Intravenous iron

Efficacious in all studies in increasing Hb, increasing

ferritin and TSAT index, and reducing EPO
requirements.
Needed in most HD patients as iron loss from GI
bleeding and blood loss in dialysis lines exceeds ability
of gut to absorb oral iron.
Potential concerns about iron overload, infection,
and cardiac dysfunction have not been realized.
Iron should be withheld if ferritin >800ng/mL to avoid iron
overload.
Increased risk of infection probably not of great
significance, but IV iron should not be given while
infection present because of theoretical risk that
neutrophil function may be adversely affected.
Macrocytosis developing during the use of IV iron
may reflect the development of folate deficiency.
Needs to be given with care to avoid adverse reactions:
Free iron reaction:
—symptoms include hypotension, nausea, vomiting,
sweating, back pain, pruritus, and a sudden feeling
of being unwell
—owing to either the effect of iron overload or the
result of infusing IV iron too rapidly
—can be treated if necessary with IV
hydrocortisone and chlorphenamine.
Anaphylaxis:
—symptoms include laryngeal oedema,
erythema, urticaria, palpitations, collapse,
loss of consciousness
—risk very low, but all nurses giving IV iron should
be trained in resuscitation, and adrenaline
(epinephrine), chlorphenamine, hydrocortisone,
and resuscitation equipment should be
immediately available.
Preparations of intravenous iron
There are various preparations available:
Iron dextran
Iron sucrose
Ferric carboxymaltose
Iron isomaltoside 1000
Ferumoxytol.
 Intravenous iron 473

Intravenous iron and hypersensitivity reactions

In August 2013, the UK Medicines and Healthcare Products
Regulatory Agency issued a warning about serious
hypersensitivity reactions with IV iron.
Life-threatening and fatal anaphylactic reactions
reported. These reactions can occur even in patients
who have previously tolerated IV iron and when the test
dose has been negative.
IV iron should therefore only be given by
appropriately trained staff and in locations where
patients can be monitored for signs of
hypersensitivity for up to 30min after administration
and where resuscitation facilities are available.
In the event of a hypersensitivity reaction, the IV
infusion should be stopped at once and appropriate
management started.
Risk of hypersensitivity is increased in patients with
known allergies, history of severe asthma, eczema or
other atopic allergy.
During pregnancy, IV iron should be avoided during the
frst trimester and only given during the second and
third if beneft is considered to outweigh the potential
risks for mother and fetus.
 Complications of ESKD:
Chapter 10
anaemia

Intravenous iron preparations

Iron sucrose
A complex of ferric hydroxide with sucrose containing
2% (20mg/mL) of iron.
Efficacious with a very low incidence of adverse
reactions, and no deaths due to anaphylaxis.
Supplied as 100mg/5mL single-dose vial.
Usual dosing:
100mg at end of HD on 10 successive dialysis
sessions if ferritin <200ng/mL, then weekly while
ferritin <600ng/mL
200mg can be given every 1–3 months in PD or pre-
dialysis patients as an IV infusion.
Can be given as IV infusion or as slow IV injection (at
20mg/min).
Administration protocols:
100–200mg undiluted over 5–10min (20mg/min) is
recommended
100mg undiluted over 2min has been reported as
being safe
100mg in 100mL normal saline over 15min.
Changes in TSAT and ferritin levels can be measured
48h after IV administration.
Sodium ferric gluconate complex in sucrose
Increasingly used.
Non-dialysable; free of dextran polysaccharides.
Fewer life-threatening and fatal adverse reactions than
iron dextran and may be safe in patients who are allergic
to or are intolerant of iron dextran.
Mild reactions not uncommon.
Usually given as 62.5–125mg IV infusions undiluted over
5–10min
(12.5mg/min) during consecutive dialysis sessions until
1g administered, then weekly (while ferritin <600ng/mL).
As with iron sucrose.
Can be given as larger doses to PD and pre-dialysis
patients (300mg 1–3-monthly, over 90min) to avoid
frequent hospital admissions, or 125mg in 100mL
normal saline over 60min.
Ferumoxytol
A complex of iron oxide with polyglucose sorbitol-
carboxymethylether containing 3% (30 mg/mL) of iron.
Appears to be safe when given as a single dose of up to
510mg iron.
Can be administered at a rapid rate—up to 30mg/sec.
For treatment of iron defciency, manufacturers
recommend single dose of 510mg followed by further
dose of 510mg within 3–8 days.
 Intravenous iron preparations 475

Iron dextran
A complex of ferric hydroxide with dextran containing 5% (50 mg/mL) of iron.
Risk of anaphylactic reactions (0.6–1.5%), but probably less commonly than previously reported.
Can lead to generation of antidextran antibodies (extremely infrequently).
Because of risk of anaphylaxis, test dose needed for first administration (20mg diluted in 50mL saline over 30min).
Other adverse effects include itching (1.5%), dyspnoea and wheeze
(1.5%), arthralgia, myalgia, fever, headache (often delayed by 24–48h).
Dose on each dialysis session initially to treat iron deficiency (usually 20–100mg, for 10–20 sessions), and then
intermittently (usually weekly, fortnightly, or monthly) to maintain iron stores (750–100mg). Alternatively, 250mg
over half an hour monthly. Give at end of dialysis by slow injection or infusion.
In PD or pre-dialysis patients, 500mg can be diluted into 250mL saline and given over 30–60min.
Total dose iron infusions of specially fractionated iron (III) dextran (20mg/kg iron over 4–6h) may avoid the need
for repeated infusions.
Not commonly used in view of adverse reactions.
Iron isomaltoside 1000
A complex of ferric iron and isomaltosides containing 10% (100 mg/mL) of iron.
Can be given as a single dose to replace iron.
Does not contain dextrans so low rate of anaphylaxis.