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| '''Radiocontrast agents''' (also simply '''contrast agents''' or '''contrast materials''') are compounds given to a patient and used to improve the visibility of internal bodily structures in an [[X-ray]] image, including [[computed tomography]] (CT). Other contrast agents are used for medical imaging not based on the transmission of X-rays through the body, such as [[gadolinium]] for [[magnetic resonance imaging]], and preparations that circulate microbubbles through the blood for contrast with [[ultrasonography]]. Not contrast agents per se, but yet other forms of medical imaging, such as [[single photon emission computed tomography]] (SPECT) and [[positron emission tomography]] (PET), are also introduced into the patient's body, but are sources of radiation rather than radiopaque materials to external radiation]].
| | In [[diagnostic imaging]], '''contrast media''' are "substances used to allow enhanced visualization of tissues."<ref>{{MeSH}}</ref> |
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| ==Types and uses==
| | Contrast media include [[radiocontrast]] agents used for [[x-ray]]s as well as other agents not based on the transmission of X-rays through the body, such as [[gadolinium]] for [[magnetic resonance imaging]], and preparations that circulate microbubbles through the blood for contrast with [[ultrasonography]]. |
| There are two basic types of contrast agents used in [[X-ray]] examinations.
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| One type of contrast agent is based on [[barium sulfate]], an insoluble white powder. This is mixed with [[water]] and some additional ingredients to make the contrast agent. As the barium sulfate doesn't dissolve, this type of contrast agent is an opaque white mixture. It is only used in the digestive tract; it is usually swallowed or administered as an enema. After the examination, it leaves the body with the [[feces]].
| | Not contrast agents per se, but yet other forms of medical imaging, such as [[single photon emission computed tomography]] (SPECT) and [[positron emission tomography]] (PET), are also introduced into the patient's body, but are sources of radiation rather than radiopaque materials to external radiation]]. |
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| The other type of contrast agent is based on [[iodine]]. This may be bound either in an organic (non-ionic) compound or an ionic compound.
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| Ionic agents were developed first and are still in widespread use depending on the examination they are required for. Ionic agents have a poorer side effect profile.
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| Organic compounds have fewer side effects as they do not dissociate into component molecules.
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| Many of the side effects are due to the hyperosmolar solution being injected. i.e. they deliver more iodine atoms per molecule. The more iodine, the more "dense" the x-ray effect.
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| There are many different molecules. Some examples of organic iodine molecules are iohexol, iodixanol, ioversol.
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| Iodine based contrast media are water soluble and harmless to the body. These contrast agents are sold as clear colorless water solutions, the concentration is usually expressed as mg I/ml. Modern iodinated contrast agents can be used almost anywhere in the body. Most often they are used [[intravenously]], but for various purposes they can also be used intraarterially, intrathecally (the spine) and intraabdominally - just about any body cavity or potential space.
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| An older type of contrast agent, [[Thorotrast]] was based on [[thorium dioxide]], but this was abandoned since it turned out to be [[carcinogenic]].
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| {| class="wikitable sortable" border="1" cellpadding="5" cellspacing="0" align="center"
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| |+'''Commonly used iodinated contrast agents'''
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| |-
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| ! style="background:#ffdead;" | Compound
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| ! style="background:#ffdead;" | Name
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| ! style="background:#ffdead;" | Type
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| ! style="background:#ffdead;" | Iodine Content
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| ! style="background:#ffdead;" | Osmolality
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| ! style="background:#ffdead;" | Level
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| |-
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| | Ionic
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| | [[Diatrizoate]] (Hypaque 50)
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| | Ionic Monomer
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| | 300
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| | 1550
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| | High Osmolar
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| |-
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| | Ionic
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| | [[Metrizoate]] (Isopaque Coronar 370)
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| | Ionic
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| | 370
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| | 2100
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| | High Osmolar
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| |-
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| | Ionic
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| | [[Ioxaglate]] (Hexabrix)
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| | Ionic dimer
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| | 320
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| | 580
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| | Low Osmolar
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| |-
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| | Non-Ionic
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| | [http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=3359 Iopamidol] (Isovue 370)
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| | Non-ionic monomer
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| | 370
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| | 796
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| | Low Osmolar
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| |-
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| | Non-Ionic
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| | [[Iohexol]] (Omnipaque 350)
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| | Non-ionic
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| | 350
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| | 884
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| | Low Osmolar
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| |-
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| | Non-Ionic
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| | [[Ioxilan]] (Oxilan)
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| | Non-ionic
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| | Low Osmolar
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| |-
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| | Non-Ionic
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| | [[Iopromide]]
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| | Non-ionic
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| | Low Osmolar
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| |-
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| | Non-Ionic
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| | [[Iodixanol]] (Visipaque 320)
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| | Non-ionic dimer
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| | 320
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| | 290
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| | Iso Osmolar
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| |}
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| ==Adverse effects==
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| Modern iodinated contrast agents are safe drugs; adverse reactions exist but they are uncommon. The major side effects of radiocontrast are anaphylactoid reactions and contrast-induced nephropathy.
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| ===Anaphylactoid reactions===
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| [[Anaphylactoid reactions]] occur rarely (Karnegis and Heinz, 1979; Lasser et al, 1987; Greenberger and Patterson, 1988), but can occur in response to injected as well as oral and rectal contrast and even retrograde pyelography. They are similar in presentation to [[anaphylaxis|anaphylactic reactions]], but are not caused by an IgE-mediated immune response. Patients with a history of contrast reactions, however, are at increased risk of anaphylactoid reactions (Greenberger and Patterson, 1988; Lang et al, 1993). Pretreatment with corticosteroids has been shown to decrease the incidence of adverse reactions (Lasser et al, 1988; Greenberger et al, 1985; Wittbrodt and Spinler, 1994).
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| Anaphylactoid reactions range from [[urticaria]] and itching, to [[bronchospasm]] and facial and laryngeal [[edema]]. For simple cases of urticaria and itching, Benadryl ([[diphenhydramine]]) oral or IV is appropriate. For more severe reactions, including bronchospasm and facial or neck edema, albuterol inhaler, or subcutaneous or IV epinephrine, plus diphenhydramine may be needed. If respiration is compromised, an airway must be established prior to medical management.
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| ====Contribution of seafood and other allergies====
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| It must be noted that suspicion of seafood "allergy", often based more on medical myth than fact, is not a sufficient contraindication to the use of iodinated contrast material. A relationship between iodine levels in seafood and seafood allergy is part of medical lore. While iodine levels in seafood are higher than in non-seafood items, the consumption of the latter exceeds that of the former by far and there is no evidence that the iodine content of seafood is related to reactions to seafood.<ref name="pmid9308442">{{cite journal |author=Coakley F, Panicek D |title=Iodine allergy: an oyster without a pearl? |journal=AJR Am J Roentgenol |volume=169 |issue=4 |pages=951-2 |year=1997 |pmid=9308442}}</ref> Available data suggests that seafood allergy increases the risk of a contrast-mediated reaction by approximately the same amount as allergies to fruits or those with asthma.<ref name="pmid1170768">{{cite journal |author=Shehadi W |title=Adverse reactions to intravascularly administered contrast media. A comprehensive study based on a prospective survey |journal=Am J Roentgenol Radium Ther Nucl Med |volume=124 |issue=1 |pages=145-52 |year=1975 |pmid=1170768}}</ref> In other words, over 85% of patients with seafood allergies will not have an adverse reaction to iodinated contrast.<ref name="pmid9308442"/> Finally, there is no evidence that adverse skin reactions to iodine-containing topical antiseptics (e.g., Betadine, Povidine) are of any specific relevance to administration of I.V. contrast material.<ref name="pmid9308442"/><ref name="pmid2302848">{{cite journal |author=van Ketel W, van den Berg W |title=Sensitization to povidone-iodine |journal=Dermatol Clin |volume=8 |issue=1 |pages=107-9 |year=1990 |pmid=2302848}}</ref>
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| ===Contrast-induced nephropathy===
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| [[Acute kidney injury]] from radiocontrast is called contrast-induced nephropathy. It is defined as either a greater than 25% increase of serum creatinine or an absolute increase in serum creatinine of 0.5 mg/dL.<ref name="pmid16436769">{{cite journal |author=Barrett BJ, Parfrey PS |title=Clinical practice. Preventing nephropathy induced by contrast medium |journal=N. Engl. J. Med. |volume=354 |issue=4 |pages=379–86 |year=2006 |pmid=16436769 |doi=10.1056/NEJMcp050801}}</ref>
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| To minimize the risk for contrast-induced nephropathy, various actions can be taken if the patient has predisposing conditions. These have been reviewed in a [[meta-analysis]].<ref name="pmid16788132">{{cite journal |author=Pannu N, Wiebe N, Tonelli M |title=Prophylaxis strategies for contrast-induced nephropathy |journal=JAMA |volume=295 |issue=23 |pages=2765-79 |year=2006 |pmid=16788132 |doi=10.1001/jama.295.23.2765}}</ref> A separate [[meta-analysis]] addresses interventions in for emergent patients with baseline renal insufficiency.<ref name="pmid17512638">{{cite journal |author=Sinert R, Doty CI |title=Evidence-based emergency medicine review. Prevention of contrast-induced nephropathy in the emergency department |journal=Annals of emergency medicine |volume=50 |issue=3 |pages=335-45, 345.e1-2 |year=2007 |pmid=17512638 |doi=10.1016/j.annemergmed.2007.01.023}}</ref>
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| Three factors have been associated with an increased risk of contrast-induced nephropathy: preexisting [[renal insufficiency]] (such as [[Creatinine clearance]] < 60 mL/min [1.00 mL/s] - [http://www.intmed.mcw.edu/clincalc/creatinine.html online calculator]), preexisting [[diabetes]], and reduced intravascular volume.<ref name="pmid9375704">{{cite journal | author=McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW | title=Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality | journal=Am J Med | year=1997 | pages=368-75 | volume=103 | issue=5 | id=PMID 9375704}}</ref><ref name="pmid10334456">{{cite journal | author=Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, Legako RD, Leon DF, Murray JA, Nissen SE, Pepine CJ, Watson RM, Ritchie JL, Gibbons RJ, Cheitlin MD, Gardner TJ, Garson A Jr, Russell RO Jr, Ryan TJ, Smith SC Jr | title=ACC/AHA guidelines for coronary angiography. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions | journal=J Am Coll Cardiol | year=1999 | pages=1756-824 | volume=33 | issue=6 | id=PMID 10334456}}</ref>
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| A [[clinical prediction rule]] is available to estimate probability of nephropathy (increase ≥25% and/or ≥0.5 mg/dl in serum creatinine at 48 h)<ref name="pmid15464318">{{cite journal |author=Mehran R, Aymong ED, Nikolsky E, ''et al'' |title=A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation |journal=J. Am. Coll. Cardiol. |volume=44 |issue=7 |pages=1393–9 |year=2004 |pmid=15464318 |doi=10.1016/j.jacc.2004.06.068}}</ref>:
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| Risk Factors:
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| * Systolic blood pressure <80 mm Hg - 5 points
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| * Intraarterial balloon pump - 5 points
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| * Congestive heart failure (Class III-IV or history of pulmonary edema) - 5 points
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| * Age >75 y - 4 points
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| * Hematocrit level <39% for men and <35% for women - 3 points
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| * Diabetes - 3 points
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| * Contrast media volume - 1 point for each 100 mL
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| * Renal insufficiency:
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| ** Serum creatinine level >1.5 g/dL - 4 points
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| :: or
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| :* Estimated [[Glomerular filtration rate]] ([http://www.intmed.mcw.edu/clincalc/creatinine.html online calculator])
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| ::* 2 for 40–60 mL/min/1.73 m2
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| ::* 4 for 20–40 mL/min/1.73 m2
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| ::* 6 for < 20 mL/min/1.73 m2
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| Scoring:<br>
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| 5 or less points
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| *Risk of CIN - 7.5
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| *Risk of Dialysis - 0.04%
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| 6–10 points
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| *Risk of CIN - 14.0
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| *Risk of Dialysis - 0.12%
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| 11–16 points
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| *Risk of CIN - 26.1*
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| *Risk of Dialysis - 1.09%
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| >16 points
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| *Risk of CIN - 57.3
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| *Risk of Dialysis - 12.8%
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| ====Choice of contrast agent====
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| The [[osmolality]] of the contrast agent is believed to be of great importance in contrast-induced nephropathy. Ideally, the contrast agent should be iso-osmolar to [[blood]]. Modern iodinated contrast agents are non-ionic, the older ionic types caused more adverse effects and are not used much anymore.
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| Iso-osmolar, nonionic contrast media may be the best according to a [[randomized controlled trial]].<ref name="pmid12571256">{{cite journal |author=Aspelin P, Aubry P, Fransson S, Strasser R, Willenbrock R, Berg K |title=Nephrotoxic effects in high-risk patients undergoing angiography |journal=N Engl J Med |volume=348 |issue=6 |pages=491-9 |year=2003 |pmid=12571256}}</ref>
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| Hypo-osmolar, non-ionic contrast agents are beneficial if iso-osmolar, nonionic contrast media is not available due to costs.<ref name="pmid2643042">{{cite journal |author=Schwab S, Hlatky M, Pieper K, Davidson C, Morris K, Skelton T, Bashore T |title=Contrast nephrotoxicity: a randomized controlled trial of a nonionic and an ionic radiographic contrast agent |journal=N Engl J Med |volume=320 |issue=3 |pages=149-53 |year=1989 |pmid=2643042}}</ref>
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| ====Hydration with or without bicarbonate====
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| Administration of sodium bicarbonate 3 mL/kg per hour for 1 hour before , followed by 1 mL/kg per hour for 6 hours after contrast was found superior to plain saline on one [[randomized controlled trial]] of patients with a creatinne of at least 1.1 mg/dL (97.2 µmol/L) .<ref name="pmid15150204">{{cite journal |author=Merten G, Burgess W, Gray L, Holleman J, Roush T, Kowalchuk G, Bersin R, Van Moore A, Simonton C, Rittase R, Norton H, Kennedy T |title=Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial |journal=JAMA |volume=291 |issue=19 |pages=2328-34 |year=2004 |pmid=15150204}}</ref> To make the solution, the study used 154 mL of 1000 mEq/L sodium bicarbonate to 846 mL of 5% dextrose. This is approximately three 50 ml ampules of bicarbonate in 850 ml of water with 5% dextrose. This was subsequently corroborated by a multi-center [[randomized controlled trial]], which also demonstrated that IV hydration with sodium bicarbonate was superior to 0.9% normal saline<ref name="pmid17309916">{{cite journal |author=Briguori C, Airoldi F, D'Andrea D, Bonizzoni E, Morici N, Focaccio A, Michev I, Montorfano M, Carlino M, Cosgrave J, Ricciardelli B, Colombo A |title=Renal Insufficiency Following Contrast Media Administration Trial (REMEDIAL): a randomized comparison of 3 preventive strategies |journal=Circulation |volume=115 |issue=10 |pages=1211-7 |year=2007 |pmid=17309916}}</ref>. The renoprotective effects of bicarbonate are thought to be due to urinary alkalinization, which creates an environment less amenable to the formation of harmful [[free radicals]].<ref name="pmid11822926">{{cite journal |author=Mueller C, Buerkle G, Buettner H, Petersen J, Perruchoud A, Eriksson U, Marsch S, Roskamm H |title=Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty |journal=Arch Intern Med |volume=162 |issue=3 |pages=329-36 |year=2002 |pmid=11822926}}</ref>.
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| Alternatively, one [[randomized controlled trial]] of patients with a creatinine over 1.6 mg per deciliter (140 µmol per liter) or creatinine clearance below 60 ml per minute used 1 ml/kg of 0.45 percent saline per per hour for 6-12 hours before and after the contrast.<ref name="pmid7969280">{{cite journal |author=Solomon R, Werner C, Mann D, D'Elia J, Silva P |title=Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents |journal=N. Engl. J. Med. |volume=331 |issue=21 |pages=1416–20 |year=1994 |pmid=7969280 |doi=|url=http://content.nejm.org/cgi/content/full/331/21/1416}}</ref>
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| ====Methylxanthines====
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| [[Adenosine]] antagonists such as the [[methylxanthine]]s [[theophylline]] and [[aminophylline]], may help<ref name="pmid17512638"/> although studies have conflicting results.<ref name="pmid15911721">{{cite journal |author=Bagshaw SM, Ghali WA |title=Theophylline for prevention of contrast-induced nephropathy: a systematic review and meta-analysis |journal=Arch. Intern. Med. |volume=165 |issue=10 |pages=1087-93 |year=2005 |pmid=15911721 |doi=10.1001/archinte.165.10.1087}}</ref> The best studied dose is 200 mg of theophylline given IV 30 minutes before contrast administration.<ref name="pmid12745095">{{cite journal |author=Huber W, Schipek C, Ilgmann K, ''et al'' |title=Effectiveness of theophylline prophylaxis of renal impairment after coronary angiography in patients with chronic renal insufficiency |journal=Am. J. Cardiol. |volume=91 |issue=10 |pages=1157–62 |year=2003 |pmid=12745095 |doi=10.1016/S0002-9149(03)00259-5 }}</ref><ref name="pmid12034949">{{cite journal |author=Huber W, Ilgmann K, Page M, ''et al'' |title=Effect of theophylline on contrast material-nephropathy in patients with chronic renal insufficiency: controlled, randomized, double-blinded study |journal=Radiology |volume=223 |issue=3 |pages=772–9 |year=2002 |pmid=12034949 |doi=}}</ref>
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| ====N-acetylcysteine====
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| N-acetylcysteine (NAC) 600 mg orally twice a day, on the day before and of the procedure if creatinine clearance is estimated to be less than 60 mL/min [1.00 mL/s]) ''may'' reduce nephropathy.<ref name="pmid12578487">{{cite journal |author=Kay J, Chow W, Chan T, Lo S, Kwok O, Yip A, Fan K, Lee C, Lam W |title=Acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention: a randomized controlled trial |journal=JAMA |volume=289 |issue=5 |pages=553-8 |year=2003 |pmid=12578487}}</ref>. A [[randomized controlled trial]] found higher doses of NAC (1200-mg IV bolus and 1200 mg orally twice daily for 2 days) benefited ([[relative risk reduction]] of 74%) patients receiving coronary angioplasty with higher volumes of contrast<ref name="pmid16807414">{{cite journal |author=Marenzi G, Assanelli E, Marana I, Lauri G, Campodonico J, Grazi M, De Metrio M, Galli S, Fabbiocchi F, Montorsi P, Veglia F, Bartorelli A |title=N-acetylcysteine and contrast-induced nephropathy in primary angioplasty |journal=N Engl J Med |volume=354 |issue=26 |pages=2773-82 |year=2006 |pmid=16807414}}</ref>.
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| Since publication of the meta-analyses, two small and underpowered negative studies, one of IV NAC<ref name="pmid17414730">{{cite journal |author=Haase M, Haase-Fielitz A, Bagshaw SM, ''et al'' |title=Phase II, randomized, controlled trial of high-dose N-acetylcysteine in high-risk cardiac surgery patients |journal=Crit. Care Med. |volume=35 |issue=5 |pages=1324–31 |year=2007 |pmid=17414730 |doi=10.1097/01.CCM.0000261887.69976.12}}</ref> and one of 600 mg give four times around coronary angiography<ref name="pmid17509426">{{cite journal |author=Seyon RA, Jensen LA, Ferguson IA, Williams RG |title=Efficacy of N-acetylcysteine and hydration versus placebo and hydration in decreasing contrast-induced renal dysfunction in patients undergoing coronary angiography with or without concomitant percutaneous coronary intervention |journal=Heart & lung : the journal of critical care |volume=36 |issue=3 |pages=195–204 |year=2007 |pmid=17509426 |doi=10.1016/j.hrtlng.2006.08.004}}</ref>, found [[statistical significance|statistically insignificant]] trends towards benefit.
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| Some authors believe the benefit is not overwhelming.<ref name="pmid15547209">{{cite journal | author=Gleeson TG, Bulugahapitiya S | title=Contrast-induced nephropathy | journal=AJR Am J Roentgenol | year=2004 | pages=1673-89 | volume=183 | issue=6 | id=PMID 15547209}}</ref> The strongest results were from an [[Blind experiment|unblinded]] [[randomized controlled trial]] that used NAC intravenously.<ref name="pmid12821233">{{cite journal |author=Baker CS, Wragg A, Kumar S, De Palma R, Baker LR, Knight CJ |title=A rapid protocol for the prevention of contrast-induced renal dysfunction: the RAPPID study |journal=J. Am. Coll. Cardiol. |volume=41 |issue=12 |pages=2114–8 |year=2003 |pmid=12821233 |doi=}}</ref> A [[systematic review]] by [http://clinicalevidence.com Clinical Evidence] concluded that NAC is "[http://clinicalevidence.bmj.com/ceweb/about/guide.jsp likely to beneficial]" but did not recommend a specific dose.<ref name="pmid16973048">{{cite journal |author=Kellum J, Leblanc M, Venkataraman R |title=Renal failure (acute) |journal=Clinical evidence |volume= |issue=15 |pages=1191–212 |year=2006 |pmid=16973048 |doi=|url=http://clinicalevidence.bmj.com/ceweb/conditions/knd/2001/2001.jsp}}</ref> One study found that the apparent benefits of NAC may be due to its interference with the creatinine laboratory test itself.<ref name="pmid14747387">{{cite journal | author=Hoffmann U, Fischereder M, Kruger B, Drobnik W, Kramer BK | title=The value of N-acetylcysteine in the prevention of radiocontrast agent-induced nephropathy seems questionable | journal=J Am Soc Nephrol | year=2004 | pages=407-10 | volume=15 | issue=2 | id=PMID 14747387}}</ref> This is supported by a lack of correlation between creatinine levels and [[cystatin C]] levels.
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| In one study 15% of patients receiving NAC intravenously had allergic reactions.<ref name="pmid12821233"/>
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| ====Prophylactic hemodialysis====
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| [[Randomized controlled trial]]s found benefit from prophylactic [[hemodialysis]] for patients with [[chronic kidney disease]] and a creatinine over 309.4 µmol/L (3.5 mg.dl) who have elective [[coronary catheterization]], .<ref name="pmid10356104">{{cite journal |author=Hart RG, Pearce LA, McBride R, Rothbart RM, Asinger RW |title=Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trials. The Stroke Prevention in Atrial Fibrillation (SPAF) Investigators |journal=Stroke |volume=30 |issue=6 |pages=1223–9 |year=1999 |pmid=10356104 |doi=}}</ref><ref name="pmid17825709">{{cite journal |author=Lee PT, Chou KJ, Liu CP, ''et al'' |title=Renal protection for coronary angiography in advanced renal failure patients by prophylactic hemodialysis. A randomized controlled trial |journal=J. Am. Coll. Cardiol. |volume=50 |issue=11 |pages=1015–20 |year=2007 |pmid=17825709 |doi=10.1016/j.jacc.2007.05.033 |issn=}}</ref>
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| ====Other interventions====
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| Other pharmacological agents, such as [[furosemide]], [[mannitol]], [[dopamine]], and [[atrial natriuretic peptide]] have been tried, but have either not had beneficial effects, or had detrimental effects.<ref name="pmid7969280"/><ref name="pmid10073832">{{cite journal | author=Abizaid AS, Clark CE, Mintz GS, Dosa S, Popma JJ, Pichard AD, Satler LF, Harvey M, Kent KM, Leon MB | title=Effects of dopamine and aminophylline on contrast-induced acute renal failure after coronary angioplasty in patients with preexisting renal insufficiency | journal=Am J Cardiol | year=1999 | pages=260-3, A5 | volume=83 | issue=2 | id=PMID 10073832}}</ref>
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| ==References== | | ==References== |
| <references/> | | <references/>[[Category:Suggestion Bot Tag]] |
| * {{cite journal | author=Greenberger PA, Patterson R, Tapio CM | title=Prophylaxis against repeated radiocontrast media reactions in 857 cases. Adverse experience with cimetidine and safety of beta-adrenergic antagonists | journal=Arch Intern Med | year=1985 | pages=2197-200 | volume=145 | issue=12 | id=PMID 2866755}}
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| * {{cite journal | author=Greenberger PA, Patterson R | title=Adverse reactions to radiocontrast media | journal=Prog Cardiovasc Dis | year=1988 | pages=239-48 | volume=31 | issue=3 | id=PMID 3055068}}
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| * {{cite journal | author=Karnegis JN, Heinz J | title=The risk of diagnostic cardiovascular catheterization | journal=Am Heart J | year=1979 | pages=291-7 | volume=97 | issue=3 | id=PMID 420067}}
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| * {{cite journal | author=Lang DM, Alpern MB, Visintainer PF, Smith ST | title=Elevated risk of anaphylactoid reaction from radiographic contrast media is associated with both beta-blocker exposure and cardiovascular disorders | journal=Arch Intern Med | year=1993 | pages=2033-40 | volume=153 | issue=17 | id=PMID 8102844}}
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| * {{cite journal | author=Lasser EC, Berry CC, Talner LB, Santini LC, Lang EK, Gerber FH, Stolberg HO | title=Pretreatment with corticosteroids to alleviate reactions to intravenous contrast material | journal=N Engl J Med | year=1987 | pages=845-9 | volume=317 | issue=14 | id=PMID 3627208}}
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| * {{cite journal | author=Lasser EC, Berry CC, Talner LB, Santini LC, Lang EK, Gerber FH, Stolberg HO | title=Protective effects of corticosteroids in contrast material anaphylaxis | journal=Invest Radiol | year=1988 | pages=S193-4 | volume=23 Suppl 1 | id=PMID 3058630}}
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| * {{cite journal | author=Wittbrodt ET, Spinler SA | title=Prevention of anaphylactoid reactions in high-risk patients receiving radiographic contrast media | journal=Ann Pharmacother | year=1994 | pages=236-41 | volume=28 | issue=2 | id=PMID 8173143}}
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