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Ibuprofen; Famotidine: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Ibuprofen; Oxycodone: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Ibuprofen; Pseudoephedrine: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Iloperidone: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure. Iloperidone has not been associated with seizure activity more frequently than placebo in clinical trials; however, lowering of the seizure threshold is generally a class effect among antipsychotics and caution is advised.
Imipramine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Indomethacin: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Irbesartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Ketoprofen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Ketorolac: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Labetalol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Levobunolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Lidocaine; Epinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Linagliptin; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Lisdexamfetamine: (Major) Use of medications that lower the seizure threshold, such as lisdexamfetamine, should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Lisinopril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Lisinopril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Loop diuretics: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Losartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Loxapine: (Major) Loxapine lower the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Lurasidone: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
Maprotiline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Maprotiline should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Meclofenamate Sodium: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Mefenamic Acid: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Meloxicam: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Metformin; Repaglinide: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Metformin; Saxagliptin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Metformin; Sitagliptin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Methamphetamine: (Major) Methamphetamine lowers the seizure threshold and should be discontinued at least 48 hours before and for at least 24 hours after intrathecal use of contrast media.
Methylphenidate Derivatives: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Methylphenidate derivatives should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Methylphenidate: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Methylphenidate derivatives should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Metolazone: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Metoprolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Metoprolol; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Midodrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Moexipril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Molindone: (Major) Molindone lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Nabumetone: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Nadolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Naproxen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Naproxen; Esomeprazole: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Naproxen; Pseudoephedrine: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Nebivolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Nebivolol; Valsartan: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Nonsteroidal antiinflammatory drugs: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Norepinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Nortriptyline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Olanzapine: (Major) Atypical antipsychotics may lower the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Olanzapine; Fluoxetine: (Major) Atypical antipsychotics may lower the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Olanzapine; Samidorphan: (Major) Atypical antipsychotics may lower the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Olmesartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Oxaliplatin: (Major) Avoid coadministration of oxaliplatin with non-ionic contrast media due to the risk of increased oxaliplatin-related adverse reactions. Non-ionic contrast media is known to be potentially nephrotoxic; because platinum-containing drugs like oxaliplatin are eliminated primarily through the kidney, oxaliplatin clearance may be decreased by coadministration with nephrotoxic agents.
Oxaprozin: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Pamidronate: (Moderate) Coadministration of pamidronate with other nephrotoxic drugs may increase the risk of developing nephrotoxicity following pamidronate administration, even in patients who have normal renal function.
Paromomycin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Perindopril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Perindopril; Amlodipine: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Perphenazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Perphenazine; Amitriptyline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure. (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Phendimetrazine: (Major) Phendimetrazine lowers the seizure threshold and should be discontinued at least 48 hours before and for at least 24 hours after intrathecal use of contrast media.
Phenothiazines: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Phentermine: (Major) Phentermine lowers the seizure threshold and should be discontinued at least 48 hours before and for at least 24 hours after intrathecal use of contrast media.
Phentermine; Topiramate: (Major) Phentermine lowers the seizure threshold and should be discontinued at least 48 hours before and for at least 24 hours after intrathecal use of contrast media.
Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Pimozide: (Major) Pimozide lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Pindolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Pioglitazone; Metformin: (Major) Discontinue metformin at the time of, or before, administration of non-ionic contrast media to patients with an eGFR of 30 to 60 mL/minute/1.73 m2, history of liver disease, alcoholism, or heart failure, or who will be administered intra-arterial iodinated contrast. Reevaluate eGFR 48 hours after the imaging procedure; restart metformin if renal function is stable. Iodinated contrast agents appear to increase the risk of metformin-induced lactic acidosis, possibly as a result of worsening renal function.
Piroxicam: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Plazomicin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Potassium-sparing diuretics: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Prilocaine; Epinephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Prochlorperazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Promethazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Promethazine; Dextromethorphan: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Promethazine; Phenylephrine: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects. (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Propranolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Protriptyline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Quetiapine: (Major) Quetiapine lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Quinapril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Quinapril; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure. (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Ramipril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Risperidone: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Serdexmethylphenidate; Dexmethylphenidate: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Methylphenidate derivatives should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Sodium Iodide: (Contraindicated) Sodium iodide should not be used concurrently with antithyroid agents. These agents can increase the likelihood of hypothyroidism when used in combination with sodium iodide. (Moderate) Administration of non-ionic contrast media may interfere with thyroid uptake of radioactive sodium iodide (I-131) and decrease therapeutic and diagnostic efficacy in patients with carcinoma of the thyroid. The decrease in efficacy lasts for 6 to 8 weeks.
Sodium Oxybate: (Major) Sodium oxybate lowers seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Sotalol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Spironolactone: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Spironolactone; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Streptomycin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Sulindac: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Sumatriptan; Naproxen: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Telmisartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Tenofovir Alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Tenofovir Alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with nephrotoxic agents, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir-containing products should be avoided with concurrent or recent use of a nephrotoxic agent, such as radiopaque contrast agents. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the co-administered drug. Drugs that decrease renal function may also increase concentrations of tenofovir. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir with a majority of the cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents. Monitor patients receiving concomitant nephrotoxic agents for changes in serum creatinine and phosphorus.
Thiazide diuretics: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Thioridazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Thiothixene: (Major) Use of medications that lower the seizure threshold, such as thiothixene, should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Timolol: (Moderate) Use caution when administering non-ionic contrast media to patients taking beta-blockers. Beta-blockers lower the threshold for and increase the severity of contrast reactions and reduce the responsiveness of treatment of hypersensitivity reactions with epinephrine.
Tobramycin: (Moderate) Because the use of other nephrotoxic drugs, such as aminoglycoside antibiotics, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
Tolmetin: (Moderate) Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk for nephrotoxicity when given to patients receiving a contrast agents. When possible, withhold NSAID therapy during administration of a contrast agent.
Torsemide: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Tramadol: (Major) Tramadol lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Tramadol; Acetaminophen: (Major) Tramadol lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Trandolapril: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Trandolapril; Verapamil: (Moderate) Because the use of other nephrotoxic drugs, including ACE inhibitors, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, ACE inhibitor therapy should be withheld, when possible, during radiopaque contrast agent administration.
Triamterene: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Triamterene; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Tricyclic antidepressants: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Trifluoperazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Phenothiazines should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Trimipramine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Tricyclic antidepressants should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Valacyclovir: (Moderate) Concomitant use of valacyclovir and contrast agents should be avoided when possible, as use of these drugs together may increase the risk for nephrotoxicity.
Valsartan; Hydrochlorothiazide, HCTZ: (Major) Do not use diuretics before non-ionic contrast media administration. Concomitant use of diuretics and non-ionic contrast media may increase the risk for acute kidney injury, including renal failure.
Vasopressin, ADH: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Vasopressors: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
Voclosporin: (Moderate) Concomitant use of voclosporin and non-ionic contrast media may result in additive nephrotoxicity. Monitor for renal toxicity if concomitant use is required.
Ziprasidone: (Major) Use of medications that lower the seizure threshold, such as ziprasidone, should be carefully evaluated when considering intrathecal radiopaque contrast agents. Antipsychotics should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
Zoledronic Acid: (Moderate) Theoretically, the chronic coadministration of zoledronic acid with other nephrotoxic drugs, such as radiopaque contrast agents, may increase the risk of developing nephrotoxicity, even in patients who have normal renal function.
Ioversol is an iodinated contrast media used to visualize the internal structures of the body including blood vessels, tissues, and organs. Iodine is the radiopaque component of ioversol, allowing for opacification of vessels in the path of the blood flow of contrast media during angiography and urography. After ioversol injection, internal structures of the human body can be visualized until significant hemodilution occurs.
Ioversol enhances computed tomographic (CT) imaging through augmentation of radiographic efficiency. The degree of enhancement is directly related to the iodine content in the administered dose; peak iodine blood levels usually occur immediately and dramatically decrease within 5-10 minutes. During computed tomographic brain imaging, a lag between contrast media administration and maximum contrast enhancement of up to one hour occurs most likely because 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. 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 ioversol 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 various interstitial tissues since no barrier exists. In contrast to brain imaging, contrast enhancement of the body is due to the relative differences in extravascular diffusion of contrast media between normal and abnormal tissue
Ioversol is administered by intravenous or intra-arterial injection. Care should be taken to avoid intrathecal administration of ioversol. Ioversol demonstrates 2-compartment model pharmacokinetics. Peak plasma concentrations occur rapidly allowing for quick visualization of the blood, liver, spleen, and other organs followed by slower urinary excretion. Enhancement of visualization of tissues by contrast media is directly related to the vascularization of the specific tissue. Ioversol is not significantly bound to to serum or plasma proteins, does not cross the blood-brain barrier, but probably does cross the placental barrier by simple diffusion. Ioversol does not undergo any significant metabolism, deiodination, or biotransformation, but is primarily eliminated via glomerular filtration through the kidneys. The biological half-life of ioversol is 1.5 hours in healthy volunteers. In addition, the mean half-life for urinary excretion following a 50 mL and a 150 mL dose is 118 minutes and 105 minutes, respectively, in patients with normal renal function. Greater than 95% of the administered dose is excreted in the first 24 hours. Fecal elimination is negligible.
-Route-Specific Pharmacokinetics
Intravenous Route
Following intravascular injection, ioversol is immediately distributed into circulating blood volume (the vascular phase). Ioversol then distributes into the interstitial space; after equilibrium, distribution into extracellular space occurs. Visualization of the renal parenchyma occurs within 30-60 seconds following rapid intravenous injection. 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 can occur up to one hour after injection depending on the type of lesion to be visualized. Contrast enhancement during computed tomography of the body appears to be greatest soon after bolus administration of the contrast medium. 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 ioversol, is reduced; the reduction in ioversol 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 are effective in removing contrast media from the body. Approximately 82% of ioversol is removed after 4 hours of hemodialysis in patients on chronic hemodialysis. The half-live of ioversol during hemodialysis is similar to that of patients with normal renal function (1.8 hours.) It is possible that in patients with severely impaired renal function, nonrenal excretion such as biliary elimination or hepatic metabolism is increased.
Pediatrics
It is possible that in infants with immature kidneys, nonrenal excretion, such as biliary elimination or hepatic metabolism, is increased for ioversol.