Iopromide (Ultravist) is a non-ionic low-osmolar contrast agent used in angiographic and other procedures requiring contrast enhancement.

Iopromide (Ultravist) Uses:

Intra-arterial:

• Used to improve imaging in aortography, coronary angiography, cerebral and peripheral angiography, visceral angiography, and left ventriculography.

Intravenous:

• Used to improve imaging in contrast-enhanced computed tomography of the head and body (intrathoracic, intraabdominal, and retroperitoneal areas) for the assessment of neoplastic and nonneoplastic lesions.

Iohexol is another similar contrast agent.

Iopromide dose in adults:

Key point:

• The highest iodine dosage that is advised is 86 g.
• Consider the patient's age, weight, body size, vessel size, and rate of blood flow while determining the appropriate dose.
• The degree of opacification necessary, the structure or area to be studied, disease processes, as well as the tools and techniques utilized, should all be taken into account.

Aortography and visceral angiography:

• Cerebral arteriography:

  • Intra-arterial (300 mg iodine/mL): Maximum dose for procedure: 150 mL

• Coronary arteriography and left ventriculography:

  • Intra-arterial (370 mg iodine/mL): Maximum dose for procedure: 225 mL
  • Left coronary: 3 to 14 mL
  • Right coronary: 3 to 14 mL
  • Left ventricle: 30 to 60 mL
  •  

• Carotid artery visualization:

  • 3 to 12 mL

• Intra-arterial (370 mg iodine/mL):

  • Based on blood flow and particular characteristics of the vessels being evaluated, determine the dosage and rate of administration; The procedure's maximal dose is 225 mL.

• Aortic arch injection:

  • 20 to 50 mL

• Vertebral artery visualization:

  • 4 to 12 mL

• Peripheral arteriography:

  • Intra-arterial (300 mg iodine/mL): Maximum dose for procedure: 250 mL
  • Subclavian or femoral artery:
    • 5 to 40 mL
  • Aortic bifurcation for distal runoff:
    • 25 to 50 mL

• Contrast-enhanced CT: IV:

  • 300 mg iodine/mL:

• Head:

  • 50 to 200 mL; highest dose for the procedure: 200 mL

• Body:

  • Single-phase:

    • Bolus injection: Maximum dose for the procedure: 200 mL; range: 50 to 200 mL
    • Rapid infusion: Maximum dosage for the procedure: 200 mL; range: 100 to 200 mL

  • Multiple-phase:

    • Use a power injector for simultaneous administration of contrast and saline (100% contrast administered in phase 1
    • 20% to 60% contrast administered in phase 2); maximum dose for the procedure: 200 mL
    • 50 to 200 mL

  • 370 mg iodine/mL:

    • Head: Maximum dosage for the procedure is 162 mL, ranging from 41 to 162 mL.
    • Body:

      • Single-phase:

        • Rapid infusion:
          • 81 to 162 mL
          • The highest dose for the process: is 162 mL
        • Bolus injection:
          • The highest dose for the process: is 162 mL
          • 41 to 162 mL

      • Multiple phases:

        • 41 to 162 mL;
        • Use a power injector to provide contrast and saline at the same time (100 percent contrast in phase 1 and 20 to 60 percent in phase 2)
        • The highest dose for the process: is 162 mL

• Excretory urography:

  • Patients with normal renal function should receive 1 mL/kg of intravenous (300 mg iodine/mL) therapy; the procedure's maximum dose is 100 mL.

Iopromide (Ultravist) dose in Children:

Heart chambers and related arteries:

• Children older than 2 years and Adolescents:

  • Maximum dose for the procedure is 4 mL/kg for intra-arterial (370 mg iodine/mL) administration.

Iopromide (Ultravist) use in contrast-enhanced CT or excretory urography:

• Children >2 years and Adolescents:

  • 1 to 2 mL/kg for intravenous (300 mg iodine/mL); 3 mL/kg as the maximum dose.

Pregnancy Risk Category: B2

• Iopromide crosses into the placenta and was found in newborns' urine and gut at birth.
• There has never been any evidence of thyroid dysfunction in neonates.
• The theory that free iodide could adversely affect the fetus is why it should not be used unless necessary to get diagnostic information that will impact the care of the mother and the fetus during pregnancy.

Iopromide use during breastfeeding:

• Breast milk may contain iodinated contrast media.
• As a result of the low anticipated excretion and low absorption rates from infants' GI tracts, breastfeeding may continue after the administration of an iodinated contrast agent is no longer necessary.
• Theoretically speaking, milk's taste could be affected if it contains contrast media.
• Women who choose to temporarily stop breastfeeding can express breast milk or discard it from one breast for 12-24 hours after administration of contrast media.
• They can store and pump milk before the procedure, then bottle-feed the milk stored during that time.
• According to the manufacturer, when deciding whether to breastfeed, you should consider the risks to infants, the benefits to the mother, and the benefits to the mother.

Iopromide (Ultravist) Dose in Kidney Disease:

• The manufacturer's labeling does not mention dosage modifications.
• Use with caution in cases of combined renal and hepatic disease and renal impairment.
• Utilizing the least amount necessary is what the manufacturer advises.

Iopromide (Ultravist) Dose in Liver disease:

• There are no dosage adjustments provided in the manufacturer's labeling.

Side Effects of Iopromide (Ultravist):

• Cardiovascular:

  • Chest Pain
  • Bradycardia
  • Vasodilation
  • Facial Edema
  • Flushing
  • Hypertension
  • Complete Atrioventricular Block
  • Coronary Thrombosis
  • Peripheral Edema
  • Peripheral Vascular Disease
  • Ventricular Premature Contractions
  • Syncope
  • Vascular Disease

• Gastrointestinal:

  • Sore Throat
  • Stomach Discomfort
  • Dysgeusia
  • Abdominal Distress
  • Abdominal Pain
  • Constipation
  • Diarrhea
  • Upper Abdominal Pain
  • Xerostomia
  • Nausea
  • Vomiting
  • Dyspepsia
  • Gastrointestinal Pain
  • Salivation
  • Tenesmus

• Central Nervous System:

  • Anxiety
  • Ataxia
  • Chest Discomfort
  • Chills
  • Headache
  • Agitation
  • Confusion
  • Seizure
  • Speech Disturbance
  • Dizziness
  • Drowsiness
  • Malaise
  • Myasthenia
  • Neuropathy
  • Feeling Hot
  • Hypertonia
  • Hypoesthesia
  • Paresthesia

• Dermatologic:

  • Urticaria
  • Pruritus
  • Skin Rash
  • Erythema
  • Hyperhidrosis

• Genitourinary:

  • Urinary Retention
  • Urinary Urgency
  • Dysuria

• Local:

  • Injection Site Reaction
    • Hemorrhage
    • Pain
    • Skin Rash
    • Warm Feeling
    • Edema
    • Erythema
    • Hematoma

• Respiratory:

  • Increased Cough
  • Pulmonary Hypertension
  • Respiratory Tract Disease
  • Dyspnea
  • Hypoxia
  • Pharyngeal Edema
  • Apnea
  • Asthma
  • Pharyngitis
  • Pleural Effusion

• Endocrine & Metabolic:

  • Increased Lactate Dehydrogenase
  • Polydipsia

• Neuromuscular & Skeletal:

  • Weakness
  • Limb Pain
  • Musculoskeletal Pain
  • Neck Pain
  • Tremor
  • Back Pain
  • Arthralgia

• Hematologic & Oncologic:

  • Leukocytosis
  • Increased Hemoglobin

• Ophthalmic:

  • Visual Field Defect
  • Visual Disturbance

• Renal:

  • Renal Pain
  • Increased Blood Urea Nitrogen

• Miscellaneous:

  • Fever

Side effects of Iopromide (Ultravist) (Frequency unknown):

• Central Nervous System:

• • Cerebral Edema

• Gastrointestinal:

  • Mucous Membrane Disease

• Hypersensitivity:

  • Fixed Drug Eruption

• Endocrine & Metabolic:

  • Diabetes Insipidus

• Cardiovascular:

  • Cerebrovascular Accident
  • Ischemic Heart Disease
  • Cardiac Arrhythmia

• Respiratory:

  • Epistaxis
  • Respiratory Insufficiency
  • Aspiration
  • Cyanosis

• Neuromuscular & Skeletal:

  • Joint Effusion
  • Muscle Cramps

• Ophthalmic:

  • Conjunctivitis

• Renal:

  • Acute Renal Failure

Contraindications to Iopromide (Ultravist):

Intrathecal use

• Iopromide injection may be given to children who have undergone preparatory dehydration (such as prolonged fasting and administration of a laxative).

Canadian labeling:

• Hypersensitivity to any ingredient in this formulation, including iopromide; hyperthyroidism. Utilize for myelography.

Warnings and precautions

• Contrast media reactions

  • Food allergies (or other hypersensitivities): If delayed reactions occur, monitor closely for between 30 and 60 minutes.
  • Bronchial asthma
  • These reactions can be life-threatening and serious. Patients with known allergies (e.g., to contrast dyes or iodine) should be treated with extreme caution.
  • Hay fever

• Acute kidney injury caused by contrast:

  • Intravascular administration of iodinated, contrast media may increase the risk. Patients with preexisting renal disease are at risk.
  • Advanced age
  • Acute kidney injury
  • Advanced vascular disease
  • heart failure,
  • Dehydration
  • diabetes mellitus,
  • Use of diuretics or nephrotoxic drugs in conjunction with nephrotoxic agents
  • multiple myeloma/paraproteinemia,
  • Or large or multiple doses of iodinated media. To minimize risk, ensure that patients are adequately hydrated before and after administration.

• Dermatological effects

  • Severe cutaneous adverse reaction (including Stevens-Johnson syndrome [SJS]),
  • toxic epidermal necrolysis [TEN],
  • acute generalized exanthematous pustulosis [AGEP],
  • Drug reaction with eosinophilia or systemic symptoms (DRESS) can occur within one hour to several weeks following administration.
  • Repeat administration may result in greater severity of reactions and a shorter time for onset.
  • Patients who have had a history of severe cutaneous reactions to iothalamate should be avoided

• Extravasation:

  • Perhaps a vesicant. Higher osmolarity contrast agents and/or greater volumes are associated with higher risks.
  • Monitor infusion site.
  • Avoid infiltration
  • Extravasation can lead to tissue necrosis, and/or compartment syndrome.
  • Patients with severe arterial and venous disease are particularly at risk.

• Events that are thromboembolic:

  • Angiographic procedures using both non-ionic and ionic contrast agents have resulted in serious thromboembolic complications.
  • Clotting can occur if blood is in direct contact with syringes that contain iodinated contrast media.
  • It is therefore essential to use a meticulous intravascular administration technique.

• Cardiovascular disease

  • Patients with heart disease or cardiovascular disease should be cautious.
  • Iodinated contrast media usage has the potential to enhance the circulatory osmotic burden and result in an acute or delayed hemodynamic alteration, especially if it is done frequently or in large doses.
  • For delayed hemodynamic changes, observe patients suffering from cardiovascular disease for several hours following the procedure.
  • Patients with advanced vascular disease or heart failure may experience acute renal failure if they are given pre-hydration.
  • These patients should avoid fluid restrictions and keep their hydration normal.

• Diabetes:

  • Patients with diabetes mellitus should be cautious. These patients could have altered renal blood flow, which may increase the risk of nephrotoxicity.
  • Patients with diabetes may be at risk from pre-dialysis. It is important to avoid fluid restriction and maintain normal water intake.

• Hepatic impairment

  • Patients with hepatic impairment should be cautious.
  • Particularly for those who have concomitant renal impairment, or when IV and oral contrast agents are used in close proximity.

• Homocystinuria

  • Patients with homocystinuria should avoid angiography; they may be at high risk of embolism and thrombosis.

• Hyperthyroidism:

  • Patients with thyroid disease should be cautious.
  • Patients with a history or an independent functioning thyroid nodule have been known to experience a thyroid storm.

• Hypothyroidism:

  • Thyroid function tests that indicate hypothyroidism, or transient thyroid suppression (uncommon) have been reported in both pediatric and adult patients (including infants). Some patients were also treated for hypothyroidism.

• Multiple myeloma

  • Utilizing intravascular contrast agents should be done with caution in multiple myeloma patients. This might compromise kidney function.
  • Particularly if you have concurrent dehydration.

• Pheochromocytoma:

  • Patients with known or suspected pheochromocytoma should be treated with caution. Reduce intravascular administration of contrast agent and closely monitor blood pressure throughout the procedure.
  • Treatment for hypertensive crises should be available immediately.

• Renal impairment

  • Patients with impaired renal function should be cautious. It may cause deterioration in renal function or an increase in serum creatinine.
  • Patients with diabetes and elderly patients are particularly vulnerable.
  • Advanced vascular disease
  • Those who are severely dehydrated.
  • Patients with impaired renal function should be given the lowest possible dose.

• Sickle cell disease:

  • Patients with sickle cell disease should be treated with caution.
  • May promote sickling.

Iopromide: Drug Interaction

Monitoring parameters:

• Monitor for extravasation during IV administration.
• Keep an eye on your blood pressure, hydration, and renal function.
• Monitor for hypersensitivity reactions for ≥30 to 60 minutes.

Coronary arteriography:

ECG (coronary arteriography); vital signs; signs and symptoms of hypersensitivity; renal function.

How to administer Iopromide (Ultravist)?

• For IV or intra-arterial use only.
• The temperature of injectable solutions should be as similar as feasible to body temperature.
• Do not administer through the same line as other medications or parenteral nutrition.
• When utilizing a power injector system may be administered simultaneously with saline.
• Patients should drink plenty of water before and after treatment.
• It is recommended that injection rates be roughly equivalent to the flow rate in the vessel being injected.
• Give yourself enough time between each substantial infusion.
• Maybe a vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid infiltration.

Extravasation management:

• If extravasation occurs, stop infusion immediately and disconnect.
• Remove needle/cannula; elevate extremity.
• Aspiration of extravasated contrast media is not recommended.
• Information conflicts regarding the use of hyaluronidase.
• The American College of Radiology (ACR) Manual on Contrast Media does not recommend hyaluronidase in the management of contrast media extravasation.
• Other sources suggest its utility in extravasation management.

If using hyaluronidase: Intradermal or SubQ:

• Inject a total of 1 to 1.7 mL (15 units/mL) as five separate 0.2 to 0.3 mL injections (using a 25-gauge needle) into the area of extravasation at the leading edge in a clockwise manner or injection of a total of 5 mL (150 units/mL) as five separate 1 mL injections around the extravasation site has been also used successfully.

Mechanism of action of Iopromide (Ultravist):

• Iopromide makes vessels opaque in its flow path, allowing radiographic visualization of internal structures.

Half-life elimination:

• Main phase: 2 hours;
• Terminal phase: 6.2 hours

Excretion: Urine 97% (as unchanged drug) 

Protein binding:

• 1%

Time to peak:

• Intravascular: Contrast enhancement: 15 to 120 seconds after bolus injection
• Intravenous: Contrast enhancement: Kidneys: 5 to 15 minutes

International Brands of Iopromide:

• Ultravist
• Ultravist 240
• Ultravist 300
• Ultravist 370
• Clarograf
• Prosure
• Ultravist

Iopromide Brand Names in Pakistan:

No Brands Available in Pakistan.