Intravenous Iron Replacement

Earlier intravenous iron formulations were associated with anaphylaxis, though rare, but several intravenous iron formulations with better safety profiles are now available. These drugs should be administered in a place where there is availability for immediate resuscitation. Equipment for resuscitation and drugs to treat serious anaphylaxis should be available including adrenaline, antihistamines and/or corticosteroids

About

• Intravenous (IV) iron products are indicated in the treatment of iron deficiency and anaemia when iron supplements cannot be given or have not worked.
• Hypersensitivity reactions are well known to occur rarely with IV iron products and may be life-threatening or fatal. Warnings about this risk are given in the product information.

Warning

• All patients must be monitored for anaphylaxis and resuscitation facilities should be available
• Large doses of iron can be given at one time when using iron dextran. Iron sucrose and ferric gluconate require more frequent doses spread over several weeks.
• Test doses are no longer recommended and caution is needed with every dose of intravenous iron.
• Allergic reactions are more common with iron dextran and may necessitate switching to a different preparation.

IV iron comes in different preparations

• Iron dextran (Cosmofer): For intravenous infusion (Cosmofer), give intermittently in Glucose 5% or Sodium chloride 0.9%, dilute 100-200 mg in 100 mL infusion fluid; give 25mg over 15 minutes initially, then give at a rate not exceeding 6.67 mg/minute; total dose infusion diluted in 500 mL infusion fluid and given over 4-6 hours (initial dose 25 mg over 15 minutes).
• Iron sucrose (Venofer): Intravenous infusion (Venofer), give intermittently in Sodium chloride 0.9%, dilute 100 mg in up to 100 mL infusion fluid; give 25 mg over 15 minutes initially, then give at a rate not exceeding 3.33 mg/minute.
• Ferinject is ferric carboxymaltose used to treat iron deficiency anaemia. Ferinject must only be administered only by the intravenous route and given using an infusion pump. Intravenous infusion- maximum single dose -1,000 mg of iron (up to 20 mg/kg body weight). Sterile 0.9% sodium chloride solution should be used to for the preparation

Side Effects

• Allergic reactions: Anaphylaxis, Urticaria (hives), pruritus (itching), and muscle and joint pain.
• Dizziness; flushing; headache; hypertension; hypophosphataemia; hypotension; nausea; taste altered
• Caution should be exercised to avoid Para venous leakage when administering Ferinject. Para venous leakage of Ferinject at the injection site may lead to irritation of the skin and potentially long lasting brown discoloration at the site of injection. In case of Para venous leakage, the administration of Ferinject must be stopped immediately. The important indicator of the severity of the extravasation is PAIN. (No necrosis of the skin has ever been reported). Apply a cold pack to the infiltrated site and elevate the affected limb.

Management of Side Effects

• Most common are nausea (occurring in 3.1% of the patients), followed by headache, dizziness, and hypertension
• Mild: Stop Infusion and assess. May consider IV antihistamine and Hydrocortisone.
• Severe: Wheeze, anaphylaxis, stridor, urticaria, hypotension: ABC, IV Access, Stop infusion, Hydrocortisone 100 mg IV, IM Adrenaline and Oxygen if anaphylaxis