Choosing Wisely:

Don’t routinely order low- or iso-osmolar radiocontrast media or pretreat with corticosteroids and antihistamines for patients with a history of seafood allergy, who require radiocontrast media.

Rationale and Comments: Although the exact mechanism for contrast media reactions is unknown, there is no cause and effect connection with seafood allergy. Consequently there is no reason to use more expensive agents or pre-medication before using contrast media in patients with a history of seafood allergy. A prior history of anaphylaxis to contrast media is an indication to use low- or iso-osmolar agents and pretreat with corticosteroids and antihistamines. Patients with a history of seafood allergy are not at elevated risk for anaphylaxis from iodinated contrast media. Similarly, patients who have had anaphylaxis from contrast media should not be told that they are allergic to seafood. Patients with a history of seafood allergy who are labeled as being at greater risk for adverse reaction from contrast infusions experience considerable morbidity from unnecessary precautions, including but not limited to denying them indicated roentgenographic procedures and adverse effects from pretreatment with antihistamine and/or corticosteroid medications. Regardless of whether these patients truly have IgE-mediated allergies to seafood (crustacean), there is no evidence in the medical literature that indicates they are at elevated risk for anaphylaxis from contrast infusion compared with the history-negative general population. In a random telephone survey of 5,529 households with a census of 14,948 individuals, seafood allergy was reported by 3.3% of survey respondents. According to current U.S. population estimates for 2013, this corresponds to 10,395,000 Americans. The mechanism for anaphylaxis to radio-iodinated contrast media relates to the physiochemical properties of these media and is unrelated to its iodine content. Further, although delayed-type hypersensitivity (allergic contact dermatitis) reactions to iodine have rarely been reported, IgE-mediated reactions to iodine have not, and neither type of reaction would be related to IgE-mediated shellfish allergy nor to contrast media reactions. Patients with a history of prior anaphylaxis to contrast media are at elevated risk for anaphylactic reaction with re-exposure to contrast media. Patients with asthma or cardiovascular disease, or who are taking beta blockers, are at increased risk for serious anaphylaxis from radiographic contrast media.
Sponsoring Organizations:
  • American Academy of Allergy, Asthma and Immunology
  • Sources:
  • Expert consensus
  • Disciplines:
  • Allergy and immunologic
  • References: • American Academy of Asthma, Allergy and Immunology. Food allergy: a practice parameter. Ann Allergy Asthma Immunol. 2006 Mar;96:S1–68.
    • Lieberman P, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol. 2010 Aug 21;126(3):477–522.
    • Solensky R, Khan DA. Drug allergy: an updated parameter. Ann Allergy Asthma Immunol. 2010 Oct;105(4):259–73.
    • Sicherer S, Munoz-Furlong A, Sampson H. Prevalence of seafood allergy in the United States determined by a random telephone survey. J Allergy Clin Immunol. 2004;114:159–65.
    • Greenberger P. Prophylaxis against repeated radio contrast media reaction in 857 cases. Arch Intern Med. 1985;145:2197–200.
    • Sicherer SH. Risk of severe allergic reactions from the use of potassium iodide for radiation emergencies. J Allergy Clin Immunol. 2004;114:1395–7.
    • Lang DM, Alpern MB, Visintainer PF, Smith ST. Elevated risk for anaphylactoid reaction from radiographic contrast media associated with both beta blocker exposure and cardiovascular disorders. Arch Intern Med. 1993;153:2033–40.

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