Table 5.

Symptom and severity based management of ferumoxytol related hypersensitivity reactions during MR imaging – our recommendation based on Rampton et al³², UpToDate database⁴⁴ and ACR Manual on Contrast Media, Version 10.2⁴⁵.

Severity	Sign/symptom	Management	Medications
Potentially life threating HSR	Cardiorespiratory arrest	Stop iron infusion Remove patient from MRI Call fast response team Start ACLS if necessary Monitor patient Medications Transfer to ICU	Start ACLS
	Anaphylaxis, shock		adrenaline (0.1 mg 1/10.000 solution over 5 min IV or 0.3–0.5 mg 1/1000 solution IM), elevate the lower extremities, O2 face mask (6–8 L/min), nebulized β2 agonist (e.g. salbutamol solution 2.5 mg/3 mL or 5 mg/3mL), rapid volume load (e.g. 1–2 L saline), IV corticosteroid (e.g. 100–500 mg hydrocortisone IV),
	Hypotension (decrease≥30 % of SBP, or SBP drops under 90 mmHg, with repeated BP measurement)		adrenaline (0.1 mg 1/10.000 solution over 5 min IV or 0.3–0.5 mg 1/1000 solution IM), elevate the lower extremities, repeat BP measurement O2 face mask (6–8 L/min), rapid volume load (e.g. 1–2 L saline), IV corticosteroid (e.g. 100–500 mg hydrocortisone IV),
	Stridor, symptomatic bronchospasm (cyanosis)		adrenaline (0.1 mg 1/10.000 solution over 5 min IV or 0.3–0.5 mg 1/1000 solution IM), O2 face mask (6–8 L/min) nebulized β2 agonist (e.g. salbutamol solution 2.5 mg/3 mL or 5 mg/3mL), rapid volume load (e.g. 1–2 L saline), IV corticosteroid (e.g. 100–500 mg hydrocortisone IV)
Mild or Moderate HSR	Hypertension (may be anxiety related)	Stop iron infusion Remove patient from MRI if needed Call physician Monitor patient Medications Observation for 1–4 hours	No therapy. Antihypertensive treatment if SBP≥180 or DBP≥120 (e.g. captopril 6.25–12.5 mg PO), repeat BP measurement
	Hypotension (decrease<30 % of SBP, 5–10% difference can be normal or measurement error)		Wait for at least 15 min, elevate lower extremities, repeat BP measurement if improving consider continuing the imaging (restart iron infusion at 25–50 % reduced rate), if not better: isotonic fluid load (e.g. 500 mL saline), IV corticosteroid (e.g. 100–500 mg hydrocortisone IV)
	Chest tightness, tachycardia		isotonic fluid load (e.g. 500 mL saline), IV corticosteroid (e.g. 100–500 mg hydrocortisone IV)
	Asymptomatic flush, rush, erythema, eruptions, edema		Wait for at least 15 min, if improving consider continuing the imaging (restart iron infusion at 25–50 % reduced rate), if not better: isotonic fluid load (e.g. 500 mL saline), IV corticosteroid (e.g. 100–500 mg hydrocortisone IV)
	Symptomatic flush, rush, erythema, eruptions, edema		isotonic fluid load (e.g. 500 mL saline), IV corticosteroid (e.g. 100–500 mg hydrocortisone IV)
	Cough-mild		Wait for at least 15 min, if improving consider continuing the imaging (restart iron infusion at 25–50 % reduced rate), if not better: isotonic fluid load (e.g. 500 mL saline), IV corticosteroid (e.g. 100–500 mg hydrocortisone IV)
	Dyspnea, wheezing, severe cough, shortness of breath		O2 face mask (1–2 L/min), isotonic fluid load (e.g. 500 mL saline), nebulized β2 agonist (e.g. salbutamol solution 2.5 mg/3 mL or 5 mg/3mL), IV corticosteroid (e.g. 100–500 mg hydrocortisone IV)
	Nausea, vomiting		Antiemetic treatment (e.g. prochlorperazine 5–10 mg PO, 2.5–10 mg IV)
	Dizziness		Wait for at least 15 min, if improving consider continuing the imaging (restart iron infusion at 25–50 % reduced rate), if not better: isotonic fluid load (e.g. 500 mL saline)
Other reactions	Back pain, myalgia, arthralgia, muscle spasm (Fishbane reaction)	Stop iron infusion Remove patient from MRI if needed Monitor patient Medications if needed	No therapy needed
	Headache		No therapy or NSAID (e.g. ketorolac 20 mg PO, 30 mg IV)
	Dysgeusia (taste alteration)		No therapy needed