What is the treatment for contrast media (contrast dye) hypersensitivity reaction?

From the Guidelines

For patients with a known contrast dye allergy, the use of premedication with glucocorticoids and/or antihistamines is not recommended as a routine practice to prevent recurrent hypersensitivity reactions (HSRs) to radiocontrast media (RCM) when a low- or iso-osmolar, nonionic RCM agent is required 1. The treatment for contrast media hypersensitivity reaction should prioritize the management of acute reactions and the prevention of future reactions.

Key Considerations

• The certainty of evidence around supplemental therapies in anaphylaxis management is very low 1.
• The use of premedication before high-osmolar agents has been shown to reduce immediate reactions of all severity in average-risk patients and mild immediate adverse effects in average-risk patients receiving low-osmolar agents, but protection from premedication against moderate to severe reactions in high-risk patients receiving low-osmolar agents is unproven by high-certainty evidence 1.
• The American College of Radiology (ACR) Manual on Contrast Media Version 10 emphasizes that no premedication strategy is a substitute for anaphylaxis preparedness, and changing to an alternative low- or iso-osmolar contrast agent may provide a greater effect size than premedication alone 1.

Management Approach

• For patients with severe previous reactions, consider using a non-ionic, low-osmolality contrast agent and having emergency medications (epinephrine, corticosteroids, antihistamines) readily available during the procedure.
• Patients should inform all healthcare providers about their contrast allergy, and medical alert bracelets may be helpful.
• In some cases, alternative imaging techniques that don't require iodinated contrast may be appropriate.

Emergency Situations

• For emergency situations where the full premedication regimen isn't possible, an accelerated protocol can be used, but the effectiveness of this approach is not well established.
• The primary focus should be on managing the acute reaction and preventing future reactions, rather than relying on premedication as a preventative measure.

From the Research

Treatment for Contrast Media Hypersensitivity Reaction

The treatment for contrast media hypersensitivity reaction involves several approaches, including:

• Administration of epinephrine, which is the most important treatment for severe allergic-like contrast reactions 2
• Premedication with corticosteroids and anti-histamines to prevent allergic reactions 3, 4, 5
• Rapid desensitization to iodinated contrast media by administering progressively incremental doses of the media 3
• Use of low-osmolar, nonionic agents to decrease the relative risk of reactions 4
• Ensuring adequate hydration and discontinuing other nephrotoxic medications before the procedure to prevent renal insufficiency induced by contrast material 4

Management of Hypersensitivity Reactions

The management of hypersensitivity reactions to contrast agents and dyes involves:

• An allergological workup for patients with a history of immediate and nonimmediate hypersensitivity reactions 6
• Skin tests with or without experimental cellular laboratory tests to provide evidence for an allergic mechanism 6
• Selection of alternative contrast agents for future procedures based on skin test results 6
• Premedication alone may be insufficient in some cases, and breakthrough reactions can occur 6

Prevention of Adverse Reactions

To prevent adverse reactions, it is recommended to:

• Prescreen patients for risk factors such as previous allergic reactions to contrast material, asthma, and allergies 4
• Use the smallest amount of contrast material possible 4
• Administer medications such as hydrocortisone and diphenhydramine as pretreatment regimens 5