Substitution with Low-Osmolar Iodinated Contrast Agent to Minimize Recurrent Immediate Hypersensitivity Reaction

Background: The recurrence of hypersensitivity reaction (HSR) to low-osmolar iodinated contrast media (LOCM) remains challenging despite premedication and substitution of the LOCM. Purpose: To determine the optimal practical preventive strategy for LOCM substitution in patients with a history of prior immediate HSR to LOCM. Materials and Methods: In a retrospective study, patients with an immediate HSR to LOCM before February 2020 and who underwent subsequent exposure to LOCM until March 2021 were enrolled in five tertiary referral hospitals in South Korea. The association of recurrence of an HSR after subsequent LOCM exposures was assessed using multivariate general estimating equation analysis according to age, sex, the severity of the index HSR, premedication, and substituting LOCM based on common carbamoyl side chains, including the N-(2,3-dihydroxypropyl)-carbamoyl and N-(2,3-dihydroxypropyl)-N-methyl-carbamoyl moieties. Results: The evaluation included 3800 subsequent LOCM exposures in 1066 patients (mean age, 56.2 years ± 13.5 [SD]; 567 [53%] female and 499 [47%] male patients). The general estimating equation analysis, using 1:1 propensity score matched data for age, sex, HSR severity, and LOCM selection, showed that premedication with corticosteroids significantly reduced recurrent HSR (odds ratio [OR], 0.72; 95% CI: 0.52, 1.00; P = .049). The change to another LOCM with a common side chain had a similar recurrence rate as using the same LOCM (OR, 0.98; 95% CI: 0.64, 1.50; P = .93), whereas the use of a different LOCM without a common side chain significantly lowered HSR recurrence (OR, 0.51; 95% CI: 0.37, 0.69; P < .001) in multivariate general estimating equation analysis. Substitution of an LOCM without a common side chain was effective regardless of the index HSR severity but was more pronounced in moderate-to-severe reactions (OR, 0.30; 95% CI: 0.16, 0.55; P < .001). Conclusion: For patients with a previous immediate HSR of any severity to LOCM, alternative LOCM without a common carbamoyl side chain reduced recurrent HSR during subsequent exposures.