Pre-medication Prior to Contrast Medium Administration

Steroid Pre-medication Guide 1:

Steroid Premedication Guideline [Department of Radiology, University of Michigan]

There is one indication for a steroid prep prior to intravenous iodinated contrast injection (e.g., CT, IVP):

• Prior allergic-like reaction to iodinated contrast (any severity)

• Examples: hives, itching, acute rash, wheezing, bronchospasm, stridor, laryngeal edema, anaphylaxis

There is one indication for a steroid prep prior to intravenous gadolinium-based contrast injection (e.g., MRI):

• Prior allergic-like reaction to gadolinium-based contrast (any severity)

• Examples: hives, itching, acute rash, wheezing, bronchospasm, stridor, laryngeal edema, anaphylaxis

The following are not considered an indication for a steroid prep:

• Asthma

• Reactions to other substances (regardless of number or severity, including shellfish and betadine)

• Physiologic reaction to contrast material such as a vasovagal reaction, nausea, vomiting

Rationale: The benefits of preps are very small relative to their indirect harms (e.g., delayed care, prolonged hospitalization). The vast majority of patients who receive a steroid prep derive no benefit (e.g., breakthrough reactions, incomplete efficacy). Steroid preps are not given for any other “drug” in patients who have these other risk factors (e.g., asthma, other allergies).

Standard oral premedication regimen:

• Prednisone – 50 mg PO, 13, 7, and 1 hour prior to the procedure* • Diphenhydramine – 50 mg PO 1 hour prior to the procedure ** *Note: Doses may be distributed unevenly to allow a patient to get a reasonable night’s sleep the evening prior to the CT; however, the first dose should be taken more than 11 hours before the time the exam is scheduled to be performed. **Note: It is not critical to administer diphenhydramine as part of the premedication regimen (there are published regimens using corticosteroids only).

Urgent IV premedication protocol:

• Hydrocortisone – 200 mg IV, 5 hours and 1 hour prior to the procedure • Diphenhydramine – 50 mg PO (or IM or IV, if patient cannot take PO), one hour prior to the procedure Note: If preferred, methylprednisolone 40 mg IV can be substituted for hydrocortisone 200 mg, dose for dose.

Steroid Pre-medication Guide 2:

Premedication Prophylaxis for Patients with Previous Acute Reaction to Iodinated Contrast [UptoDate]

Non-urgent oral premedication:

Glucocorticoid-preferred regimen:

Adult: Oral prednisone 50 mg at 13, 7, and 1 hour prior to contrast administration

Pediatric: Prednisone 0.5 to 0.7 mg/kg oral (maximum 50 mg per dose) at 13, 7, and 1 hour prior to contrast administration.

Glucocorticoid-alternate:

Adult: Methylprednisolone 32 mg IV at 12 and 2 hours prior to contrast administration.

Pediatric: Methylprednisolone 1 mg/kg IV (maximum 32 mg per dose) at 12 and 2 hours prior to contrast administration.

AND

H1 antihistamine:

Adult: Diphenhydramine 50 mg oral, IM, or IV 1 hour prior to contrast administration.

Pediatric: Diphenhydramine 1.25 mg/kg oral, IM, or IV (maximum 50 mg) 1 hour prior to contrast administration.

Urgent intravenous premedication (eg, inpatients, emergency department):*

Hydrocortisone 200 mg IV 5 and 1 hour prior to contrast administration and 50 mg IV diphenhydramine 1 hour prior to contrast administration.

* Premedication regimens less than four to five hours in duration (oral or IV) have not been shown to be effective.

* Prednisone and prednisolone are equivalent in terms of steroid conversion. They also have similar pharmacokinetics profile.

Steroid Pre-medication Guide 3:

ACR Manual on Contrast Media - Version 10.3 @ 2018 (American College of Radiology)

Elective Premedication (12- or 13-hour oral premedication)

1.    Prednisone-based: 50 mg prednisone by mouth at 13 hours, 7 hours, and 1 hour before contrast medium administration, plus 50 mg diphenhydramine intravenously, intramuscularly, or by mouth 1 hour before contrast medium administration. OR 2.    Methylprednisolone-based: 32 mg methylprednisolone by mouth 12 hours and 2 hours before contrast medium administration. 50 mg diphenhydramine may be added as in option 1. *Although never formally compared, both regimens are considered similarly effective. The presence of diphenhydramine in regimen 1 and not in regimen 2 is historical and not evidence-based. Therefore, diphenhydramine may be considered optional. *If a patient is unable to take oral medication, option 1 may be used substituting 200 mg hydrocortisone IV for each dose of oral prednisone.

Accelerated IV Premedication (in decreasing order of desirability)

1.      Methylprednisolone sodium succinate (e.g., Solu-Medrol®) 40 mg IV or hydrocortisone sodium succinate (e.g., Solu-Cortef®) 200 mg IV immediately, and then every 4 hours until contrast medium administration, plus diphenhydramine 50 mg IV 1 hour before contrast medium administration. This regimen usually is 4-5 hours in duration. 2.      Dexamethasone sodium sulfate (e.g., Decadron®) 7.5 mg IV immediately, and then every 4 hours until contrast medium administration, plus diphenhydramine 50 mg IV 1 hour before contrast medium administration. This regimen may be useful in patients with an allergy to methylprednisolone and is also usually 4-5 hours in duration. 3.      Methylprednisolone sodium succinate (e.g., Solu-Medrol®) 40 mg IV or hydrocortisone sodium succinate (e.g., Solu-Cortef®) 200 mg IV, plus diphenhydramine 50 mg IV, each 1 hour before contrast medium administration. This regimen, and all other regimens with a duration less than 4-5 hours, has no evidence of efficacy. It may be considered in emergent situations when there are no alternatives. *Note: Premedication regimens less than 4-5 hours in duration (oral or IV) have not been shown to be effective. The accelerated 4-5-hour regimen listed as Accelerated IV option 1 is supported by a case series and by a retrospective cohort study with 828 subjects.

References:

1.  UptoDate: Immediate hypersensitivity reactions to radiocontrast media: Prevention of recurrent reactions [Accessed 14 Dec 2018]

2. http://www.med.umich.edu/radiology/steroid-prep.pdf [Accessed 14 Dec 2018]

3. https://www.professionalradiology.com/media/documents/ACR%20Premedication%20for%20Contrast%20Allergies%20.pdf [Accessed 26 Dec 2018]

4. Davenport M.S. et al., on behalf of American College of Radiology Committee on Drugs and Contrast Media. ACR Manual on Contrast Media (Version 10.3, 2018) – accessed via https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf#page=95 [Accessed 26 Dec 2018]