Consider Expanding Use of Intravenous Iron to More Patients

You'll see expanded use of IV iron in medical patients.

More experts are advocating for IV iron replacement beyond patients with chronic kidney disease (CKD). This is due to faster repletion...poor tolerability of oral iron...and low adverse event risk.

But IV iron costs about $250 or more for 1,000 mg...a typical dose in a non-CKD patient.

We know to consider IV iron when oral iron won't likely be fast enough...such as those with recent blood loss or severe anemia.

IV iron can also help limit blood transfusions in iron-deficient patients. But keep in mind that each unit of blood has 200 to 250 mg of iron...so if blood is given, additional IV iron may not be needed.

Start to look for other patients who may benefit.

Lean toward IV iron for acute heart failure patients with ferritin less than 100 mcg/L AND transferrin saturation (TSAT) less than 20%. IV iron may lead to fewer 30-day readmissions in these patients.

Also consider IV iron for patients with inflammatory bowel disease (IBD). Oral iron may worsen bowel inflammation. And think about IV iron for bariatric or other patients with unreliable PO absorption.

When IV iron is used, feel comfortable giving 1,000 mg as a single dose for iron dextran (Infed), ferumoxytol (Feraheme), or ferric carboxymaltose (Injectafer).

But generally limit sodium ferric gluconate (Ferrlecit) to 250 mg or iron sucrose (Venofer) to 300 mg...to minimize hypotension. Consider up to 500 mg of iron sucrose...with close monitoring and a longer infusion.

All IV irons have a small risk of infusion reactions...flushing, fever, myalgia, etc. But dispel the myth that iron dextran causes more anaphylaxis. It's a LOW-molecular-weight agent. The HIGH-molecular-weight iron dextrans (Dexferrum, etc) now off the market seem to be what caused most cases of anaphylaxis.

Weigh the pros and cons of delaying IV iron if patients have infections. Evidence is limited...but there's concern that IV iron might worsen an active infection, since bacteria use iron to grow.

Use our chart, Comparison of Parenteral Iron Replacement, for more on dosing and cost...and get our Reducing Perioperative Blood Transfusions chart for guidance on IV iron use in surgical patients.

Key References

  • Blood Rev 2017;31(4):225-33
  • Hematology Am Soc Hematol Educ Program 2016;2016(1):57-66
  • Eur J Heart Fail 2016;18(7):798-802
  • Therap Adv Gastroenterol 2018;11:1756284818769074
  • Medication pricing by Elsevier, accessed Dec 2018
Hospital Prescriber's Letter. Jan 2019, No. 350119



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