June 19, 2015

Change in Steroid Prep Policy for Patients Receiving Intravenous Contrast Material - Effective 6/1/15

Printable Steroid Prep Policy

 

There is one indication for a steroid prep prior to intravenous iodinated contrast injection (e.g., CT, IVP):

  • Prior allergic-like reaction to iodinated contrast (any severity)
    • Examples: hives, itching, acute rash, wheezing, bronchospasm, stridor, laryngeal edema, anaphylaxis

There is one indication for a steroid prep prior to intravenous gadolinium-based contrast injection (e.g., MRI):

  • Prior allergic-like reaction to gadolinium-based contrast (any severity)
    • Examples: hives, itching, acute rash, wheezing, bronchospasm, stridor, laryngeal edema, anaphylaxis

The following are not considered an indication for a steroid prep:

  • Asthma
  • Reactions to other substances (regardless of number or severity, including shellfish and betadine)
  • Physiologic reaction to iodinated contrast material  such as a vasovagal reaction, nausea, vomiting

Rationale: The benefits of preps are very small relative to their indirect harms (e.g., delayed care, prolonged hospitalization). The vast majority of patients who receive a steroid prep derive no benefit (e.g., breakthrough reactions, incomplete efficacy).  Steroid preps are not given for any other “drug” in patients who have these other risk factors (e.g., asthma, other allergies).

HOW TO PREMEDICATE for Adult Patient

Standard oral premedication regimen:

  • Prednisone – 50 mg PO, 13, 7, and 1 hour prior to the procedure*
  • Diphenhydramine – 50 mg PO 1 hour prior to the procedure**

*Note: doses may be distributed unevenly to allow a patient to get a reasonable night’s sleep the evening prior to the CT; however, the first dose should be taken more than 12 hours before the time the exam is scheduled to be performed

**Note: it is not critical to administer diphenhydramine as part of the premedication regimen (there are published regimens using corticosteroids only).  In other words, although it is part of the UM premedication protocol, it is not considered mandatory.

Alternate IV protocol if a patient cannot take oral medications:

  • Hydrocortisone – 200 mg IV, 13, 7, and 1 hour prior to the procedure
  • Diphenhydramine – 50 mg IM or IV, 1 hour prior to the procedure

Urgent IV premedication protocol, when iodinated contrast is needed on an urgent/emergent basis only:

  • Hydrocortisone – 200 mg IV, 5 hours and 1 hour prior to the procedure
  • Diphenhydramine – 50 mg PO (or IM or IV, if patient cannot take PO), one hour prior to the procedure(if blood pressure permits)

Note: If preferred, methylprednisolone 40 mg IV can be substituted for hydrocortisone 200 mg, dose for dose.

Source: MD/RHC/JHE/EK  10/1/2012

 

HOW TO PREMEDICATE for Pediatric Patient

Standard oral premedication regimen:

  • Prednisone – 0.5-0.7 mg/kg PO, 13, 7, and 1 hour prior to the procedure(50 mg maximum dose)
  • Diphenhydramine –1.25 mg/kg PO 1 hour prior (50 mg maximum dose)

Source: PJS  1/19/09

Please note: if a patient requires premedication that includes diphenhydramine (Benadryl), they will need to arrange for a driver to and from the appointment, due to the possibility of drowsiness from the required medication.