Can I administer intravenous (IV) iron to a patient with active cytomegalovirus (CMV) colitis?

From the Guidelines

Administering IV iron to a patient with active CMV colitis should be done with caution, and the most recent evidence suggests that IV iron therapy can be given in individuals with inflammatory bowel disease, iron-deficiency anemia, and active inflammation with compromised absorption, as stated in the 2024 AGA clinical practice update 1. When considering IV iron for a patient with active CMV colitis, it's essential to weigh the benefits of correcting iron deficiency anemia against the potential risks of exacerbating inflammation or supporting viral replication. The priority should be treating the underlying CMV infection with appropriate antiviral medications. If iron deficiency anemia is severe and requires urgent correction, consultation with both infectious disease and gastroenterology specialists is recommended before proceeding with IV iron. Some key points to consider when managing iron deficiency anemia in patients with IBD include:

• Iron supplementation should be given to all patients with IBD and IDA, as stated in the 2024 AGA clinical practice update 1.
• IV iron appears to be more effective and better tolerated than oral iron in patients with IBD, according to a systematic review and meta-analysis of 5 randomized controlled trials 1.
• Current consensus recommendations by the European Crohn’s and Colitis Organization recommend IV over oral iron as first-line therapy for patients with a hemoglobin level <10 g/dL, as mentioned in the 2017 ESPEN guideline 1. When the CMV colitis has improved and if IV iron is still needed, options like iron sucrose (Venofer) or ferric carboxymaltose (Injectafer) may be considered, starting with a test dose to monitor for adverse reactions. The concern with IV iron during active infection stems from iron's role in inflammatory processes and its potential availability to pathogens, which could theoretically worsen outcomes in active infections. However, the most recent evidence suggests that IV iron therapy can be given in individuals with inflammatory bowel disease, iron-deficiency anemia, and active inflammation with compromised absorption, as stated in the 2024 AGA clinical practice update 1.

From the Research

Administration of IV Iron in Patients with Active CMV Colitis

• There is no direct evidence to suggest that IV iron should not be administered to patients with active CMV colitis 2, 3, 4, 5.
• However, it is essential to consider the patient's overall clinical condition and the potential risks and benefits of IV iron therapy in the context of CMV colitis.
• CMV colitis can lead to iron deficiency anemia, and IV iron may be necessary to correct this deficiency 3.
• A study on inflammatory bowel disease patients found that IV iron treatment was effective and well-tolerated in correcting iron deficiency anemia, without exacerbating the underlying disease symptoms 6.

Considerations for IV Iron Administration

• The decision to administer IV iron to a patient with active CMV colitis should be made on a case-by-case basis, taking into account the patient's individual needs and clinical status.
• It is crucial to monitor the patient's response to IV iron therapy and adjust the treatment plan as needed.
• The potential benefits of IV iron therapy in correcting iron deficiency anemia and improving quality of life should be weighed against the potential risks and complications of CMV colitis 3, 6.

Diagnostic and Treatment Considerations

• CMV colitis diagnosis is typically made through histopathological examination, immunohistochemistry, or PCR testing 2, 4, 5.
• Treatment of CMV colitis usually involves antiviral therapy, such as ganciclovir, and may require adjustments to immunosuppressive therapy 4, 5.
• The presence of CMV colitis can impact the clinical course and treatment outcomes of patients with inflammatory bowel disease 4, 5.