International Iohexol Shortage: Alternative Contrast Agents and Imaging Procedures for the Urologist

Abstract

Introduction:In April 2022, GE Healthcare announced a COVID-19–related interruption in iohexol manufacturing, leading to an international iodinated contrast shortage. The shortage greatly impacted urological practice, highlighting the value of alternative contrast agents and imaging/procedure alternatives. These alternatives are reviewed in this work.Methods:A review of existing literature describing the use of alternative contrast agents, alternative imaging procedures, and contrast conservation strategies in urological care was performed using the PubMed database. The review was not performed systematically.Results:Older iodinated contrast agents such as ioxaglate and diatrizoate can replace iohexol for intravascular imaging in patients without renal impairment. These agents, along with gadolinium-based agents such as Gadavist, have been used intraluminally for urological procedures and diagnostic imaging. Several lesser-known imaging and procedure alternatives are described and include air contrast pyelography, contrast-enhanced ultrasound, voiding urosonography, and low tube voltage CT urography. Conservation strategies include contrast dose reductions and use of contrast management devices for contrast vial splitting.Conclusions:The COVID-19–related iohexol shortage caused significant hardship for urological care internationally, leading to delayed contrasted imaging studies and urological procedures. Alternative contrast agents, imaging/procedure alternatives, and conservation strategies are reviewed in this work with the goal of equipping the urologist to mitigate the current iodinated contrast shortage and to prepare in the event of a future shortage.

Editorial Commentary

“…Examples in our practice include low-contrast studies or noncontrast alternatives to preserve iohexol supply for emergent procedures, or multimodal nonopioid regimens to address symptomatic bladder spasms after surgery. 5 Taken together, the present review 6 and the threat of contemporary shortages underscore the importance of maintaining a diverse range of diagnostic approaches and therapeutic options to ensure our patients’ access to timely, effective urological care.…”