A COVID-related lockdown in Shanghai, China, is creating a shortage of iohexol, a contrast dye that is widely used in computed tomography (CT) procedures. Hospitals and other facilities find themselves rationing medical scans and procedures in the wake of the lockdown, which has affected operations at a Shanghai-based plant that produces the dye.
"Made by General Electric, [the contrast dye] is used for a variety of purposes, many of them lifesaving," NBC News' Elizabeth Chuck recently wrote. "Typically injected into patients' veins, it provides higher contrast than imaging procedures like CT scans without dye. The increased contrast helps doctors more easily diagnose a brain bleed or clot, see how a heart or other organ is functioning, or determine whether a tumor is growing or shrinking, among other things."
A spike in the number of COVID-19 cases in Shanghai led to the Chinese government's decision to lock down more than 26 million people on March 31, as a team of researchers wrote in a Radiology report, where they shared short- and long-term strategies for managing the shortage of iohexol (2022; https://doi.org/10.1148/radiol.221183).
In the midst of the shutdown, the GE Healthcare facility that produces the dye is operating at partial capacity, the authors noted, adding that supply chain issues associated with the stay-at-home orders have created delays in transport and distribution of the dye.
"Therefore, the expectation is that only 20 percent of the demand for iohexol will be available for the near term," they wrote, noting that the only other pharmaceutical facility capable of producing the dye is already operating at maximum capacity. GE Healthcare expected the shortage to be most severe in mid-to-late May, with persistent supply issues through the end of June 2022, assuming a return to normal production capacity within that period.
The shortage has created "a national crisis in the ability of radiology departments to provide healthcare to patients needing contrast-enhanced exams," the researchers wrote. As such, affected radiology departments "will need to institute emergency changes in imaging protocols and patient triage," according to the authors, who made a series of recommendations to manage the issue. For example:
* Short-term strategies to mitigate the shortage include establishing an incident command center to direct and monitor iodinated contrast usage, delaying elective contrast-enhanced CT exams, contrast dose reduction, and alternative diagnostic modalities.
* Mid-term strategies include contrast repackaging, multi-use, and multi-access strategies; communication and negotiation with payers on billing and reimbursement; and communication with ordering providers to ensure compliance.
* Long-term strategies include advocating for legislation to facilitate expansion of contrast manufacturing plants, including in the United States, and institutional stockpiling of contrast supplies.
According to the American College of Radiology (ACR), an estimated 50 million scans are performed with contrast in the United States each year. The ACR has provided a number of resources designed to help practices continue to provide necessary care during the ongoing iohexol shortage, and the organization has issued a statement outlining a number of risk mitigation strategies (https://bit.ly/39lD4sC). Examples include the following:
* Utilizing alternative studies to answer the clinical question such as non-contrast CT, MR with or without gadolinium-based contrast media, ultrasound with or without ultrasound contrast agents, nuclear medicine, or PET/CT, when feasible. (The ACR suggests referring to the ACR Appropriateness Criteria guidelines for indicated alternative studies as needed (https://bit.ly/3NEkOtC). Scroll down to AC Portal and use the "Explore by scenario" icon.)
* Looking for alternative versions of contrast agents, which may be marketed under a different brand name or intended clinical use. Note: U.S. market availability may differ from global availability.
* Sourcing contrast from other vendors, if able, and considering having at least two vendor products on formulary.
"It's very difficult to know what harms are going to occur from this, either from a delayed diagnosis or a misdiagnosis," said Matthew Davenport, MD, Vice Chair of the American College of Radiology Commission on Quality and Safety. "And I'm confident that there will be some delayed diagnoses or misdiagnoses because we are using imaging techniques that are not optimized, not perfect.
"Unfortunately, we don't have the option to just give everybody contrast like we used to, so a bit of it is going to be the best of the bad option: Would I rather have no imaging, or an imaging technique that's not optimal?"
Ultimately, the key in navigating the current contrast dye shortage is "not to compromise patient care," noted Elliott Fishman, MD, Professor of Radiology, Surgery, Oncology, and Urology at Johns Hopkins Hospital, and a co-author of the aforementioned Radiology report. "The shortage of IV contrast will vary depending on the site, and whether or not [a site's] entire supply is from GE.
"Everyone is committed to making sure patient care is still our No. 1 priority, but we are using lower volumes of contrast (often 75 mL as opposed to 100 mL) per patient. We are also careful to make sure critical studies like pre-op for OR or acute dissection have appropriate contrast volumes."
Similarly, Fishman said, "oncology patients must have appropriate contrast volumes for lesion detection and follow-up. Use of dual energy CT imaging, as well as increased use of saline flush, has also been helpful at many sites. When possible, other imaging modalities like MR or ultrasound are being used for select applications. Some routine follow-up studies are also delayed a month or so."
Mark McGraw is a contributing writer.