intravenous iron Rx

see also:

• iron deficiency anaemia
• intravenous iron Rx (ferric carboxymaltose) at Western Health
• NPS.org.au: ferric carboxymatose
• Nat. Blood Authority Australia March 2016: Iron product choice and dose calculation for adults (pdf)

• there are 3 forms of parenteral iron for use in Australia:
  • iron polymaltose (Ferrum H and Ferrosig)
    • immediate HS reactions are common with iron polymatose - one MUST first use a small test dose
  • iron sucrose (Venofer)
    • PBS usage for the treatment of iron-deficiency anaemia in patients undergoing chronic haemodialysis and who are receiving supplemental erythropoietin therapy
  • iron carboxymaltose (Ferinject)
    • can now be ordered for outpatients on PBS without restriction as it has a shorter administration time of only 15 minutes which is suitable for outpatient Mx ¹⁾
    • patients should be aged 14yrs or older who are not on haemodialysis and who have documented iron deficiency and oral iron not appropriate
    • maximum dose via intravenous infusion of iron carboxymaltose is 1000mg (20mg/kg) in 250mL of sodium chloride 0.9%, over at least 15 minutes. The maximum dose per week is 1000mg.

• intolerance of, poor compliance or inadequate response to oral iron Rx
• malabsorption conditions
• high iron dose needed (eg. haemodialysis (use repeated small iv doses and if anaphylaxis to iron polymaltose, one can use iron sucrose with PBS authority), ongoing blood loss)
• chronic renal failure with iron deficiency states

• anaemia not caused by iron deficiency
• iron overload (eg. haemochromatosis, haemosiderosis)
• 1st trimester pregnancy
• ferritin > 500mcg/litre
• transferrin saturation > 40%
• Osler-Rendu-Weber syndrome
• chronic polyarthritis
• asthma
• infectious renal complaints in acute phase
• uncontrolled hyperparathyroidism
• decompensated cirrhosis
• infectious hepatitis
• severe inflammation or infection of the kidney or liver (due to iron accumulating in inflamed tissues)
• specific to iron polymaltose (Ferrum H):
  • HS to iron III hydroxide polymaltose complex
• specific to iron sucrose (Venofer):
  • HS to Venofer or its inactive constituents
• specific to ferric carboxymaltose (FCM):
  • HS to FCM or its inactive constituents
  • age < 14yrs
  • haemodialysis patients
  • NB. may cause transient hypophosphataemia

• ensure emergency resuscitation facilities and medical officer are available in case immediate HS reactions occur
• patients on dialysis are generally given infusions on specific days of the week (often Wed/Thurs) to help with accurate monthly blood results.
• total adult dose is usually 100mg of either iron polymatose or iron sucrose
  • haemodialysis patients receiving ESA with ferritin < 200mcg/litre and transferrin saturation < 40% are usually given weekly doses for 2 months then repeat iron studies
  • haemodialysis patients receiving ESA with ferritin 200-400mcg/litre and transferrin saturation < 40% are usually given fortnightly doses for 2 months then repeat iron studies
  • haemodialysis patients receiving ESA with ferritin 400-500mcg/litre and transferrin saturation < 40% are usually given monthly doses for 2 months then repeat iron studies
  • haemodialysis patients NOT receiving ESA are usually given 10 doses given over 10 sequential haemodialysis treatments.
  • peritoneal dialysis and CKD patients are usually given 1g iv iron polymatose or 500mg iv iron sucrose
• infusion is usually given via venous bubble trap
• test dose is usually 25mg iron polymaltose or 20mg iron sucrose diluted in 0.9% saline given over 1 minute (polymaltose), or over 15min (sucrose)
• test dose is then flushed with 10ml 0.9% saline
• if no adverse reactions after 30min observations, the remaining dose is infused over 5-10 minutes and then further 5ml 0.9% saline flush is given.
• iron studies should be taken at least 1 week after a course of doses