Bridging the Gap Between Primary Care and Radiology

Bridging the Gap Between Primary Care and Radiology

Author: Jessica L. Tremblay, BSN, RN, DNP-FNP Student Faculty Chair: Kristine Ruggiero, Ph.D., MSN, RN, CPNP Site Mentor: David P. Munger, DO, MPH, MHL

Purpose Statement

The purpose of this Doctor of Nursing Practice (DNP) project is to educate primary care providers (PCPs) about hypersensitivity reactions (HRs) to contrast media, and increase provider knowledge on the risk factors, and best practice guidelines for the management of contrast-induced HRs.

Participation in this quality improvement project is all online, and involves completing an eLearning and two brief, anonymous questionnaires (immediately before and after the eLearning). This should take approximately 30 minutes to complete. There are no risks or benefits involved with this project. You will never be identified as a participant, and your responses will be kept anonymous. There is no compensation for participating in this project and there is no penalty for not participating. Your participation is completely voluntary, and you may withdraw from the project at any time without consequence. If you have any questions about the project, please contact Jessica Tremblay, DNP student, University of Massachusetts Amherst College of Nursing (jltremblay@umass.edu), or Dr. Kristine Ruggiero, Project Chair (kmruggiero@umass.edu). By proceeding, you are agreeing to the following statement: I voluntarily agree to participate in this project, and I have read the information above. I am at least 18 years of age and am a primary care provider. By proceeding, I am giving my informed consent to participate in this DNP project.

Problem Statement

Objectives

Modules 1-5

References

Problem Statement

Despite the increasing reliance on contrast imaging, there are no standardized education efforts for primary care providers regarding hypersensitivity risks and prevention strategies, resulting in inconsistent practices and potential patient harm.

Objectives

By the end of this eLearning, you will have a better understanding of the following:

• Risk factors of allergic-like reactions to contrast media
• Common allergy myths
• Types of reactions to contrast media
• Best practice pre-medication procedures
• Considerations when ordering radiologic imaging with contrast media

Module 1

Module 2

Background info, risk factors, allergy myths, and types of reactions.

Acute reactions to contrast media.

Module 5

Module 4

Module 3

Summary of best practice pre-medication procedures.

Delayed reactions to contrast media.

Considerations for primary care providers.

Modules

Module 1.

Background info, risk factors, allergy myths, and types of reactions.

Background Info

• Every year, over 70 million diagnostic imaging exams are conducted worldwide using contrast media.

• Allergic-like reactions to contrast media can occur immediately after contrast administration or up to 10 days after, and they vary in severity.

• The prevention and management of contrast-induced allergic-like reactions require a multi-disciplinary and collaborative approach to enhance patient safety.

(Brockow, 2022)

Risk Factors of Allergic-Like Reactions to Contrast

History of Atopy (multiple allergies, asthma, eczema, etc.).

History of previous reactions, particularly severe reactions.

Female Gender

(American College of Radiology [ACR], 2025; Ahn et al., 2022; Hojreh et al., 2020; Kang et al., 2022; Kim et al., 2019; Kim et al., 2021; Meucci et al., 2020; Nucera et al., 2022; Talmon et al., 2022)

Allergy Myths

Info

Types of Reactions to Contrast

(ACR, 2025)

Conclusions

Types of reactions to contrast include immediate acute allergic-like reactions, physiologic reactions, and non-immediate or delayed allergic-like reactions.

Those who are female, have a history of atopy, and/or a history of previous allergic-like reaction(s) to contrast have a greater risk of future reactions.

Allergic-like reactions to contrast media can occur immediately after contrast administration or up to 10 days after.

"Patients with shellfish or povidone-iodine (e.g., Betadine®) allergies are at no greater risk from iodinated contrast medium than are patients with other allergies (i.e., neither is a significant risk factor)."

-American College of Radiology (2025, p. 5)

Module 2.

Acute Reactions to Contrast

(ACR, 2025, p.95)

Mild Acute Reactions Include:

(ACR, 2025, p.95)

Moderate Acute Reactions Include:

(ACR, 2025, p.95)

Severe Acute Reactions Include:

Info

(ACR, 2025, p.96)

Treatment of acute allergic-like and physiologic reactions will occur immediately by radiology staff, and will vary depending on the presenting signs and symptoms.

Optional Info

But what can primary care providers do?

Role of Primary Care Providers

Remain Educated

Practice Mitigation Strategies

Know the difference between allergic-like and physiologic reactions, and how to differentiate between the two. Be able to recognize signs and symptoms of delayed reactions to contrast media.

Understand the risk factors of allergic-like reactions to contrast media. Know when pre-medication is indicated, and the current pre-medication regimen recommendations according to the American College of Radiology.

(ACR, 2025)

Purpose of Pre-Medication

Info

Indications for Pre-Medication

Indications for pre-medication include:

• Previous moderate acute allergic-like reaction to contrast media.
• Previous severe acute allergic-like reaction to contrast media.

Please Note:

Pre-medication may also be indicated in those with a history of severe delayed reactions* to contrast media. In those cases, a radiologist should be consulted to conduct individualized risk assessment and discuss best course of action. *More on delayed reactions in the next module.

(ACR, 2025)

Indications for Pre-Medication

Rationales

American College of Radiology's Pre-Medication Recommendations

12-13 Hour Oral Pre-Medication Regimens:

• Option 1: 50 mg prednisone by mouth at 13 hours, 7 hours, and 1 hour before contrast administration, and 50 mg diphenhydramine intravenously, intramuscularly, or by mouth 1 hour before contrast administration.

• Option 2: 32 mg methylprednisolone by mouth 12 hours and 2 hours before contrast administration. 50 mg diphenhydramine may be added.

*Please note institutional policies should always be followed, however these are the recommendations set forth by the American Academy of Radiology.

OR

(ACR, 2025)

Conclusions

For high-risk patients, oral corticosteroids are used as pre-medication to reduce the likelihood of an allergic-like reaction.

Only patients who have had previous moderate or severe acute allergic-like reactions to contrast should be pre-medicated prior to subsequent contrast- enhanced imaging.

Acute allergic-like and physiologic reactions range in severity from mild, to moderate, and severe reactions.

"Premedication does not prevent all contrast reactions."

-American College of Radiology (2025, p. 8)

Module 3.

Delayed Reactions to Contrast

"The incidence of delayed allergic-like reactions has been reported to range from 0.5% to 14%."

-American College of Radiology (2025, p. 29)

Timing of Delayed Reactions

1 week

2 days

3 hours

60 min

30 min

Delayed reactions can occur anywhere from 30 minutes after recieving contrast, up to one week after, with most delayed reactions occurring between 3 hours and 2 days.

(ACR, 2025)

Presentation of Delayed Allergic-Like Reactions

Moderate

Mild

Severe

(ACR, 2025)

Treatment of Delayed Reactions to Contrast

Delayed reactions to contrast media are usually self-limiting, and most cases require little to no supportive treatment.

Info

(ACR, 2025)

Delayed Reactions to Contrast: Recurrence and Prophylaxis

Efficacy of pre-medication prophylaxis on delayed reactions is unknown. Therefore, pre-medication is not indicated for patients whose history includes only mild delayed cutaneous reactions to contrast.

Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.

Exact recurrence rate of delayed allergic-like reactions is unknown but may be 25% or more.

Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.

Title

Prophylaxis

Write a brief description here

Title

Recurrence Rates

Write a brief description here

(ACR, 2025)

Conclusions

Pre-medication is not indiacted for patients who have a history of mild or moderate delayed cutanous reactions to contrast.

Delayed reactions are usually self-limiting, but in some cases, supportive treatment is required and determined by the presenting symptoms.

Delayed allergic-like reactions range in severity from mild, moderate, to severe, with the most frequent reactions being cutaneous in nature.

In those with a history of severe delayed reactions, consultation with a radiologist should occur prior to future imaging with contrast.

(ACR, 2025)

Module 4.

Summary of Best Practice Pre-Medication Procedures

To Pre-Medicate or to Not Pre-Medicate?

(ACR, 2025)

To Pre-Medicate or to Not Pre-Medicate?

(ACR, 2025)

Review of ACR's Pre-Medication Recommendations

12-13 Hour Oral Pre-Medication Regimens:

• Option 1: Prednisone 50 mg PO at 13 hours, 7 hours, and 1 hour before contrast administration, and Diphenhydramine 50 mg IV, IM, or PO, 1 hour before contrast administration.

• Option 2: Methylprednisolone 32 mg PO 12 hours and 2 hours before contrast administration. Diphenhydramine 50 mg may also be added.

*Please note institutional policies should always be followed, however these are the recommendations set forth by the American Academy of Radiology.

OR

(ACR, 2025)

Module 5.

Considerations for Primary Care Providers

Preliminary Considerations for PCPs

Conduct a risk versus potential benefit analysis for each patient recieving contrast-assisted imaging.

Explore imaging alternatitives that may provide the same, or better, diagnostic information.

Ensure there is a valid clinical indication for every radiologic imaging order.

(ACR, 2025)

Additional Considerations

Become familiar with available resources for radiologic imaging and contrast: ACR Appropriateness Criteria https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria Manual on Contrast Media https://www.acr.org/clinical-resources/clinical-tools-and-reference/contrast-manual

(ACR, 2025)

Parting Thoughts

Multi-disciplinary collaboration between prescribing providers and radiologists is crucial to ensure maximum patient safety. When in doubt, consult a radiologist.

(Meucci et al., 2020; Nucera et al., 2022)

References

Ahn, Y. H., Kang, D. Y., Park, S.-B., Kim, H. H., Kim, H. J., Park, G.-Y., Yoon, S.-H., Choi, Y.-H., Lee, S. Y., & Kang, H.-R. (2022). Allergic-like Hypersensitivity Reactions to Gadolinium-based Contrast Agents: An 8-year Cohort Study of 154 539 Patients. Radiology, 303(2), 329–336. https://doi.org/10.1148/radiol.210545 American College of Radiology. (2025). ACR Manual on Contrast Media. https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Contrast-Manual/ACR-Manual-on-Contrast-Media.pdf#page=4 Brockow, K. (2022). Allergy to Radiocontrast Dye. Immunology and Allergy Clinics of North America, 42(2), 391–401. https://doi.org/10.1016/j.iac.2021.12.001 Hojreh, A., Peyrl, A., Bundalo, A., & Szepfalusi, Z. (2020). Subsequent MRI of pediatric patients after an adverse reaction to Gadolinium-based contrast agents. PloS One, 15(4), e0230781. https://doi.org/10.1371/journal.pone.0230781 Kang, D. Y., Lee, S.-Y., Ahn, Y. H., Yoon, S. H., Choi, Y. H., Lee, W., & Kang, H.-R. (2022). Incidence and risk factors of late adverse reactions to low-osmolar contrast media: A prospective observational study of 10,540 exposures. European Journal of Radiology, 146, 110101. https://doi.org/10.1016/j.ejrad.2021.110101 Kim, J.-H., Choi, S. I., Lee, Y. J., Kim, B.-K., Park, H.-W., Cho, S.-H., Chang, Y.-S., & Kim, S.-H. (2021). Pharmacological prevention of delayed hypersensitivity reactions caused by iodinated contrast media. The World Allergy Organization Journal, 14(7), 100561. https://doi.org/10.1016/j.waojou.2021.100561 Kim, S., Park, K., Hong, Y., Oh, Y., Pork, J., & Lee, J. (2019). Intradermal Testing With Radiocontrast Media to Prevent Recurrent Adverse Reactions. American Journal of Roentgenology, 213(6), 1187–1193. https://doi.org/10.2214/AJR.19.21547 Meucci, E., Radice, A., Fassio, F., Sibilio, M., Iorno, M. L. C., Testi, S., Severino, M., & Macchia, D. (2020). Diagnostic approach to hypersensitivity reactions to iodinated contrast media: A single-center experience on 98 patients. European Annals of Allergy and Clinical Immunology, 52(5), 220–229. https://doi.org/10.23822/EurAnnACI.1764-1489.129 Nucera, E., Parrinello, G., Gangemi, S., Buonomo, A., Aruanno, A., Lohmeyer, F. M., Inchingolo, R., & Rizzi, A. (2022). Contrast Medium Hypersensitivity: A Large Italian Study with Long-Term Follow-Up. Biomedicines, 10(4), 759. https://doi.org/10.3390/biomedicines10040759 Talmon, A., Tal, Y., Moss, J., Hershkowitz, I., Shaham, D., Sosna, J., & Hershko, A. Y. (2022). Clinical impact of allergy and pre-medication in CT studies with low-osmolality intravenous iodinated contrast media. Clinical Radiology, 77(3), 210–215. https://doi.org/10.1016/j.crad.2021.12.009

Course Complete!

Optional Info

For more information about the treatment of acute allergic-like reactions to contrast, click the following links.

ACR's Adult Contrast Reaction Card

ACR's Pediatric Contrast Reaction Card

Pre-medication for Acute Allergic-like Reactions

For high-risk patients, oral corticosteroids are used as pre-medication to mitigate the likelihood of an allergic-like reaction to contrast.

(ACR, 2025)

Treatment of Delayed Reactions to Contrast

(ACR, 2025)

Indications for Pre-Medications

Yes, Pre-Medications Indicated: Patient with a history of a previous moderate acute allergic-like reaction to contrast. Rationale: Individuals who have a history of a previous allergic-like reaction to contrast are at a much higher risk for subsequent reactions and would require pre-medication prior to (ACR, 2025). All patients who have had a moderate acute allergic-like reaction to contrast in the past, should be pre-medicated prior to future contrast administration (ACR, 2025). No, Pre-Medications Not Indicated: Patient with a history of prior vasovagal event after receiving contrast. Rationale: A history of prior physiologic reaction is not an indication for a corticosteroid pre-medication regimen (ACR, 2025). Yes, Pre-Medications Indicated: Patient who experienced diffuse erythema with hypotension after their last CT scan with contrast. Rationale: For patients with a history of severe acute allergic-like reactions to contrast, a radiologist should consulted (ACR, 2025). Together the PCP and radiologist would conduct an individualized risk assessment and discuss the best course of action for that patient (ACR, 2025). This may include pre-medications or alternative imaging (ACR, 2025). No, Pre-Medications Not Indicated: Patient with a history of limited pruritis, and a “scratchy” throat after receiving contrast. Rationale: Although individuals with a history of previous allergic-like reactions to contrast are at a much higher risk for subsequent reactions, the American College of Radiology (2025) does not recommend pre-medicating for a history of mild allergic-like reactions. No, Pre-Medications Not Indicated: Patient with a history of asthma, eczema, and severe allergic reactions to shellfish. Rationale: “Restricting contrast medium use or pre-medicating solely on the basis of unrelated allergies is not recommended (ACR, 2025, p.5).” Yes, Pre-Medications Indicated: Patient who experienced diffuse urticaria and pruritis after receiving contrast. Rationale: A patient with a history of hives and itching after receiving contrast are indications for pre-medication before subsequent imaging with contrast (ARC, 2025).

Severe Acute Reactions

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(ACR, 2025, p.96)

Allergy Myths

Allergies to shellfish and/or topical iodine (i.e. Betadine®) are NOT associated with a higher risk for allergic-like reactions to contrast. Therefore, patients with shellfish and/or iodine can receive contrast media, as they are at no greater risk than patients with other allergies.

(ACR, 2025)