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  • CLASSES

    Radiodiagnostic Agents

    DEA CLASS

    Rx

    DESCRIPTION

    Iodinated, nonionic radiographic contrast agent
    Used for intra-arterial digital subtraction angiography; cerebral and peripheral arteriography; coronary arteriography and left ventriculography, visceral angiography, and aortography; peripheral venography; excretory urography; contrast CT of head and body
    Hydrate and use lowest volume and concentration to minimize toxicity

    COMMON BRAND NAMES

    Ultravist

    HOW SUPPLIED

    Ultravist Intra-Arterial Inj Sol: 1mL, 623.4mg, 768.86mg
    Ultravist Intravenous Inj Sol: 1mL, 623.4mg, 768.86mg

    DOSAGE & INDICATIONS

    For use as contrast in angiography.
    For use as a contrast in cerebral arteriography.
    Intra-arterial dosage
    Adults

    3 to 12 mL/injection of 300 mg iodine/mL intra-arterial for carotid arteries; 4 to 12 mL/injection of 300 mg iodine/mL intra-arterial for vertebral arteries; 20 to 50 mL/injection of 300 mg iodine/mL intra-arterial for aortic arch (4 vessel study). Do not exceed a total volume of 150 mL.

    For use as a contrast in angiocardiography including left ventriculography and coronary arteriography.
    Intra-arterial dosage
    Adults

    3 to 14 mL/injection of 370 mg iodine/mL intra-arterial for left or right coronary artery and 30 to 60 mL/injection of 370 mg iodine/mL intra-arterial for left ventricle. Do not exceed a total volume of 225 mL.

    Children 3 years and older and Adolescents

    1 to 2 mL/kg/dose of 370 mg iodine/mL intra-arterial. Do not exceed a total dose of 4 mL/kg.

    For use as contrast in aortography.
    Intra-arterial dosage
    Adults

    Use a volume of 370 mg iodine/mL intra-arterial that is proportional to the blood flow and related to the vascular and pathological characteristics of the specific vessel being examined. Do not exceed a total dose of 225 mL.

    Children 3 years and older and Adolescents

    1 to 2 mL/kg/dose of 370 mg iodine/mL intra-arterial. Do not exceed a total dose of 4 mL/kg.

    For use as a contrast in visceral angiography.
    Intra-arterial dosage
    Adults

    Use a volume of 370 mg iodine/mL intra-arterial that is proportional to the blood flow and related to the vascular and pathological characteristics of the specific vessel being examined. Do not exceed a total dose of 225 mL.

    For use as a contrast in peripheral arteriography.
    Intra-arterial dosage
    Adults

    25 to 50 mL/injection of 300 mg iodine/mL intra-arterial for aortic bifurcation (distal runoff) and 5 to 40 mL/injection of 300 mg iodine/mL intra-arterial for subclavian or femoral artery. Do not exceed a total volume of 250 mL.

    For use as a contrast in peripheral venography.
    Intravenous dosage
    Adults

    Use the minimum volume of 240 mg iodine/mL IV necessary to satisfactorily visualize the structures under examination. Do not exceed a total volume of 250 mL.

    For use as a contrast in excretory urography.
    Intravenous dosage
    Adults

    1 mL/kg/dose of 300 mg iodine/mL IV. Do not exceed a total volume of 100 mL.

    Children 3 years and older and Adolescents

    1 to 2 mL/kg/dose of 300 mg iodine/mL IV. Do not exceed 3 mL/kg.

    For use as contrast during computed tomography (CT) imaging of the head and body to evaluate for neoplastic and non-neoplastic lesions.
    For computed tomography (CT) imaging of the head.
    Intravenous dosage
    Adults

    50 to 200 mL/dose of 300 mg iodine/mL IV or 41 to 162 mL/dose of 370 mg iodine/mL IV. Do not exceed a total iodine dose of 60 g (i.e., 200 mL/dose of 300 mg iodine/mL or 162 mL/dose of 370 mg iodine/mL).

    Children 3 years and older and Adolescents

    1 to 2 mL/kg/dose of 300 mg iodine/mL IV. Do not exceed 3 mL/kg.

    For computed tomography (CT) imaging of the body.
    Intravenous dosage
    Adults

    50 to 200 mL/dose of 300 mg iodine/mL or 41 to 162 mL/dose of 370 mg iodine/mL IV bolus. Alternately, 100 to 200 mL/dose of 300 mg iodine/mL or 81 to 162 mL/dose of 370 mg iodine/mL rapid IV infusion. Do not exceed a total iodine dose of 60 g (i.e., 200 mL/dose of 300 mg iodine/mL or 162 mL/dose of 370 mg iodine/mL.

    Children 3 years and older and Adolescents

    1 to 2 mL/kg/dose of 300 mg iodine/mL IV. Do not exceed 3 mL/kg.

    MAXIMUM DOSAGE

    Adults

    Do not exceed the recommended volume or concentration for the particular intravascular indication; maximum recommended total dose of iodine is 86 g.

    Geriatric

    Do not exceed the recommended volume or concentration for the particular intravascular indication; maximum recommended total dose of iodine is 86 g.

    Adolescents

    4 mL/kg of the 370 mg iodine/mL intra-arterially; 3 mL/kg of the 300 mg iodine/mL IV.

    Children

    3 to 12 years: 4 mL/kg of the 370 mg iodine/mL intra-arterially; 3 mL/kg of the 300 mg iodine/mL IV.
    1 to 2 years: Safety and efficacy have not been established.

    Infants

    Safety and efficacy have not been established.

    Neonates

    Safety and efficacy have not been established.

    DOSING CONSIDERATIONS

    Hepatic Impairment

    Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

    Renal Impairment

    Specific guidelines for dosage adjustments in renal impairment are not available; however, iopromide 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.

    ADMINISTRATION

    NOTE: Patients should be well hydrated prior to and following iopromide administration. A suggested common regimen in eligible patients (e.g., those patients in which fluid administration would not be contraindicated) is 1 mL/kg/hour of 0.9% Sodium Chloride Injection starting at least 4 hours prior to the procedure or exam and continuing for at least 12 hours after.
    NOTE: In patients with a history of allergic reaction to contrast media or iodine, those with a history of asthma or allergic reactions to drugs or foods, nonionic contrast media should be used. In addition, consider administering prednisone 50 mg PO (or equivalent dose of other steroids) 13 hours, 7 hours, and 1 hour prior to the exam or procedure plus diphenhydramine 50 mg IM or PO 1 hour prior to the procedure. The administration of prophylactic steroids and antihistamines does not prevent all hypersensitivity reactions, but reduces the likelihood and may decrease the severity of the reaction.
    NOTE: Only the lowest dose of iopromide necessary to obtain adequate visualization should be used. Using lower doses reduces the risk of adverse reactions. The dose and concentration of iopromide, age of the patient, patient's body weight, size of the vessel and its blood flow, pathology and degree and extent of opacification required, area to be examined, the patient's disease states, and technique to be employed should all be considered when determining the necessary dose.

    Injectable Administration

    Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit. The solution should be clear and colorless to pale yellow. If discoloration or particulate matter is present, do not use.
    Sterile technique must be used in all methods of administration. If non-disposable equipment is used, scrupulous care should be taken to prevent residual contamination with traces of cleansing agents.
    Do not mix other drugs with iopromide.
    Take care to avoid inadvertent intrathecal administration. The solution must be administered intravascularly (via intravenous or intra-arterial injection).
    Contrast agents that have been transferred to other delivery systems should be used immediately.
    Warming iopromide to body temperature shortly before administering may help improve tolerability and ease of injection.

    Intravenous Administration

    Due to potential chemical incompatibilities, do not inject iopromide in intravenous administration lines containing other drugs or solutions.
    Inject the minimum volume necessary to visualize satisfactorily the structures under examination.
    Administer either by bolus injection or rapid infusion.

    Other Injectable Administration

    Intra-arterial Administration
    When using iopromide for coronary arteriography, left ventriculography, or pediatric angiocardiography, monitor electrocardiograms and vital signs throughout the procedure.
    Ensure proper catheter placement with test injections.
    Inject contrast at rates approximately equal to the flow rate in the vessel being injected.

    STORAGE

    Ultravist:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion 10 hours after initial puncture of container
    - Protect from light
    - Store at 77 degrees F; excursions permitted to 59-86 degrees F

    CONTRAINDICATIONS / PRECAUTIONS

    Intrathecal administration


    Intrathecal administration of iopromide is contraindicated. Ensure precautions are taken to avoid intrathecal administration of iopromide. Severe and fatal neurotoxic adverse reactions including convulsions or seizures, cerebral hemorrhage, coma, paralysis, arachnoiditis, hyperthermia, and brain edema have been reported following inadvertent intrathecal administration of nonionic contrast media. In addition, renal failure, cardiac arrest, and rhabdomyolysis have also been reported.

    Asthma, atopy, iodine hypersensitivity, radiopaque contrast media hypersensitivity

    Serious, life-threatening, and fatal anaphylactoid or cardiovascular reactions have been reported with the use of contrast media such as iopromide. The majority of fatal reactions occur during injection or within the first 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.

    Dehydration, diabetes mellitus, females, hepatic disease, renal disease, renal failure, renal impairment

    Both ionic and nonionic contrast media can cause nephrotoxicity including acute renal failure sometimes requiring dialysis. The definition of contrast-induced nephrotoxicity (CIN) varies but is generally recognized as a rise in serum creatinine of at least 25% to 50% or more than 0.5 mg/dL over baseline. Risk factors for CIN include advanced age, pre-existing renal impairment (usually defined as a creatinine clearance less than 50 to 60 mL/minute), combined renal disease and hepatic disease, concurrent use of nephrotoxic or diuretic medications, diabetes mellitus, dehydration, ejection fraction 40% or less, females, excretory urography, repeat contrast media exposure within 72 hours, reduced effective arterial volume (i.e., cirrhosis and nephrosis), contrast media type (e.g., ionic contrast media is associated with a higher incidence of CIN than nonionic), and contrast media dose (e.g., higher doses of contrast media are associated with more nephrotoxicity). The patient's risk factors should be taken into consideration before administering contrast such as iopromide during an exam or procedure as the presence of multiple risk factors increases the risk for CIN considerably. The most compelling risk factors for CIN are pre-existing renal impairment, and pre-existing renal impairment plus diabetes mellitus. It may be prudent for all patients with a history of renal insufficiency, diabetes mellitus, or advanced age to have a baseline creatinine clearance calculated prior to the procedure or exam. Preventive measures should be considered in all patients regardless of risk factors. Adequate hydration has repeatedly been the only intervention to show success in reducing the incidence of CIN. In addition to hydration, the use of nonionic contrast media and avoiding the concomitant use of nephrotoxic drugs (i.e., non-steroidal anti-inflammatory drugs, aminoglycosides, etc.), laxatives, and diuretics may be prudent. Several studies have evaluated the use of n-acetylcysteine (600 mg PO twice daily for 2 days given the day prior to and the day of the procedure or exam); while conflicting data exists, it appears that n-acetylcysteine may provide some benefit in preventing CIN in high-risk patients. Furthermore, some data indicate that the effects of n-acetylcysteine may be dose-dependent. In patients with myocardial infarction undergoing angioplasty, n-acetylcysteine 1,200 mg IV prior to angioplasty followed by 1,200 mg PO twice daily for 48 hours has been reported to be significantly more effective at reducing the incidence of CIN vs. a lower dose or placebo. Other interventions including administration of loop diuretics, calcium antagonists, mannitol, theophylline, or low-dose dopamine have not been successful. Iodinated contrast media may cross the blood-brain barrier and accumulate in patients where the blood-brain barrier is known or suspected to be disrupted or in patients with a normal blood-brain barrier and renal impairment.

    Cardiac disease, pulmonary hypertension, QT prolongation, valvular heart disease

    Selective coronary arteriography should be performed only in selected patients where the expected benefits outweigh the procedural risk. Monitor electrocardiograms (ECGs) and vital signs during this procedure. Contrast media injected directly into coronary arteries or chambers of the heart may cause ECG 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 torsade de pointes (TdP). 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, cardiac failure, ischemic cardiac 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 (i.e., iopromide) contrast media than ionic. In terms of overall cardiovascular safety, nonionic contrast media such as iopromide tend to be less arrhythmogenic and cause less hemodynamic and electrophysiologic changes than their ionic counterparts.

    Heart failure

    Contrast media such as iopromide should be used cautiously in patients with 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 iopromide is considerably less hyper-osmolar when compared to the ionic agents such as diatrizoate, iopromide 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 of 40% or less developed CIN at a rate of almost 3-times that of patients with an ejection fraction of more than 40%. The combination of low ejection fraction and a creatinine clearance of 60 mL/minute or less was associated with a 5-times increased incidence of CIN. After contrast media administration, patients with congestive heart failure should be observed closely for several hours.

    Coagulopathy, thromboembolic disease

    Serious, rarely fatal, thromboembolic events causing myocardial infarction and stroke have been reported during angiographic procedures with ionic and nonionic contrast media. Meticulous intravascular administration technique has reduced the incidence of such complications; however, controversy exists as to whether nonionic contrast media such as iopromide are more thrombogenic than ionic contrast media. The American College of Cardiology has recommended to consider the concomitant administration of heparin to patients when nonionic agents were used; however, this recommendation has been refuted by some authors as they believe the procedure itself is thrombogenic, not the contrast media (i.e., clots forming on the catheters and guidewires, catheter manipulation causing existing plaques to dislodge, or damage and perforation of the vessel wall). Because many factors contribute to thromboembolic events including length of procedure, catheter and syringe material, underlying disease states, and concomitant medications, meticulous intravascular technique is necessary to minimize thromboembolic events. Measures that should be considered to minimize this risk include close attention to guidewire and catheter manipulation, use of manifold systems or 3-way stopcocks, frequent catheter flushing with heparinized saline solutions, and minimizing the length of the procedure. Test injections to ensure proper catheter placement may also be prudent. Clotting has been reported when blood remains in contact with syringes containing nonionic contrast media; the use of plastic syringes in place of glass may minimize in vitro clotting. Special care is necessary when venography is performed in patients with suspected thromboembolic disease such as thrombosis, phlebitis, severe ischemic disease, local infection, 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).

    Serious rash

    Avoid use of iopromide in patients with a history of contrast-induced serious rash. 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.

    Sickle cell disease

    Use iopromide in patients with sickle cell disease only if the necessary imaging information cannot be obtained with alternative modalities. If iopromide use is necessary in these patients, hydrate patients prior to and after iopromide administration. Intravascular administration of iodinated contrast agents, such as iopromide, may promote sickling in individuals who are homozygous for sickle cell disease.

    Multiple myeloma

    Contrast media such as iopromide 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.

    Hyperthyroidism, hypothyroidism, thyroid disease, thyrotoxicosis

    Administration of iopromide 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 iopromide, evaluate all patients for thyroid-associated risk factors.

    Myasthenia gravis

    The exacerbation of myasthenia gravis has been reported after the use of contrast media such as iopromide. 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.

    Pheochromocytoma

    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 iopromide 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.

    Extravasation

    Take care to avoid extravasation of contrast media such as iopromide, especially in those patients with arterial insufficiency, compromised venous drainage, or compromised lymphatic systems. Ensure intravascular placement of the catheter prior to drug administration. 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 has been reported to be successful in treating extravasation.

    Emphysema, pulmonary disease

    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. These drug-induced effects can contribute to adverse reactions in patients with pulmonary disease including emphysema and asthma.

    Radiation exposure

    Contrast agents are associated with risk and increased radiation exposure. Base the decision to use iopromide upon a careful evaluation of clinical, other radiological data, and the results of non-contrast computed tomography (CT) findings, taking into account the increased radiation dose and other risks. In addition, use of iodinated contrast media may obscure some lesions which were previously observed on non-contrast CT scans.

    Children, infants, neonates, premature neonates

    Rare cases of underactive thyroid have been reported in neonates and infants after the use of iodine-containing contrast media, such as iopromide. Reported cases (n = 10) have involved premature neonates or patients younger than 4 months with serious underlying medical conditions; several of the patients also received a topical iodine product that is no longer recommended for young infants, which may have contributed to thyroid suppression. All patients were diagnosed within 1 month of receiving iodinated contrast media. Available evidence suggests occurrence is temporary and resolves spontaneously without treatment or lasting effect. Changes to prescribing, administration, or monitoring practices are not currently recommended. Health care professionals should continue to follow labeled recommendations for iodinated contrast media. Infants typically do not show any visible signs of underactive thyroid; practitioners should use clinical judgment to determine if testing for hypothyroidism is necessary until further information is available. Safety and effectiveness of iopromide have not been established in neonates, infants, or children 2 years and younger. For pediatric patients older than 2 years, iopromide is approved for intravenous use during computerized tomography and excretory urography, and for intra-arterial administration to evaluate cardiac chambers and related arteries. Children may be at more risk for adverse effects, especially those with asthma, a history of hypersensitivity to drugs or allergens, cyanotic and acyanotic heart disease, congestive heart failure, or a serum creatinine greater than 1.5 mg/dL. In addition, pediatric patients with immature renal function or dehydration may be at increased risk for adverse events due to slower drug elimination; it is unknown if dose adjustment based on immature renal function is required. Due to the risk for acute renal failure, preparatory dehydration (i.e., prolonged fasting, use of laxatives) before iopromide administration is contraindicated in pediatric patients.

    Pregnancy

    Iopromide is classified as FDA pregnancy category B. There are no adequate and well-controlled studies with iopromide in pregnant women. In animal reproduction studies, no adverse effects were noted in rats and rabbits at doses up to 3.7 g iodine/kg (approximately 0.7 times the human dose after normalization of the data to body surface area estimates). Because animal reproduction studies are not always predictive of human response, the manufacturer recommends iopromide be used during pregnancy only if clearly needed. Similarly, due to the potential risks to the fetus, the American College of Radiology (ACR) recommends iodinated contrast agents be administered during pregnancy only if necessary and only after informed consent is obtained. In contrast, the Guidelines for Computed Tomography and Magnetic Resonance Imaging in Pregnancy and Lactation state that use of iodinated contrast during pregnancy appears to be safe and should be administered as per usual. It is advised to screen neonates whose mother received iodinated contrast during pregnancy for hypothyroidism.

    Breast-feeding

    It is unknown whether iopromide is excreted in human milk. However, many injectable contrast agents are excreted unchanged in human milk. Because of potential for a serious adverse reaction in a breast-feeding infant, the manufacturer recommends caution and considering temporarily discontinuing breast-feeding when intravascular contrast agents are administered to breast-feeding women. The Guidelines for Computed Tomography and Magnetic Resonance Imaging Use During Pregnancy and Lactation and the American College of Radiology (ACR) manual on contrast media state that lactating women receiving iodinated contrast can continue breast-feeding without interruption. The reasoning for this recommendation is based on estimates of limited systemic exposure in breast-fed infants and reviews that conclude maternally administered iodinated contrast pose no risk to nursing infants.

    ADVERSE REACTIONS

    Severe

    nephrotoxicity / Delayed / 10.0-50.0
    visual impairment / Early / 1.1-1.1
    anaphylactoid reactions / Rapid / 0-1.0
    bradycardia / Rapid / 0-1.0
    AV block / Early / 0-1.0
    thrombosis / Delayed / 0-1.0
    apnea / Delayed / 0-1.0
    pulmonary hypertension / Delayed / 0-1.0
    pleural effusion / Delayed / 0-1.0
    acute generalized exanthematous pustulosis (AGEP) / Delayed / Incidence not known
    Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) / Delayed / Incidence not known
    toxic epidermal necrolysis / Delayed / Incidence not known
    Stevens-Johnson syndrome / Delayed / Incidence not known
    cardiac arrest / Early / Incidence not known
    coma / Early / Incidence not known
    respiratory arrest / Rapid / Incidence not known
    anaphylactic shock / Rapid / Incidence not known
    angioedema / Rapid / Incidence not known
    laryngeal edema / Rapid / Incidence not known
    laryngospasm / Rapid / Incidence not known
    bronchospasm / Rapid / Incidence not known
    renal failure (unspecified) / Delayed / Incidence not known
    stroke / Early / Incidence not known
    seizures / Delayed / Incidence not known
    arachnoiditis / Early / Incidence not known
    cerebral edema / Early / Incidence not known
    rhabdomyolysis / Delayed / Incidence not known
    myocardial infarction / Delayed / Incidence not known
    heart failure / Delayed / Incidence not known
    ventricular fibrillation / Early / Incidence not known
    atrial fibrillation / Early / Incidence not known
    skin necrosis / Early / Incidence not known
    muscle paralysis / Delayed / Incidence not known
    acute respiratory distress syndrome (ARDS) / Early / Incidence not known
    pulmonary edema / Early / Incidence not known
    diabetes insipidus / Delayed / Incidence not known

    Moderate

    peripheral vasodilation / Rapid / 2.6-2.6
    chest pain (unspecified) / Early / 1.8-1.8
    erythema / Early / 0-1.0
    dysuria / Early / 0-1.0
    urinary retention / Early / 0-1.0
    hypertension / Early / 0-1.0
    hypotension / Rapid / 0-1.0
    peripheral edema / Delayed / 0-1.0
    hyperesthesia / Delayed / 0-1.0
    confusion / Early / 0-1.0
    hypertonia / Delayed / 0-1.0
    constipation / Delayed / 0-1.0
    dyspnea / Early / 0-1.0
    hypoxia / Early / 0-1.0
    hematuria / Delayed / Incidence not known
    hypothyroidism / Delayed / Incidence not known
    thyrotoxicosis / Delayed / Incidence not known
    hyperthyroidism / Delayed / Incidence not known
    hyperthermia / Delayed / Incidence not known
    sinus tachycardia / Rapid / Incidence not known
    angina / Early / Incidence not known
    palpitations / Early / Incidence not known
    hematoma / Early / Incidence not known
    myasthenia / Delayed / Incidence not known
    amnesia / Delayed / Incidence not known
    paresis / Delayed / Incidence not known
    dysphagia / Delayed / Incidence not known
    aphasia / Delayed / Incidence not known
    conjunctivitis / Delayed / Incidence not known
    migraine / Early / Incidence not known

    Mild

    headache / Early / 4.0-4.0
    nausea / Early / 3.7-3.7
    injection site reaction / Rapid / 3.7-3.7
    vomiting / Early / 1.9-1.9
    back pain / Delayed / 1.9-1.9
    urinary urgency / Early / 1.8-1.8
    dysgeusia / Early / 1.3-1.3
    rash (unspecified) / Early / 0-1.0
    urticaria / Rapid / 0-1.0
    pruritus / Rapid / 0-1.0
    flushing / Rapid / 0-1.0
    syncope / Early / 0-1.0
    polydipsia / Early / 0-1.0
    malaise / Early / 0-1.0
    chills / Rapid / 0-1.0
    fever / Early / 0-1.0
    asthenia / Delayed / 0-1.0
    hyperhidrosis / Delayed / 0-1.0
    musculoskeletal pain / Early / 0-1.0
    arthralgia / Delayed / 0-1.0
    paresthesias / Delayed / 0-1.0
    dizziness / Early / 0-1.0
    anxiety / Delayed / 0-1.0
    agitation / Early / 0-1.0
    xerostomia / Early / 0-1.0
    diarrhea / Early / 0-1.0
    dyspepsia / Early / 0-1.0
    tenesmus / Delayed / 0-1.0
    abdominal pain / Early / 0-1.0
    leukocytosis / Delayed / 0-1.0
    pharyngitis / Delayed / 0-1.0
    throat irritation / Early / 0-1.0
    cough / Delayed / 0-1.0
    maculopapular rash / Early / Incidence not known
    sneezing / Early / Incidence not known
    nasal congestion / Early / Incidence not known
    tremor / Early / Incidence not known
    tinnitus / Delayed / Incidence not known
    vertigo / Early / Incidence not known
    mydriasis / Early / Incidence not known
    lacrimation / Early / Incidence not known
    epistaxis / Delayed / Incidence not known
    muscle cramps / Delayed / Incidence not known

    DRUG INTERACTIONS

    Acebutolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    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; 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.
    Acetaminophen; Butalbital; 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.
    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; Magnesium Salicylate; Phenyltoloxamine: (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; Phenyltoloxamine; Salicylamide: (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) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Acetaminophen; Chlorpheniramine; Phenylephrine; Phenyltoloxamine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Acetaminophen; Dextromethorphan; Guaifenesin; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Acetaminophen; Dextromethorphan; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Acetaminophen; Guaifenesin; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Acetaminophen; 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.
    Aldesleukin, IL-2: (Moderate) Patients have reported 'recall reactions' of aldesleukin therapy and delayed reactions to contrast when used concomitantly with radiopaque contrast agents. The reactions responded to supportive therapy. Such recall reactions were minimized by using nonionic contrast media and waiting four weeks between aldesleukin treatment and radiopaque contrast agents.
    Alogliptin; Metformin: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    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.
    Amitriptyline; Chlordiazepoxide: (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.
    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-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.
    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; Butalbital; 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.
    Aspirin, ASA; 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.
    Atenolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Atenolol; Chlorthalidone: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Bendroflumethiazide; Nadolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    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) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Betaxolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Bisoprolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    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) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Brompheniramine; Carbetapentane; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Bumetanide: (Moderate) Because patients should be well-hydrated prior to the administration of contrast media, loop diuretics such as furosemide that cause intravascular volume depletion might increase the risk of nephrotoxicity when using radiopaque contrast agents. In addition, furosemide plus normal saline have been evaluated for the prevention of contrast induced nephropathy; in one retrospective review, the incidence of contrast-induced nephropathy in the furosemide plus saline group was almost four times that of the saline only group (40% versus 11%, respectively). Other studies have shown no benefit with combination therapy.
    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.
    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. (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.
    Caffeine; Ergotamine: (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.
    Canagliflozin; Metformin: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    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.
    Carbetapentane; Chlorpheniramine; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Carbetapentane; Diphenhydramine; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Carbetapentane; Guaifenesin; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Carbetapentane; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Carbetapentane; Phenylephrine; Pyrilamine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Carbinoxamine; Hydrocodone; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Carbinoxamine; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Carteolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Carvedilol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Chlophedianol; Guaifenesin; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Chlorpheniramine; Dextromethorphan; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Chlorpheniramine; Dihydrocodeine; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Chlorpheniramine; Hydrocodone; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Chlorpheniramine; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Cisplatin: (Moderate) Because the use of other nephrotoxic drugs, including cisplatin, is an additive risk factor for nephrotoxicity in patients receiving radiopaque contrast agents, concomitant use should be avoided when possible.
    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.
    Cobicistat; Elvitegravir; Emtricitabine; Tenofovir Alafenamide: (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 alafenamide 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, and urine glucose and protein.
    Cobicistat; Elvitegravir; 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.
    Codeine; Phenylephrine; Promethazine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis. (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Promethazine 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. Promethazine 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.
    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: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    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, such as dexmethylphenidate, should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Dexmethylphenidate should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours post-procedure.
    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; Diphenhydramine; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Dextromethorphan; Guaifenesin; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Dextromethorphan; Promethazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Promethazine should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
    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.
    Diphenhydramine; Hydrocodone; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Diphenhydramine; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Dopamine: (Major) Per the manufacturer of ioversol, radiopaque contrast agents should not be injected arterially following the administration of vasopressors, such as dopamine, as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Dorzolamide; Timolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    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.
    Efavirenz; Emtricitabine; Tenofovir: (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; Metformin: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    Emtricitabine; Rilpivirine; Tenofovir alafenamide: (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 alafenamide 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, and urine glucose and protein.
    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) 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 alafenamide 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, and urine glucose and protein.
    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.
    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) Per the manufacturer of ioversol, radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Esmolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Ethacrynic Acid: (Moderate) Because patients should be well-hydrated prior to the administration of contrast media, loop diuretics such as furosemide that cause intravascular volume depletion might increase the risk of nephrotoxicity when using radiopaque contrast agents. In addition, furosemide plus normal saline have been evaluated for the prevention of contrast induced nephropathy; in one retrospective review, the incidence of contrast-induced nephropathy in the furosemide plus saline group was almost four times that of the saline only group (40% versus 11%, respectively). Other studies have shown no benefit with combination therapy.
    Ethanol: (Moderate) Ethanol abuse or abrupt discontinuation of chronic ethanol use has been associated with seizures and fatalities; intrathecal radiopaque contrast agents should be administered cautiously in patients who chronically abuse alcohol.
    Fluoxetine; 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.
    Furosemide: (Moderate) Because patients should be well-hydrated prior to the administration of contrast media, loop diuretics such as furosemide that cause intravascular volume depletion might increase the risk of nephrotoxicity when using radiopaque contrast agents. In addition, furosemide plus normal saline have been evaluated for the prevention of contrast induced nephropathy; in one retrospective review, the incidence of contrast-induced nephropathy in the furosemide plus saline group was almost four times that of the saline only group (40% versus 11%, respectively). Other studies have shown no benefit with combination therapy.
    Glipizide; Metformin: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    Glyburide; Metformin: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    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) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Guarana: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Caffeine and caffeine-containing products (e.g., guarana) should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
    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; Metoprolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Hydrochlorothiazide, HCTZ; Propranolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Hydrocodone; Phenylephrine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Ibandronate: (Moderate) Theoretically, coadministration of intravenous ibandronate with other potentially nephrotoxic drugs, such as radiopaque contrast agents, may increase the risk of developing nephrotoxicity.
    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.
    Labetalol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Levobetaxolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Levobunolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Linagliptin; Metformin: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    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.
    Loop diuretics: (Moderate) Because patients should be well-hydrated prior to the administration of contrast media, loop diuretics such as furosemide that cause intravascular volume depletion might increase the risk of nephrotoxicity when using radiopaque contrast agents. In addition, furosemide plus normal saline have been evaluated for the prevention of contrast induced nephropathy; in one retrospective review, the incidence of contrast-induced nephropathy in the furosemide plus saline group was almost four times that of the saline only group (40% versus 11%, respectively). Other studies have shown no benefit with combination therapy.
    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.
    Meperidine; Promethazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Promethazine should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
    Metformin: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    Metformin; Pioglitazone: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    Metformin; Repaglinide: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    Metformin; Rosiglitazone: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    Metformin; Saxagliptin: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    Metformin; Sitagliptin: (Severe) Metformin and combination products containing metformin should be temporarily discontinued prior to the administration of iodinated radiopaque contrast agents. Metformin should be held for at least 48 hours after contrast administration and not restarted until renal function returns to normal post-procedure. Lactic acidosis has been reported in patients taking metformin that experience nephrotoxicity after iodinated contrast media.
    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: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Methylphenidate should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
    Metoprolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Midodrine: (Major) Contrast media should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Molindone: (Major) Molindone lowers the seizure threshold and should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
    Monoamine oxidase inhibitors: (Major) Use of medications that lower the seizure threshold, such as monoamine oxidase inhibitors, should be carefully evaluated when considering intrathecal radiopaque contrast agents. 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.
    Nadolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Nebivolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Nebivolol; Valsartan: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    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) Contrast media should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    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.
    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.
    Pemoline: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering intrathecal radiopaque contrast agents. Pemoline should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
    Penbutolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Perphenazine; 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.
    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) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis.
    Phenylephrine; Promethazine: (Major) Radiopaque contrast agents should not be injected arterially following the administration of vasopressors as they strongly potentiate the neurologic effects of contrast media such as paralysis. (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Promethazine should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
    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) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Polymyxins: (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.
    Promethazine: (Major) Use of medications that lower the seizure threshold should be carefully evaluated when considering the use of intrathecal radiopaque contrast agents. Promethazine should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
    Propranolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    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.
    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.
    Sodium Iodide: (Major) Certain medications should not be administered prior to therapy with sodium iodide I-131 in order to reduce interference with diagnostic or therapeutic use of sodium iodide I-131. Although various protocols are used, the following withdrawal timing recommendations were set forth in a procedure guideline published by the Society of Nuclear Medicine in February 2002. Avoid intravenous radiopaque contrast agents for one month prior to treatment with sodium iodide I-131; patients with renal deficiency may require additional time to clear these agents. Iodide containing contrast agents may affect iodide protein binding for up to a year.
    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) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Telbivudine: (Moderate) Drugs that alter renal function, such as radiopaque contrast agents, may alter telbivudine plasma concentrations because telbivudine is eliminated primarily by renal excretion. Monitor renal function before and during telbivudine treatment.
    Temsirolimus: (Moderate) Sirolimus, the active metabolite of temsirolimus, has been associated with the development of angioedema. The use of temsirolimus with other drugs known to cause angioedema, such as non-ionic contrast media (e.g., iodixanol, iohexol, iopamidol, ioversol), may increase the risk of developing angioedema. Monitor patients for angioedema if these drugs are coadministered.
    Tenofovir Alafenamide: (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 alafenamide 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, and urine glucose and protein.
    Tenofovir Alafenamide: (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 alafenamide 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, and urine glucose and protein.
    Tenofovir, PMPA: (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.
    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.
    Thyroid hormones: (Moderate) Radiopaque contrast agents that contain iodine (e.g., iohexol, ioversol, iopamidol, and iodixanol) may cause either hypothyroidism or hyperthyroidism in previously euthyroid patients. Patients receiving thyroid hormones and drugs that contain iodine should be monitored for changes in thyroid function.
    Timolol: (Moderate) Some clinicians consider patients taking beta-blockers to be at increased risk for anaphylactoid reactions and administer prophylactic corticosteroids/antihistamines prior to the administration of radiopaque contrast agents.
    Torsemide: (Moderate) Because patients should be well-hydrated prior to the administration of contrast media, loop diuretics such as furosemide that cause intravascular volume depletion might increase the risk of nephrotoxicity when using radiopaque contrast agents. In addition, furosemide plus normal saline have been evaluated for the prevention of contrast induced nephropathy; in one retrospective review, the incidence of contrast-induced nephropathy in the furosemide plus saline group was almost four times that of the saline only group (40% versus 11%, respectively). Other studies have shown no benefit with combination therapy.
    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.
    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.
    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.
    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.

    PREGNANCY AND LACTATION

    Pregnancy

    Iopromide is classified as FDA pregnancy category B. There are no adequate and well-controlled studies with iopromide in pregnant women. In animal reproduction studies, no adverse effects were noted in rats and rabbits at doses up to 3.7 g iodine/kg (approximately 0.7 times the human dose after normalization of the data to body surface area estimates). Because animal reproduction studies are not always predictive of human response, the manufacturer recommends iopromide be used during pregnancy only if clearly needed. Similarly, due to the potential risks to the fetus, the American College of Radiology (ACR) recommends iodinated contrast agents be administered during pregnancy only if necessary and only after informed consent is obtained. In contrast, the Guidelines for Computed Tomography and Magnetic Resonance Imaging in Pregnancy and Lactation state that use of iodinated contrast during pregnancy appears to be safe and should be administered as per usual. It is advised to screen neonates whose mother received iodinated contrast during pregnancy for hypothyroidism.

    It is unknown whether iopromide is excreted in human milk. However, many injectable contrast agents are excreted unchanged in human milk. Because of potential for a serious adverse reaction in a breast-feeding infant, the manufacturer recommends caution and considering temporarily discontinuing breast-feeding when intravascular contrast agents are administered to breast-feeding women. The Guidelines for Computed Tomography and Magnetic Resonance Imaging Use During Pregnancy and Lactation and the American College of Radiology (ACR) manual on contrast media state that lactating women receiving iodinated contrast can continue breast-feeding without interruption. The reasoning for this recommendation is based on estimates of limited systemic exposure in breast-fed infants and reviews that conclude maternally administered iodinated contrast pose no risk to nursing infants.

    MECHANISM OF ACTION

    Iopromide 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 iopromide, allowing for opacification of vessels in the path of the blood flow of contrast media during angiography and urography. After iopromide injection, internal structures of the human body can be visualized until significant hemodilution occurs.
     
    Iopromide 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 concentrations usually occur immediately and dramatically decrease within 5 to 10 minutes. During CT brain imaging, a lag between contrast media administration and maximum contrast enhancement of up to 1 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 iopromide accumulation within the blood pool. In the presence of a break in the blood-brain barrier, however, contrast media does accumulate within the interstitial spaces of the brain. In addition, iopromide itself can cause blood-brain barrier disruption and accumulate in the central nervous system in patients with previously normal blood-brain barriers and renal impairment. During CT imaging of the body, enhancement is related to blood flow, concentration of the contrast medium, and extraction of the contrast medium by interstitial tissue of tumors since no barrier exists. In contrast to brain imaging, contrast enhancement during body imaging is due to the relative differences in extravascular diffusion of contrast media between normal and abnormal tissue.

    PHARMACOKINETICS

    Iopromide is administered by intravenous or intra-arterial injection. After intravascular injection, iopromide is immediately distributed into circulating blood volume. Iopromide then distributes into the interstitial space; after equilibrium, distribution into extracellular space occurs. The volume of distribution at steady state is approximately 16 L. Iopromide is not significantly bound to plasma proteins (1%), and normally does not cross the blood-brain barrier. However, in patients with a disrupted blood-brain barrier or in some patients with normal blood-brain barriers and renal impairment, iopromide can accumulate in the brain. Iopromide does not undergo any significant metabolism and is primarily eliminated unchanged via glomerular filtration (97%); fecal elimination is negligible (2%). The mean total and renal clearances are 107 mL/minute and 104 mL/minute, respectively. The main elimination phase half-life is 2 hours, and the terminal elimination phase half-life is 6.2 hours.
     
    Affected cytochrome P450 isoenzymes and drug transporters: none

    Intravenous Route

    Enhanced visualization of tissues by contrast media is directly related to the vascularization of the specific tissue. Visualization of the renal parenchyma occurs within 30 to 60 seconds after rapid intravenous injection of iopromide. The calyces and pelves in patients can be visualized within 1 to 3 minutes, with optimal contrast occurring after 5 to 15 minutes. Maximum contrast enhancement during computed tomography brain imaging can occur up to 1 hour after injection depending on the type of lesion to be visualized. Contrast enhancement during computed tomography of the body appears to be greatest soon after bolus administration of the contrast medium (15 to 120 seconds). The greatest enhancement may be detected by a series of consecutive 2 to 3 second scans (e.g., dynamic computed tomography imaging) performed within 30 to 90 seconds after injection.