Consider more use of INTRAVENOUS iron to patients

As a pharmacist, 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. A typical dose in a non-CKD patient is 1,000 mg over one hour. 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 1000 mg as a single dose for iron dextran (Cosmofer, Fercayl), ferumoxytol (Feraheme), or ferric carboxymaltose (Injectafer). But generally limit sodium ferric gluconate (Ferrlecit) to 250 mg or iron sucrose (Ferosac, Sacrofer) 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 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.

References

• Camaschella C. New insights into iron deficiency and iron deficiency anemia. Blood Rev. 2017 Jul;31(4):225-233. Available at: https://pubmed.ncbi.nlm.nih.gov/28216263

  Auerbach M, Deloughery T. Single-dose intravenous iron for iron deficiency: a new paradigm. Hematology Am Soc Hematol Educ Program. 2016 Dec 2;2016(1):57-66. Available: https://pubmed.ncbi.nlm.nih.gov/27913463

  Núñez J, Comín-Colet J, Miñana G, Núñez E, Santas E, Mollar A, Valero E, García-Blas S, Cardells I, Bodí V, Chorro FJ, Sanchis J. Iron deficiency and risk of early readmission following a hospitalization for acute heart failure. Eur J Heart Fail. 2016 Jul;18(7):798-802. Available: https://pubmed.ncbi.nlm.nih.gov/27030541

  Niepel D, Klag T, Malek NP, Wehkamp J. Practical guidance for the management of iron deficiency in patients with inflammatory bowel disease. Therap Adv Gastroenterol. 2018 Apr 26;11:1756284818769074. Available at: https://pubmed.ncbi.nlm.nih.gov/29760784