What is the procedure for intravenous iron infusion (IV iron infusion)?

From the Guidelines

Iron infusions are a highly effective treatment for iron deficiency anemia, particularly when oral supplements are not effective or appropriate, and should be administered with caution and monitoring for potential reactions, as recommended by the most recent expert consensus guidelines 1.

Key Considerations for Iron Infusions

• The most common preparations include iron sucrose (Venofer), ferric carboxymaltose (Injectafer), and ferumoxytol (Feraheme) 1.
• Dosing varies by preparation, with iron sucrose typically requiring multiple sessions of 200-300mg per infusion, while ferric carboxymaltose can deliver 750-1000mg in just one or two sessions 1.
• Before receiving an infusion, patients should have confirmed iron deficiency through blood tests showing low ferritin, transferrin saturation, or hemoglobin levels 1.
• During administration, patients are monitored for potential reactions like headache, flushing, or hypotension, though serious allergic reactions are rare 1.
• The infusion process typically takes 15-60 minutes depending on the preparation, and most patients notice improvement in energy levels within 1-2 weeks as their hemoglobin rises 1.

Preferred Formulations and Administration

• Formulations that can replace iron deficits with 1 or 2 infusions are preferred over those that require more than 2 infusions, as recommended by the AGA clinical practice update 1.
• Ferric carboxymaltose can be given as an injection or infusion, with a maximum recommended cumulative dose of 1000 mg iron (20 mL FCM)/week 1.

Monitoring and Management of Reactions

• Patients should be observed for adverse effects for at least 30 min following each IV injection, and iron status should be re-evaluated at 3 months after IV administration of the correction dose 1.
• Infusion reactions, such as complement activated related pseudo-allergy (CARPA), can be managed by stopping the infusion and restarting at a slower rate, or with corticosteroids for more severe reactions 1.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

1. 1 Recommended Dosage Recommended Dosage for Treatment of Iron Deficiency Anemia For patients weighing 50 kg or more, the recommended dosage is: Injectafer 750 mg intravenously in two doses separated by at least 7 days for a total cumulative dose of 1,500 mg of iron per course In adult patients, Injectafer 15 mg/kg body weight up to a maximum of 1,000 mg intravenously may be administered as a single-dose per course.

2.2 Preparation and Administration Administer Injectafer intravenously, either as an undiluted slow intravenous push or by infusion. When administered via infusion, dilute up to 1,000 mg of iron in no more than 250 mL of sterile 0. 9% sodium chloride injection, USP, such that the concentration of the infusion is not less than 2 mg of iron per mL and administer over at least 15 minutes.

The recommended dosage of iron infusion using ferric carboxymaltose (IV) is:

• For patients weighing 50 kg or more: 750 mg intravenously in two doses separated by at least 7 days for a total cumulative dose of 1,500 mg of iron per course
• For adult patients: 15 mg/kg body weight up to a maximum of 1,000 mg intravenously may be administered as a single-dose per course The administration of Injectafer can be done either as an undiluted slow intravenous push or by infusion, with a concentration of not less than 2 mg of iron per mL and administered over at least 15 minutes 2.

From the Research

Iron Infusion Overview

• Iron infusion is a treatment for iron deficiency anemia, which can arise from various diseases and conditions, such as gastrointestinal, renal, and cardiac disease, as well as pregnancy, heavy menstrual bleeding, and surgery 3.
• Modern intravenous iron preparations can facilitate rapid iron repletion in one or two doses, both for absolute iron deficiency and functional iron deficiency, where oral iron therapy is ineffective or has not worked 3.

Indications and Administration

• Intravenous iron preparations are indicated for the treatment of iron deficiency when oral preparations are ineffective or cannot be used, and have applicability in a wide range of clinical contexts, including chronic inflammatory conditions, perioperative settings, and disorders associated with chronic blood loss 3, 4.
• The administration of intravenous iron should be guided by the presence of inflammation, the time available for iron replenishment, and the anticipated risk of side-effects or intolerance 3.
• Ferric carboxymaltose, a novel iron complex, allows for controlled delivery of iron to target tissues and is effective in the treatment of iron-deficiency anemia, delivering a replenishment dose of up to 1000 mg of iron during a minimum administration time of ≤15 minutes 5.

Benefits and Risks

• Intravenous iron therapy can improve the quality of life, with hemoglobin as a surrogate marker, and is reserved for iron deficiency anemia patients with intolerance or unresponsiveness to oral iron 4.
• However, intravenous iron therapy is associated with a risk of severe infusion reactions, and individual selection of the appropriate iron therapy and evaluation of treatment response are mandatory to safely deliver improved outcomes 4.
• A cumulative dose of 1500 mg of intravenous iron may be more effective than 1000 mg in iron repletion, with a lower percentage of patients requiring retreatment 6.

Specific Iron Preparations

• Ferric carboxymaltose is a well-tolerated and effective option for the treatment of iron-deficiency anemia, with rapid and sustained increases in hemoglobin levels and replenishment of depleted iron stores 5, 7.
• Other intravenous iron preparations, such as iron dextran, iron derisomaltose, and iron sucrose, are also available, but may have different dosing regimens and side-effect profiles 4.