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Contrast Allergy and Reactions

Contrast Allergy and Reactions is a topic covered in the 5-Minute Clinical Consult.

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  • A contrast allergy or reaction is the immunologic or physiologic response to IV iodinated contrast media (ICM) administered during a CT scan.
  • Reaction timing can be acute or delayed (1).
  • Acute reactions can be allergic, allergic-like (a.k.a. anaphylactoid), idiosyncratic or physiologic (a.k.a. chemotoxic or osmotoxic) (1).
  • Acute reactions are categorized as mild, moderate, or severe.
  • Delayed reactions occur from 1 hour to 1 week after ICM administration (2).
  • Contrast-induced nephropathy (CIN) is a sudden decrease in renal function following IV ICM administration without another known cause for renal insult (3).
  • A breakthrough reaction refers to a reaction that occurs in a patient who has been premedicated for such reactions (2).
  • MRI contrast media is not included in this chapter.


  • High-osmolality contrast media (HOCM) has associated acute adverse events in 5–15% of cases. It is rarely or ever used now because of its side effects (1).
  • Low-osmolality contrast media (LOCM) has associated acute adverse events incidence reported between 0.2% and 0.7% in three different studies reviewed by the ACR Committee Manual. Serious acute adverse events are rare (0.04% per Katayama et al.) (1).
  • CIN incidence is difficult to assess because there is no standard definition for diagnosing CIN and the criteria utilized in different studies vary.

Etiology and Pathophysiology

  • The pathogenesis of allergic-like reactions is not known, with several possible mechanisms resulting in immunologic mediator activation. Most are not associated with increased IgE (and therefore are not true allergic reactions). Allergic-like reactions are not dose or concentration dependent (1,4).
  • The pathogenesis of physiologic reactions is probably the result of the ICM physiologic properties (i.e., osmolality, molecular binding, or chemotoxicity). Physiologic reactions are dose and concentration dependent (1,4).
  • The pathogenesis of CIN is not well understood at this time, but several factors have been suggested.

Risk Factors

  • Prior ICM reaction
  • History of asthma, atopy or allergy (attention to significant allergic reactions), cardiovascular disease (CVD), anxiety
  • For CIN: renal insufficiency/disease, diabetes mellitus, dehydration, CVD, diuretic use, advanced age, hypertension, hyperuricemia, and multiple doses of ICM in <24 hours
  • Metformin (risk of lactic acidosis)
  • Contraindicated with myasthenia gravis
  • Package inserts suggest necessary precautions for known or suspected pheochromocytoma, thyrotoxicosis, dysproteinemias (like multiple myeloma), or sickle cell disease (1).
  • An allergy to shellfish itself is not associated with an increased risk of ICM allergic-like reaction (3,4).

General Prevention

  • For patients with risk factors for CIN (including age >60 years, history of renal disease, treated hypertension, diabetes mellitus, and patients taking metformin or metformin-containing drugs), precontrast administration serum creatinine (Cr) and GFR measurements should be obtained for risk stratification (1)[C].
  • Consult radiology for patients with GFR <45 mL/min to evaluate need for CIN prevention steps/strategies (which may include PO or IV hydration, decreasing contrast dose or alternative imaging depending on the level of risk). A stable baseline GFR >45 mL/min is not an independent nephrotoxic risk factor (1)[C].
  • Consult radiology for patients taking metformin regarding the need for temporary discontinuation of medication and renal function follow-up.
  • For prevention of allergic-like reactions, a frequently used elective premedication regimen is prednisone 50 mg PO at 13 hours, 7 hours, and 1 hour prior to IV ICM injection PLUS diphenhydramine 50 mg IV/IM/PO 1 hour prior to ICM injection. If the patient cannot take PO, hydrocortisone 200 mg IV may be substituted for oral prednisone (1)[C].
  • For patients with allergic-like reaction history, consideration changing the type of ICM used
  • Assess alternative imaging modalities.
  • Avoid HOCM.

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Stephens, Mark B., et al., editors. "Contrast Allergy and Reactions." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816903/all/Contrast_Allergy_and_Reactions.
Contrast Allergy and Reactions. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816903/all/Contrast_Allergy_and_Reactions. Accessed March 22, 2019.
Contrast Allergy and Reactions. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816903/all/Contrast_Allergy_and_Reactions
Contrast Allergy and Reactions [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 March 22]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816903/all/Contrast_Allergy_and_Reactions.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Contrast Allergy and Reactions ID - 816903 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816903/all/Contrast_Allergy_and_Reactions PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -