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Parenteral Iron

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Parenteral Iron, Iron Dextran, Imferon, Sodium Ferric Gluconate, Ferrlecit, Iron Sucrose Injection, Venofer, Ferumoxytol, Intravenous Iron

  • Indications
  1. Severe Iron Deficiency Anemia and iron malabsorption
  2. Chronic bleeding not corrected by other means
  3. Oral iron not tolerated
  4. Severe Anemia and refusal of Blood Transfusion
  • Preparations
  1. Sodium Ferric Gluconate (Ferrlecit)
    1. Dosing: 125 mg (10 ml) of 62.5 mg/5 ml solution diluted in 100 ml saline
    2. May give weekly IV for 8 weeks (total: 1 gram)
    3. Much safer than Iron Dextran
    4. Test dose recommended with 2 ml diluted in 50 ml saline infused over 1 hour prior to first infusion
  2. Iron sucrose (Venofer)
    1. Much safer than Iron Dextran (no test dose needed)
    2. Dosing: 100 mg (20 ml) IV of 20 mg/ml solution for 5 doses over 2 week period (1-3 times per week)
  3. Ferumoxytol (Feraheme)
    1. Single infusion given over 5 minutes supplies 510 mg elemental iron per 17 ml solution
    2. May repeat in 3-8 days for second injection
    3. U.S. FDA black box warning for serious Allergic Reactions (monitor for Hypersensitivity, Hypotension)
  4. Ferric Carboxymaltose (Injectafer)
    1. Available as 750 mg/15 ml solution
    2. Monitor for Hypersensitivity
    3. Variable Blood Pressure effects with Hypertension in 3.8% and Hypotension in 1% of patients
    4. Dosing
      1. Weight >50 kg (110 lb): Give 750 mg (15 ml) in 2 doses at 7 days apart
      2. Weight <50 kg (110 lb): Give 15 mg/kg in 2 doses at 7 days apart
  5. Iron Dextran (Imferon, Dexferrum, Infed)
    1. High rate of serious reaction (requires test dose of 0.5 ml one hour before infusion)
    2. Replaced by newer agents (e.g. Ferrlecit, Feraheme, Venofer)
    3. Intramuscular or Intravenous
    4. Available as 50 mg/ml
    5. Dose based on estimated iron deficits
  • Precautions
  1. Intravenous Iron must be started very slowly
  2. Avoid in patients with acute or chronic infections
  • Efficacy
  1. Hemoglobin increased 2 g/dl (NNT 5)
  2. Red Blood Cell Transfusion avoided (NNT 36)
  3. Oral iron is as effective as Parenteral Iron in preventing Blood Transfusion and mortality
    1. Oral iron is preferred in those without significant malabsorption or other barriers to oral ingestion
    2. Mounsey (2022) Am Fam Physician 106(2): 191-2 [PubMed]
  • Adverse Effects
  1. Skin staining at site of Intramuscular Injection
    1. Consider Z-tract injection technique
  2. Severe pain at injection site
  3. Infection Risk (NNH: 62)
    1. Beaudoin (2022) Am Fam Physician 106(3): 245A-C [PubMed]
    2. Shah (2021) JAMA Netw Open 4(11): e2133935 [PubMed]
  4. Delayed reaction (24-48 hours after administered)
    1. Myalgias and Arthralgias
    2. Headache
  5. Anaphylaxis
    1. Occurs in 0.61% of patients given Iron Dextran
    2. Occurs in 0.04% of patients given ferric gluconate
  • References
  1. Killip (2007) Am Fam Physician 75:671-8 [PubMed]
  2. Lanier (2018) Am Fam Physician 98(7): 437-42 [PubMed]
  3. Michael (2002) Kidney Int 61:1830-9 [PubMed]
  4. Silverstein (2004) Am J Hematol 76(1): 74-8 [PubMed]