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Prevention of Contrast Induced Nephropathy - Adult - Inpatient/Ambulatory

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1
Prevention of Contrast Induced Nephropathy – Adult –
Inpatient/Ambulatory
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 2
SCOPE ...................................................................................................................................... 3
METHODOLOGY ...................................................................................................................... 3
DEFINITIONS ............................................................................................................................ 3
INTRODUCTION ....................................................................................................................... 3
RECOMMENDATIONS .............................................................................................................. 4
UW HEALTH IMPLEMENTATION ............................................................................................. 8
APPENDIX A ............................................................................................................................13
APPENDIX B ............................................................................................................................14
APPENDIX C ............................................................................................................................15
CPG Contact for Changes Content: CPG Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS Name: Cindy Gaston, PharmD, BCPS
Phone Number: 265-0341 Phone Number: 265-8161
Email Address: ptrapskin@uwhealth.org Email Address: cgaston@uwhealth.org
Updated by: Cindy Gaston, PharmD, BCPS
Coordinating Team Members: Cindy Gaston, PharmD, BCPS
Review Individuals/Bodies:
Myron Pozniak, MD; Maryl Johnson, MD; Jessica Robbins, MD; Peter Chase, MD; Laura
Maursetter, DO
Committee Approvals/Dates: Pharmacy & Therapeutics Committee – December 2014
Release Date: Initial: April 2006; Update: December 2014
Next Review Date: December 2016
Note: Active Table of Contents
Click to follow link
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2
Executive Summary
Guideline Overview
The guideline reviews the treatment options for the prevention of intravenous or intra-arterial contrast
reagents in adult patients
Target Population
Adult patients receiving intravenous or intra-arterial contrast reagent.
Key Practice Recommendations
Some patients are at higher risk of developing contrast induced nephropathy (CIN) and modifiable risks
should be addressed whenever possible (e.g., hypotension, volume depletion, anemia, administration of
concomitant nephrotoxic medications, heart failure symptoms). Metformin should only be held in select
patients. Renal function should be evaluated prior to administration of contrast in patients with risk factors
for CIN. Patients should receive intravenous hydration before and after administration of iodinated
contrast in conjunction with the smallest dose of contrast.
Current literature does not support the routine use of sodium bicarbonate, acetylcysteine, mannitol or
furosemide for the prevention of CIN.
Companion Documents
Algorithm for Prevention of Contrast-Induced Nephropathy
Recommendations for Holding Metformin with IV Iodinated Contrast Administration
Pertinent UWHC Policies & Procedures
NA
Patient Resources:
NA
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3
Scope
Disease/Condition(s):
Prevention of contrast induced nephropathy in adult patients
Clinical Specialty:
Radiology, nephrology, cardiology, pharmacy
Intended Users:
Physicians, mid-level providers, pharmacists, nurses.
CPG objective(s):
To provide evidence-based guidelines for the prevention of contrast induced nephropathy.
Guideline Metrics:
Incidence of contrast induced nephropathy reported through the Patient Safety Network (PSN).
Methodology
Methods Used to Collect/Select the Evidence:
The UWHC Guidelines for the Prevention of Contrast-induced Nephropathy in Adults was updated with a
literature search using MEDLINE, Cochrane, Agency for Healthcare Research and Quality Reports and
International Pharmaceutical Abstracts (IPI) from 2011 to 2014 and evaluation of referenced literature.
Searches were extended to reviews and studies conducted in humans and published in English.
Reference lists of relevant studies were also reviewed.
Rating Scheme for the Strength of the Evidence and Recommendations:
A modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) developed
by the American Heart Association and American College of Cardiology has been used to assess the
Quality and Strength of the Evidence in this Clinical Practice Guideline (Figure 1).1
Methods Used to Formulate the Recommendations:
Recommendations were based on strength of evidence, clinical expert consensus and cost assessment
Definitions
Contrast induced nephropathy is a sudden deterioration is renal function within 48 to 72 hours of contrast
administration in patients without other attributable factors for renal insufficiency.2 The requirements for
determining reduction in renal function vary by trial. Some define renal deterioration as a 20 to 50 %
increase in serum creatinine; others use absolute increases in serum creatinine of 0.5 to 2 mg/dL.3, 4 Most
clinical trials limit evaluation of renal function to 48 to 72 hours after contrast administration. All increases
in serum creatinine cannot be interpreted as CIN since intrapersonal variation in creatinine occurs and
coadministered medications and comorbidities can confound data. Studies illustrate that in adult
inpatients not receiving contrast over 50% of patients experience at least a 25% increase in serum
creatinine within five consecutive days.
For the purposes of this guideline CIN is considered an increase in serum creatinine of greater than 0.5
mg/dL or 25% above baseline within 72 hours, which is consistent with the majority of trials.5
Introduction
Many diagnostic procedures require administration of intravascular or intra-arterial infusion of iod6inated
contrast material and the number of patients treated with these agents is increasing. The potentially
serious complication of CIN in patients with normal renal function is relatively low, but reports of incidence
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vary depending on the defined criteria for CIN and patient comorbidities.7, 8 Patients with renal
insufficiency and diabetes are more likely to experience CIN after administration of iodinated contrast
material.9, 10 In patients receiving intra-arterial infusions of contrast for coronary angiogram the risk is also
higher, which some have attributed to comorbidities associated with cardiac disease rather than the
contrast.11 Most cases of CIN are generally mild and transient; however, there are reports of acute renal
failure requiring dialysis and increased mortality.8, 12-14
Gadolinium based contrast reagents are well tolerated at usual doses and the risk of CIN is extremely
rare.2, 15-22
The exact mechanism of CIN is unknown, but considered multifactorial and attributed to direct tubular
injury as a consequence of proximal tubule cell exposure to contrast media, as well as a decrease in
renal perfusion due to vasoconstriction.13, 23 In addition, animal studies demonstrate tubular damage from
oxygen free radicals generated after administration of contrast media.24, 25
Based on the attributed causes of CIN multiple strategies have been evaluated to minimize the incidence
in high risk patients, but despite the expansive literature reported and meta-analyses there is no universal
approach for prevention. There is consensus among clinicians that modifiable risk factors for CIN should
be minimized.2
Recommendations
1. The risk of CIN is higher in patients with concomitant morbidities, procedures and
conditions and all patients should be assessed for risk and monitored closely.2, 6, 14, 26-28
Steps should be taken to minimize all potential risk factors such as of hypotension, volume
depletion, anemia, heart failure symptoms, and administration of concomitant nephrotoxic
medications. (Class I, Level A)
The following are associated with an increased risk of CIN:
- Renal insufficiency (serum creatinine > 1.5 mg/dL or glomerular filtration rate (GFR) <60
mL/min/1.73 m2)
- Diabetes
- Heart failure
- Cirrhosis
- Anemia
- Hypotension
- Age over 75 years
- Intravascular volume depletion
- Concomitant administration of nephrotoxic medications
- Intra-arterial administration of contrast
- High volume of contrast or multiple sequential procedures requiring contrast.
2. In patients with a high risk for CIN iodinated contrast administer iodinated contrast only
when the risk outweighs the benefit.2 (Class I, Level C)
3. Evaluate kidney function prior to the procedure in select patients.29 (Class 1, Level A)
3.1. If a patient has suspected renal dysfunction or is at risk for CIN (as listed under item 1
above) then evaluate a baseline serum creatinine or GFR.2 (Class 1, Level C) Also
consider creatinine measurements in the following patients:
3.1.1. History of kidney disease, renal tumor, renal transplant or prior renal surgery
3.1.2. Family history of kidney failure
3.1.3. Paraproteinemia syndromes (e.g., multiple myeloma)
3.1.4. Collagen vascular disease (e.g., scleroderma, systemic lupus erythematosa)
3.1.5. Diagnosis of hypertension
3.1.6. Inpatients
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3.1.7. Patients taking the following medications: metformin, chronic or high dose non-
steroidal anti-inflammatory agents, aminoglycosides
3.2. For high risk patients (Class I, Level C):
3.2.1. Obtain a serum creatinine within two weeks of planned contrast administration.
3.2.2. Estimate GFR.
3.2.3. In patients with acute renal failure, administer contrast only when the benefit
outweighs the risk.2
The risk of CIN is low and adequately controlled trials demonstrated no increase in CIN in
patients receiving low-osmolar contrast with a serum creatinine below 1.8 mg/dL.4, 7, 30, 31
Outpatients without previous renal disease or diabetes are unlikely to have unidentified increases
in serum creatinine.32
A pooled analysis of patients receiving intravenous contrast demonstrated a 0.6% incidence of
CIN in patients with GFR greater than 40 mL/min, versus 4.6% with GFR less 40 mL/min and
7.8% with GFR less 30 mL/min.33 Patients with GFR less than 60 mL/min/1.73 m2 and
concomitant diabetes are considered at an even higher risk for CIN.10, 29
Serum creatinine is limited as a measure of renal function in that it is impacted by gender, age,
and muscle mass and nutritional status. An alternative method for evaluating renal function is
estimating creatinine clearance using the Cockcroft-Gault formula or GFR which is estimated by
the Modification of Diet in Renal Disease (MDRD) formula.2, 34, 35 The Cockcroft-Gault equation:
[(140-age) X Actual Body Weight (kg) / (Serum Cr X 72)] multiply the result by 0.85 for females
is utilized in Health Link to estimate creatinine clearance. UWHC Laboratory calculates “eGFR”
on outpatients with a measured serum creatinine using the MDRD equation:
GFR (mL/min/1.73m2) = 175 x (SCr)-1.154 x (Age)-0.203 x (0.742 if female) x (1.212 if African
American)
If requested, the GFR can be calculated for inpatients. Alternatively, an on line calculator is on the
National Kidney Foundation website.34 A limitation of both equations includes development in
select a population with stable renal function.
4. Creatinine monitoring after contrast administration is only required for patients at risk with
a recommended baseline serum creatinine (see item 2).2 The optimum time for creatinine
monitoring after contrast administration is undefined, but usually within 96 hours. If
creatinine increases by 0.25 mg/dL or over 25% above baseline, then continue to monitor
serum creatinine. If serum creatinine does not return to baseline within 1 week, consult
nephrology. (Class I, Level C)
5. Hold metformin containing agents prior to administering iodinated contrast in select
patients only.2 (Class I, Level C)
Several case reports of lactic acidosis occurred in patients receiving iodinated contrast dye while
on metformin.36 These reports resulted in a change in labeling to hold metformin prior to and 48
hours after the administration of contrast and restart only after renal function is re-evaluated.37
The rationale for this recommendation is that CIN could cause an accumulation of metformin and
result in lactic acidosis. Based on this rationale, only patients at a higher risk for CIN require
withholding of metformin.2 Further evaluation of the case reports revealed that most cases of
reported lactic acidosis with iodinated contrast and metformin occurred in patient with
comorbidities (e.g., renal disease, alcohol abuse, cardiac failure).
The American College of Radiology provides the following recommendations for holding
metformin:2
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Category 1: For patients with eGFR ≥ 45 mL/min without liver dysfunction, alcohol abuse, cardiac
failure, myocardial or peripheral muscle ischemia, sepsis or severe infection:
Do not hold metformin* or check creatinine after contrast administration.
Category 2: For patients with eGFR ≥ 45 mL/min with liver dysfunction, alcohol abuse, cardiac
failure, myocardial or peripheral muscle ischemia, sepsis or severe infection:
Hold metformin* for 48 hours. The procedure for assessing renal function and time to
restart metformin will be determined by the radiologist and practitioner and
communicated to the patient.
Category 3: For patients with impaired renal function, eGFR < 45 mL/min:
Hold metformin* at the time of contrast administration and follow renal function until
metformin can be re-instituted safely.
* Trade names of medications include (but are not limited to): ActoPlus Met®, ActoPlus Met XR®,
Avandamet®, Fortamet®, Glucophage®, Glucophage XR®, Glucovance®, Glumetza®, Invokamet®,
Janumet®, Janumet XR®, Jentadueto®, Kazano®, Kombiglyze XR®, Metaglip®, PrandiMet®,
Riomet®, Xigduo XR.
6. Hold potentially nephrotoxic medications whenever possible.2 (Class I, Level C)
Hold non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen, naproxen,
celecoxib.
7. In patients at high risk for CIN undergoing cardioangiography holding ACEI and ARB may
be considered, but effectiveness is not well established.38-41 Consider the risk versus
benefit of holding an ACEI or ARB especially in patients established on therapy for HL.
(Class IIb, Level C)
Current studies evaluating CIN incidence in patients on chronic ACEI or ARB therapy report
conflicting results which may be explained by differences in populations, retrospective design,
and single center studies.
8. Ensure patients are fully hydrated.2 (Level 1, Class A)
If a patient has been kept NPO or there is potential for hypovolemia, then the patient should be
hydrated with 0.9% sodium chloride solution at a rate of 1 – 1.5 mL/kg/hour initiated 2 -12 hours
prior to the contrast administration.2, 42 (Level I, Class A)
Not all trials have demonstrated hypovolemia as a major risk factor for CIN, but renal blood flow is
diminished in hypovolemic patients and decreased perfusion could enhance the toxicity of
iodinated contrast reagents.43, 44
9. Isotonic intravenous hydration is preferred over hypotonic or oral fluid hydration.2, 44
(Class I, Level B)
In one trial administration of 0.45 or 0.9% sodium chloride 12 hours prior to and after contrast in
renal insufficiency patients significantly reduced the incidence of CIN in patients undergoing
angiography.45 However, another trial indicated 0.45% saline was not as effective as 0.9%
saline.44
10. Consider iso-osmolar (iodixanol) contrast reagents in patients with renal insufficiency and
diabetes who are receiving intra-arterial administration of contrast.
10.1. Intravenous administration of iso-osmolar iodixanol does not reduce CIN compared to low-
osmolarity contrast (iohexol) after intravenous administration without underlying
comorbidities of renal dysfunction or diabetes .4, 46-49 (Class 1, Level A)
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10.2. Intra-arterial administration in high-risk patients with iso-osmolar contrast (iodixanol) may
provide a lower risk of CIN.46, 49, 50 (Class IIb, Level B)
A meta-analysis of 25 trials comparing iso-osmolar iodixanol with nonionic low-osmolar contrast
media failed to demonstrate a reduced incidence of CIN for iodixanol.46 In subgroup analysis
there was no reduction in CIN with administration of iodixanol after intravenous administration or
in patients with renal insufficiency. However, in the subgroup with renal insufficiency and intra-
arterial administration of contrast, there was a reduced risk for CIN when iodixanol was
compared to iohexol. When comparing iodixanol to low-osmolar contrast agents other than
iohexol, no reduction in CIN was identified.
A randomized, double-blind multicenter trial of 129 diabetic patients with a serum creatinine of
1.5 to 3.5 mg/dL undergoing coronary angiography or aortofemoral angiography demonstrated a
smaller mean peak in increase of serum creatinine with iso-osmolar iodixanol than low-osmolar
iohexol (0.13 mg/dL vs 0.55 mg/dL, p=0.001).51 However, further trials evaluating intra-arterial
infusion of contrast do not demonstrate a reduction in CIN for iodixanol compared to low-osmolar
contrast reagents.52, 53 A Swedish Coronary Angiography an Angioplasty registry demonstrated a
higher incidence of renal failure in patients receiving iodixanol.54 A meta-analysis of 2727
patients in 16 doub55le-blind randomized controls evaluated patients undergoing cardiac
angiography compared the incidence CIN in patients receiving iso-osmolar contrast reagent
(iodixanol) versus low-osmolarity contrast.56 Patients with chronic kidney disease experienced a
lower incidence of CIN with iso-osmolar intra-arterial contrast than low-osmolar contrast.
11. Minimize the amount of contrast administered.2, 26, 57 (Class I, Level A)
Automated contrast injector administration for cardiac imaging can decrease the amount of
contrast administered and incidence of CIN.58
12. In patients with chronic renal insufficiency balance the risk of worsening impairment
against the diagnostic value of the procedure. When necessary use low or iso-osmolar
agents and the lowest dose possible, hydrate before and after the procedure, and
measure renal function 48 – 72 hours after contrast administrations. 59 (Class I, Level C)
13. Current data does not support the routine use of isotonic sodium bicarbonate infusions
for the prevention of CIN. (Class IIb, Level C)
Bicarbonate infusions should not be administered to patients with pulmonary edema,
uncontrolled hypertension (SBP>160 or DBP >100, or patient at high risk for severe fluid
overload. (Class III, Level C)
The use of isotonic sodium bicarbonate solution to prevent CIN is controversial. Multiple single-
center, prospective trials have evaluated the use of isotonic sodium bicarbonate infusions with
mixed results.55, 60-67 One trial of 353 patients with stable renal insufficiency, in addition to one
risk factor for CIN, compared isotonic sodium bicarbonate to sodium chloride at a rate of 3 mL/kg
for 1 hour prior to coronary angiography, 1.5 mL/hour during the procedure and for 4 hours after
completion of the procedure.67 No difference in the primary endpoint of 25% or greater decrease
in GFR or secondary endpoints of death, dialysis, myocardial infarction or cerebral vascular
events was identified.
A systematic review of 23 published and unpublished randomized, controlled trials of sodium
bicarbonate that specified the outcome of CIN included 3563 patient with 396 CIN events
determined there was significant heterogeneity across studies (I2 = 49.1%, p = 0.004) which
limits the validity of further analysis.68 Smaller, non-blinded trials prior to 2008 with fewer CIN
events were more likely to demonstrate benefit from sodium bicarbonate.
A retrospective cohort study evaluated contrast administration in 11,516 exposures of contrast
media and specifically identified the use of sodium bicarbonate in 268 cases.62 The use of
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8
bicarbonate infusion was associated with an increase in risk of CIN after adjustment for
hydration, medication, age, gender, prior creatinine, contrast iodine load, type of imaging and
comorbidities.
UWHC isotonic bicarbonate solution is prepared as dextrose 5% with sodium bicarbonate 200
mEq for a total volume of 1250 mL. Most trials administered bicarbonate solution at
1-3 mL/kg/hour prior to the procedure, and then 1 mL/kg/hour after the procedure.62
14. Current data does not support the routine use of acetylcysteine (Mucomyst®) for the
prevention of CIN.69, 70 (Class IIb, Level C)
The use of N-acetylcysteine in the prevention of CIN is controversial since multiple studies and
meta-analysis demonstrate conflicting data.69, 71 Heterogeneity of trials with moderate quality
may account for the discrepancies. A recent large randomized controlled trial of 2308 patients
with one risk factor and undergoing an angiographic procedure did not demonstrate a reduction
in CIN after administration of acetylcysteine 1200 mg BID.69 Similarly, the subgroup analysis of
patients with renal insufficiency (serum creatinine >1.5 mg/dL), diabetes, age over 70 years or
high volumes of contrast did not demonstrate benefit.72
A few trials have evaluated the combination of isotonic sodium bicarbonate and acetylcysteine,
with mixed results.68, 73, 74 A multicenter trial of diabetic patients with renal insufficiency receiving
oral acetylcysteine did not demonstrate a decreased incidence of CIN in patients receiving
sodium bicarbonate infusion compared to sodium chloride infusion.73 Alternatively a trial of
patients receiving contrast for emergency percutaneous intervention and administered
acetylcysteine demonstrated a reduction in CIN in patients receiving bicarbonate infusion as
compared to sodium chloride infusion.74
Due to conflicting literature, minimal toxicity and low cost, some clinicians choose to order
acetylcysteine 800 mg orally twice daily for two days with initiation prior to contrast
administration. Intravenous acetylcysteine offers no advantage over oral and is associated with a
higher incidence of adverse events, notably anaphylaxis.75
15. Mannitol does not reduce the incidence of CIN in patients with chronic renal insufficiency
(serum creatinine >1.6 mg/dL) when included with saline hydration.76 (Level III, Class B)
16. Furosemide administered along with hydration prior to the administration of contrast
reagent does not reduce the incidence of CIN in patients with chronic renal insufficiency.76
(Level III, Class B)
UW Health Implementation
Potential Benefits:
Implementation of recommendations within this guideline provides a consistent approach to minimizing
CIN while avoiding adverse drug reactions from unnecessary medications.
Potential Harms:
Patients may become fluid overloaded after administration of fluid to prevent CIN.
Qualifying Statements
There are several studies and meta-analyses on treatment modalities for the prevention of CIN; however,
treatment doses, administration methods, and outcomes are variable. As new data becomes available
recommendations may change.
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9
Implementation Plan
The guideline update will be disseminated to clinical staff frequently using iodinated contrast reagents in
their practice and posted electronically at point of use sites. This guideline will be posted on UConnect
and associated with medication order records for iodinated contrast material and on the medication
administration record.
Implementation Tools
The guideline will be associated with the medication records for contrast media.
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and treatment of
patients. This Clinical Practice Guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that
some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely
establish the only appropriate approach to a problem.
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Copyright © 2014 Univ ersity of Wisconsin Hospitals and Clinics Authority
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13
Appendix A
Quality of Evidence and Strength of Recommendation Grading Matrix
Copyright © 2014 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2014CCKM@uwhealth.org

14
Appendix B
Assess patient risk factors:
- Serum creatinine > 1.5 mg/dL or GFR <60 mL/min/1.73m
2
- Diabetes
- Heart failure
- Cirrhosis
- Anemia
- Hypotension
- Age > 75 years
- Intravascular volume depletion
- Concomittant administration of nephrotoxic medications such as metformin,
chronic or high dose NSAIDs, aminoglycosides
- Intra-arterial administration of contrast
- Anticipate high volume contrast administration
- Multiple sequential procedures with contrast media
[Class I, Level A]
Perform original test.
No additional measures
needed.
Is appropriate
alternative test
available?
Perform alternative test.
No additional prophlyactic measures
required.
Perform original test in high risk patient.
- Hold metformin if GFR < 45 mL/min or patient has history of
hepatic dysfunction, alcohol abuse, cardiac failure, myocardial or
peripheral ischemia, sepsis or severe infection [Class I, Level C]
- Hold potentially nephrotoxic medications prior to contrast [Class I,
Level C]
- Ensure patients are sufficiently hydrated [Class I, Level A]
- Recommend administration of 0.9% sodium chloride [Class I,
Level A]
- Limit contrast dose [Class I, Level A]
- Recommend low or iso-osmolar contrast for intra-arterial
administration [Class IIb,Level B]
- May consider sodium bicaronate infusion [Class IIb,Level C]
- May consider acetylcysteine [Class IIb,Level C]
- Monitor creatinine and GFR post contrast [Class I, Level C]
Algorithm for Prevention of Contrast-Induced Nephropathy
YES
NO
Evaluate serum creatinine in select patients prior to
procedure:
- Patients with a risk factor for CIN
- History of kidney disease, renal tumor, renal transplant or
prior renal surgery
- Family history of kidney failure
- Paraproteinemia syndromes (e.g., multiple myeloma)
- Collagen vascular disease (e.g., scleroderma, systemic
lupus erythematosa)
- Diagnosis of hypertension.
- Inpatients
[Class I, Level C]
Is patient at risk for
CIN based on risk factor
assessment?
NO
YES
Abbreviations:
GFR – glomerular filtration rate
CIN – contrast induced nephropathy
Last reviewed: 12/2014
Contact Drug Policy Program
Prevention of Contrast-Induced Nephropathy Guideline
Copyright © 2014 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2014CCKM@uwhealth.org

15
Appendix C
Recommendations for Holding Metformin with IV Iodinated Contrast
Administration
Category 1: Estimated eGFR > 45 and no comorbidities*:
No need to discontinue Metformin or check creatinine.
Category 2: Estimated eGFR eGFR > 45 and comorbidities*:
Withhold Metformin for 48 hours. Patient should communicate with their doctor prior to
restarting Metformin. The clinician may elect observation, serum creatinine
measurement, and/or hydration to ensure stable renal function. Serum creatinine
measurement is not required in the absence of recent risk factors for renal damage. (I.e.
nephrotoxic drugs)
Category 3: Estimated eGFR eGFR < 45:
Metformin should be suspended at the time of contrast administration and cautious
follow-up of renal function should be performed until safe reinstitution of Metformin can
be assured.
*Comorbidities:
ξ Liver dysfunction
ξ Alcohol abuse
ξ Cardiac failure
ξ Myocardial or peripheral muscle ischemia
ξ Sepsis or severe infection
Medications containing metformin include (but are not limited to):
Generic Ingredients Trade Names
Metformin Glucophage, Glucophage XR, Fortamet, Glumetza, Riomet
Alogliptin/metformin Kazano
Canagliflozin/metformin Invokamet
Dapagliflozin/metformin Xigduo XR
Glipizide/metformin Metaglip
Glyburide/metformin Glucovance
Linagliptin/metformin Jentadueto
Pioglitazone/metformin ActoPlus Met
Repaglinide/metformin PrandiMet
Rosiglitazone/metformin Avandamet
Saxagliptin/metformin Kombiglyze
Sitagliptin/ metformin Janumet
Last reviewed: 12/2014
Contact Drug Policy Program
Prevention of Contrast-Induced Nephropathy Guideline
Copyright © 2014 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2014CCKM@uwhealth.org