From the Guidelines
Premedication is generally not routinely recommended for all patients receiving intravenous iron, but for those with a history of mild allergic reactions or higher risk, a premedication regimen may be considered. For patients with a history of mild allergic reactions or those at higher risk, consider the following premedication regimen:
- Diphenhydramine is not recommended as its side effects can be mistaken for worsening of the reaction 1
- Acetaminophen 650 mg orally, 30 minutes before infusion
- For patients with a history of more severe reactions or asthma, corticosteroids may be of benefit 1 These medications help prevent or reduce the risk of infusion reactions. Always have emergency medications (epinephrine, additional antihistamines, and corticosteroids) readily available during the infusion. Monitor patients closely for signs of hypersensitivity reactions, especially during the first 15-30 minutes of the infusion, as anaphylaxis-like reactions to iron dextran usually occur within a few minutes after injection 1. The most recent and highest quality study, an expert consensus guideline published in 2024, provides comprehensive guidance on the administration of IV iron, recognition, and management of infusion reactions 1. Remember, the need for premedication should be assessed on an individual basis, considering the patient's history and risk factors, as being truly allergic to IV iron is very rare and almost all reactions are complement activation–related pseudo-allergy 1. Many patients can safely receive IV iron without premedication.
From the Research
Premedication Administration with Intravenous Iron
The administration of premedications with intravenous iron is a topic of discussion among medical professionals. According to the available evidence:
- The use of routine prophylactic premedication in all patients is not justified, but should be considered in high-risk patients 2.
- Premedication with diphenhydramine, cimetidine, and dexamethasone has been used in the past to mitigate the risk of adverse reactions 3.
- However, the incidence of adverse events among those who received premedication was 23-fold higher compared to those who did not 4.
- The use of premedication and test doses is unnecessary, and optimal prevention and management of infusion-related reactions warrant further study 4.
Recommended Premedication Approach
Based on the available evidence:
- Premedication should not be administered routinely to all patients receiving intravenous iron 2, 4.
- Patients with a history of infusion reaction should be managed carefully, and the use of premedication should be considered on a case-by-case basis 4.
- The administration of intravenous iron should be guided by the patient's individual risk factors and medical history 2, 4.
Types of Premedication
The following types of premedication have been mentioned in the available evidence: