Empiric Switching of Gadolinium-Based Contrast Agents in Patients With History of Previous Immediate Hypersensitivity Reaction to GBCA A Prospective Single-Center, Single-Arm Efficacy Trial

Background Breakthrough hypersensitivity reactions (HRs) to gadolinium-based contrast agent (GBCA) occur in 40% of patients despite corticosteroid premedication. Other strategies to reduce HRs are not well studied. Objective The aim of this study was to prospectively evaluate HR rate to GBCA among patients with history of HR to GBCA, empirically given an alternative GBCA prior to repeat administration. Materials and Methods From September 2019 to September 2020, patients with prior HR to GBCA received 13-hour oral corticosteroid and diphenhydramine premedication prescription with switching of GBCA to gadoterate (previously unavailable at our institution before September 2019). Power analysis (alpha error, 0.05; beta error, 0.80) determined 21 patients were required. Patients were evaluated under a quality assurance waiver from the institutional review board. A radiologist documented the nature of initial HR and inciting GBCA, premedication received, incidence, and severity of breakthrough HR. Results After exclusions, we evaluated 26 patients with mild (92.3% [24/26]) or moderate (7.7% [2/26]) HR to gadobutrol (53.8% [14/26]), gadoxetate (3.8% [1/26]), and gadopentetate (3.8% [1/26]). In 38.5% (10/26), inciting GBCA was unknown but was likely gadobutrol or gadopentetate based on availability. There were 22 females. The mean patient age was 52.1 +/- 15.8 years. From 27 gadoterate administrations, 59.3% (16/27) patients received corticosteroid and diphenhydramine premedication, 11.1% (3/27) received only diphenhydramine, and 29.6% (8/27) with no premedication. Hypersensitivity reaction rate after empiric switching to gadoterate was 3.7% (1 mild reaction; 95% confidence interval [CI], 0.09%-18.9%) overall with no difference in patients with (6.3% [1/16]; 95% CI, 0.15%-28.7%) or without (0%; [0/11] upper bound 95% CI, 25.0%) corticosteroid premedication. Conclusions In this prospective single-arm study, empirically switching GBCA to gadoterate in patients with prior HR to GBCA substantially reduced the expected rate of subsequent HRs in patients with and without the use of corticosteroid premedication. Implications for Patient Care Empirically switching GBCAs, with or without the use of corticosteroid premedication, can substantially reduce the rate of hypersensitivity breakthrough reactions.