¹Clínica Centro S.A, Barranquilla, Colombia ²Grupo de investigación en farmacia asistencial y farmacología (GIFAF), Universidad del Atlántico, Barranquilla, Colombia ³Clínica Santa Ana De Dios, Barranquilla, Colombia ⁴Residencia en Medicina Interna, Colombia

*Corresponding Author: Dadier Antonio Arroyo, Monterroza, Calle 40 N° 41 – 110, Colombia; Tel: 301 4862898; Email: [email protected]

Received Date: 22  September, 2023

Published Date: 3 November, 2023

Citation: Arroyo DA, et al. (2023). Desensitization in a Patient with Hypersensitivity to the Iodinated Contrast Medium Iopromide: A Clinical Case Report. Mathews J Pharma Sci. 7(3):23.

Copyrights: Arroyo DA, et al. © (2023). 

SUMMARY Introduction: A contrast agent is a substance that, when introduced into the body, it makes possible to observe organs anatomically, or tumors at a pathological level. These contrast media are administered daily to many people, unfortunately they eventually produce adverse reactions, which in some cases can be lethal. Objective: Describe the desensitization process in a patient with hypersensitivity to the iodinated contrast medium iopromide. Results: A case of a male patient with hypersensitivity is introduced to contrast medium, who underwent angioplasty to achieve a positive result within minutes after administrating 2998.83 mg/mL of iopromide (300 mg/mL) without any associated post-surgical complications, resulting in a favorable clinical outcome and the patient was medically discharged thereafter. Conclusion: The desensitization process is an opportunity that would allow different procedures and/or complementary studies to be carried out quickly and safely in order to clarify diagnoses and therapeutics. Therefore, this process must be carried out by multidisciplinary personnel trained in the management of hypersensitivity states. Keywords: hypersensitivity, contrast agent, iopromide, immunological desensitization

INTRODUCTION

Contrast media are chemical substances that fulfill the function of inhibiting or absorbing ionizing radiation, causing changes in the radiographic image when introduced into the body, thus achieving differentiation in the different organic structure due to the type of density that they produce [1,2].

There are several types of contrast media: A) ICM (iodinated contrast media), typically used for X-rays and CT scans, B) GBCM (gadolinium-based contrast media), English) for MRI and C) dyes such as patent blue, methylene blue and fluorescein, some used for the detection of lymph nodes or melanoma and sometimes for the diagnosis and monitoring of diseases [3]. Although its use has many diagnostic benefits, the probability of adverse reactions occurring is present in the use of any type of contrast agent, and in unpredictable cases it can be lethal (representing 1 in 100,000 cases) [4,5]. The density of soft tissue is approximately equal to the density of water (0.92 to 1.065 g/cm³) compared to the density of the whole, which is 4.94 g/cm³. The regularity of the presentation of allergic reactions is based on different compounds (these differ in osmolarity, viscosity and ionic strength) [5] and factors that include both the risk profile of each patient, as well as the type of contrast material used [1].

Within adverse reactions, two classes must be differentiated: A) IHR (immediate hypersensitivity reactions) and B) NIHR (non-immediate hypersensitivity reactions).

In IHR, the appearance of adverse symptoms is 2-4% for moderate reactions and severe in less than 1%, in which anaphylaxis is one of the representative symptoms [6]. Generally these occur one hour after the administration of the medication, unlike NIHR where they can occur in up to 10 days after the administration of the contrast agent [3].

Among the prevention methods we find: allergy studies, pre-medication, adequate selection of contrast media and also the treatment with antihistamines and corticosteroids to avoid these adverse events. However, these methods do not guarantee that hypersensitivity to the elements will not occur. For this reason, a desensitization strategy is suggested [4] as an unusual measure in hospitals, which can offer an alternative for the continuity of pharmacological treatment(s). Respectively, extensive knowledge regarding the treatment and diagnosis (before, during and after) of the administration of any contrast agent is essential [6].

CLINICAL CASE DESCRIPTION

First desensitization

This is a 71-year-old male patient, from and residing in the municipality of Barranquilla, Department of Atlántico (Colombia), who denies any significant pathological history; however, is an active smoker with a pack-year index (IPA) of 50 pack-years which represents a high risk for lung cancer. Patient was admitted to the emergency department complaining of pain in the precordial region of sudden and progressive onset, lasting 6 days, which worsened in the last few hours of an oppressive type, not radiating, with an intensity of 7/10 made worse with movements. Additionally, reports that it is accompanied by dyspnea with great exertion, assessed by the internal medicine service with Troponin I and positive Troponin delta, which is why they contextualize it as an acute coronary syndrome type, acute myocardial infarction without ST segment elevation. Coronary stratification is indicated. Subsequently, he was taken by the cardiology service for coronary catheterization, which showed disease in two main vessels (Anterior Descending Artery and Right Coronary Artery) requiring angioplasty with STENT in the anterior descending artery and right coronary artery. However, during the procedure, the patient presented with a skin rash that was generalized, associated with pruritus, in which the procedure was suspended. This probably represented a hypersensitivity reaction to contrast medium, so the clinical pharmacology service proceeded with a desensitization process, directed at the contrast medium, so that a second surgical procedure could be performed later for a second-stage stent implantation of the compromised artery. The risks and benefits of the procedure were explained to the patient, understanding and accepting by signing an informed consent. After this, he is transferred to the intermediate ICU service for monitoring during the procedure.

Desensitization procedure

The method proposed by Josephson R. et al. was adapted [4]. Those who used the contrast medium, Visipaque, in the development of the protocol. However, the contrast medium Iopromide was used, which is the one approved in the hospital institution for hemodynamic procedures, for which the same solutions were maintained but with variations in the doses to be administered.

A rapid intravenous protocol was designed (Table 1) that consisted of a series of 13 dilutions of increasing concentrations of Iopromide (300 mg/mL) and their respective administration times (every 10 and 15 minutes), which were prepared in the mixing center by the Pharmaceutical Chemist.

Table 1: Contrast media desensitization protocol with Iopromide.

Iopromide Desensitization
Time interval for	No of		Concentration		Volume	Administration
		Dissolution		dose(mg)
admin. (min)	Doses		(mg/mL)		(mL)	time
	1	1:10000	0.03	0.12	5	6:45 AM
10	2	1:5000	0.6	0.3	5	6:55 AM
	3	1:1000	0.29	1.46	5	7:05 AM
	4	1:500	0.58	2.93	5	7:15 AM
	5	1:250	1.17	5.85	5	7:25 AM
	6	1:125	2.34	11.71	5	7:35 AM
	7	1:62.5	4.68	23.43	5	7:45 AM
	8	1:32	9.37	46.87	5	7:55 AM
	9	1:16	18.75	93.75	5	8:10 AM
	10	1:8	37.5	187.5	5	8:25 AM
15	11	1:4	75	375	5	8:40 AM
	12	1:2	150	750	5	8:55 AM
-	13	1:1	300	1500	5	9:10 AM