Allergologia e Immunologia Clinica Ospedale Nuovo San Giovanni di Dio Azienda Sanitaria di Firenze Responsabile: Donatella Macchia Responsabile: Donatella Macchia Stefania Capretti, Giuseppe Ermini, Maria L Iorno, Elisa Meucci, Sergio Testi Sergio Testi Elisa Meucci,
Iodinated contrast media (ICM) early twentieth century were introduced into clinical practice (however, their application was initially limited owing to poor radiopacity and toxicity) 1950s ICM were increasingly used thanks to new formulations with higher resolution and lower toxicity 1970s nonionic dimeric ICM and derivatives with higher physiological osmolality were developed Nowadays ICM are administered more than 75 million times per year worldwide
Classificazione dei Mezzi di Contrasto per esami radiografici Il contrasto negli esami radiologici è generato dall’assorbimento dei raggi X operato dal mezzo presente lungo il decorso del fascio radiante Sostanze a bassa densità (aria o anidride carbonica) riducono l’assorbimento delle radiazioni Sostanze che contengono elementi ad elevato numero atomico (bario o iodio) aumentano l’assorbimento delle radiazioni La Radiologia Medica – Radiol Med 107 (suppl 1 al N. 4):8-31,2004 Edizione Minerva Medica -Torino
Struttura di base e classificazione dei Mezzi di Contrasto iodati • Anello benzenico 1 6 2 • Tre atomi di Iodio in posizione 2-4-6 5 3 • Catene laterali in posizione 1-3-5 , 4 (a cui sono affidate le proprietà fisico-chimiche e biologiche) La Radiologia Medica – Radiol Med 107 (suppl 1 al N. 4):8-31,2004 Edizione Minerva Medica -Torino
Properties of the 4 classes of Iodinate Contrast Agents Non vengono più usati Non vengono più usati per via e.v. per l’alto per via e.v. per l’alto rischio di reazioni rischio di reazioni avverse avverse Jeffrey J Mayo Clin Proc 2012
Classification of adverse events after contrast medium administration The prevalence of nonimmediate reactions , however, has increased in the last decade, to the extent that they are now more common than immediate reactions Brockow K Allergy 2005
Rosado Ingelmo A J Investig Allergol Clin Immunol 2016
Risk Factors for Immediate and Nonimmediate Reactions • Female gender Additional risk factors for immediate reactions (common to allergic drug reactions) • Acute or chronic kidney failure. Serum creatinine >2 mg/dL • poorly controlled bronchial asthma • Other diseases with renovascular involvement, eg, diabetes, myeloma, dehydration • Cardiopulmonary disease • concomitant medications (eg, ß-blockers, ACE inhibitors) • mastocytosis • Previous reaction with ICM • Repeated administration of ICM • viral infections • Using ionic monomeric high hosmolality ICM • autoimmune diseases •Treatment with IL-2 • rapid administration of the drug • Previous drug allergy Rosado Ingelmo A J Investig Allergol Clin Immunol 2016
Epidemiology The prevalence of allergic reactions to ICM is estimated to be 1:170 000, that is, 0.05%-0.1% of patients undergoing radiologic studies with ICM These percentages are generally higher for ionic ICM (0.16%-12.66%) than for nonionic ICM (0.03%-3%) Rosado Ingelmo A et al. J Investig Allergol Clin Immunol 2016 Even the newer generation CM cause immediate and nonimmediate reactions in about 1–3% of applications Brockow K et al. Allergy 2009 The risk of reactions to ICM in children is lower Total CM adverse reaction was 1.05% Rosado Ingelmo et al. J Investig Allergol Clin Immunol 2016 Pradubpongsa P et al. Asian Pac J Allergy Immunol 2013 As low osmolality nonionic contrast agents replaced high-osmolality ionic ones, the incidence of immediate RCM hypersensitivity diminished remarkably from 3.8–12.7% to 0.7–3.1% Kim MH et al. PLOS ONE 2014 The incidence of these reactions is difficult to establish ( 1–25% according to various sources) Mruk B et al. Pol J Radiol 2016
Reazioni da Ipersensibilità immediata a causa della frequenza con cui i a causa della frequenza con cui i da Mezzi di Contrasto RCM vengono utilizzati, questi RCM vengono utilizzati, questi Prevalenza agenti diagnostici sono tra i agenti diagnostici sono tra i farmaci che più frequentemente farmaci che più frequentemente MORTALITA’ causano anafilassi fatale. causano anafilassi fatale. Pumphrey RS Clin Exp Allergy 20000 Pumphrey RS Clin Exp Allergy 20000 1 – 3/100.000 somministrazioni 1 – 3/100.000 somministrazioni (non dovute ad un particolare tipo di M. di C.) (non dovute ad un particolare tipo di M. di C.) 75 milioni di trattamenti/anno 75 milioni di trattamenti/anno Ingelmo R J Investig Allergol Clin Immunol 2016
Clinical Manifestations Immediate Nonimmediate Nonallergic Reactions Reactions Reactions (can occur immediately after administration of ICM and usually resolve spontaneously) • erythema and urticaria • maculopapular rash • heat with or without (30-90%), • facial flushing angioedema • delayed urticaria, with • dizziness (more than 70%) or without angioedema • nausea (40%-60%) • dyspnea, • contact dermatitis • nausea • fixed drug eruption • vomiting •Stevens-Johnson syndrome • hypotension • toxic epidermal necrolysis • anaphylactic shock • acute generalized pustulosis • acute coronary syndrome • vasculitis (Kounis syndrome) Rosado Ingelmo A J Investig Allergol Clin Immunol 2016
Time to onset of reaction Immediate reactors Immediate reactors 84.9% 84.9% Time to onset of the reaction was known for 107 patients in the immediate group Reaction after CM injection: • within 1–5 min 72 (67.2%) • after 10–15 min 19 (17.7%) • after 20–30 min 13 (12.1%) Time to onset of immediate reactions for patients • after 45–60 min 3 with ( ) or without ( ) previous contrast (2.8%) medium exposure. Brockow K Allergy 2009
Severity of the immediate reactions Severity of the immediate reactions (122 patients) (122 patients) 76% 76% Grade I ………………………………….. in 38 patients (31%), Grade I ………………………………….. in 38 patients (31%), Generalized cutaneous Generalized cutaneous and/or mucocutaneous symptoms and/or mucocutaneous symptoms Grade II ………………………………….. in 55 patients (45%), Grade II ………………………………….. in 55 patients (45%), Mild systemic reactions Mild systemic reactions Grade III ………………………………… in 27 patients (22%) Grade III ………………………………… in 27 patients (22%) Life-threatening systemic reactions Life-threatening systemic reactions Grade IV …………………………………. in 2 patients (1.6%) Grade IV …………………………………. in 2 patients (1.6%) Cardiac and/or respiratory arrest Cardiac and/or respiratory arrest The scoring system of Ring and Messmer The scoring system of Ring and Messmer Brockow K Allergy 2009
Time to onset of reaction Nonimmediate reactors Nonimmediate reactors 78% 78% Time to onset of the reaction was known for 95 patients in the nonimmediate group • 1–6 h 18 (18.9%) • 7–12 h 21 (22.1%) • 13–24 h 21 (22.1%) • >1–2 days 14 (14.7%) • >2–3 days 9 (9.4%) • >3 days 12 (12.6%) Time to onset of nonimmediate reactions for patients with ( ) or without ( ) previous contrast medium exposure. Brockow K Allergy 2009
Severity of the nonimmediate Severity of the nonimmediate reactions (98 patients) reactions (98 patients) Mild Mild When non treatmen was required When non treatmen was required Moderate Moderate When the patient responded readly to appropriate tretment and no When the patient responded readly to appropriate tretment and no hospitalization was nedeed hospitalization was nedeed Severe Severe When the reaction required hospitalization or was life-threatening When the reaction required hospitalization or was life-threatening Brockow K Allergy 2009
Severity of the nonimmediate reactions Severity of the nonimmediate reactions (98 patients) (98 patients) Were mainly mild to moderate skin eruptions (81%) that were Were mainly mild to moderate skin eruptions (81%) that were often treated with either antihistamines (12%), often treated with either antihistamines (12%), corticosteroids (29%) or a combination of the two (40%) corticosteroids (29%) or a combination of the two (40%) Occasionally, more severe skin eruptions were observed. Occasionally, more severe skin eruptions were observed. (bullous exanthema, flexuralexanthema, palpable purpura, purpura/maculopapular (bullous exanthema, flexuralexanthema, palpable purpura, purpura/maculopapular eruption combined with eosinophilia, psoriasis-like exanthema, acute generalized eruption combined with eosinophilia, psoriasis-like exanthema, acute generalized exanthematous pustulosis (AGEP), exfoliative eruption) exanthematous pustulosis (AGEP), exfoliative eruption)
Diagnosis (acute phase) Immediate reactions Nonimmediate reactions measurements of serum tryptase complete blood count and serum (at the onset of the reaction and 2 and chemistry 24 hours later) - detection of peripheral blood eosinophilia - evaluation of renal and hepatic function biopsy of the affected skin Rosado Ingelmo A J Investig Allergol Clin Immunol 2016
Recommend
More recommend
