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What to do if your doctor wants you to get a GBCA-enhanced MRI

This question was poised to me by a patient who was worried about getting a GBCA-enhanced MRI to evaluate a liver lesion seen on ultrasound.

This is a circumstance that patients are left to make their own risk-benefit analysis.

The first thing to realize is that you don't have to receive anything you don't want to get. Perhaps this alone is a liberating thought, and I think many patients when confronted by an insistent physician feel they have no choice - but you do. If you don't want something don't get it.

However, realize the down-side that maybe something important like a cancer can be missed.

1. Subjects at the highest risk for GDD, which is someone who had a GBCA injection and feel they have symptoms of GDD, should never get a GBCA injection again.

Other groups the absolute risk is unknown, and for many very low - but we now know is real.

2. The highest risk of those who may get GDD, perhaps 1 in 500 chance are white females with pre-existent autoimmune disease or strong family history.

3. If you add into the risk profile recent high dose antibiotic therapy, then the risk goes up even higher, maybe 1 in 100.

4. white men with the same associations as described above, probably have 1/4 the risk. So for 2. above probably a 1 in 2000 chance, and 3. 1 in 400 chance.

The best alternative for liver imaging after MRI with GBCA, is either dynamic iodine contrast enhanced multipass CT, and probably next a noncontrast MRI.

But recall the risks that I have previously written on CT. A 3-phase CT delivers about 10 mSv of radiation which is about a 1 in 1,000 chance of cancer.

So you have to pick the risk you are most comfortable to accept. For me, for a liver study, 1,000 out of 1,000 times I would get a GBCA-enhanced MRI, but I have undergone maybe 12 GBCA injections and am not sick from it, so my risk of GDD I estimate at no higher than 1 in 500,000.

Of all the patients I think a white person with autoimmune disease and recent high dose antibiotic treatment is likely the one group that I would recommend staving off MRI with GBCA, atleast until the microbiome is restored.

This explains why I focus on finding predictors of disease for prevention (ideal is finding a specific gene or gene cluster) or finding optimal treatment for fast cure. Unfortunately no where near that. My close colleague at Stanford, with my prompting, has reached out to their rare disease group to see if they are interested in looking for a gene in GDD sufferers. I will post if there is interest to test GDD sufferers.

Richard Semelka MD Consulting

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