From the Guidelines
Iron deficiency anemia (IDA) in congestive heart failure (CHF) should be treated with intravenous iron supplementation, preferably with ferric carboxymaltose (FCM), as it has been shown to improve patient self-reported quality of life, heart failure symptoms, and exercise capacity, as well as reduce the risk of hospitalization 1. The treatment regimen typically involves administering 1000 mg of FCM as two 500 mg infusions separated by one week. Key points to consider when treating IDA in CHF include:
- Monitoring treatment response by checking hemoglobin levels, ferritin, and transferrin saturation (TSAT) at 4-12 weeks after treatment, with target ferritin levels >100-300 ng/mL and TSAT >20% 1.
- Reassessing patients every 3-6 months thereafter, with maintenance dosing as needed, and checking ferritin + TSAT 1-2 times per year or if there is a change in clinical picture or if hemoglobin decreases 1.
- Considering oral iron ineffective in CHF patients due to poor absorption related to hepcidin upregulation from the inflammatory state.
- Recognizing that IV iron improves not only anemia but also exercise capacity, quality of life, and may reduce heart failure hospitalizations, even in non-anemic iron-deficient CHF patients 1. For ongoing monitoring, clinicians should assess for symptom improvement (reduced fatigue, improved exercise tolerance) alongside laboratory parameters, and consider repeat infusions when iron indices fall below target levels.
From the FDA Drug Label
2 DOSAGE AND ADMINISTRATION
2.1 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. For patients weighing less than 50 kg, the recommended dosage is Injectafer 15 mg/kg body weight intravenously in two doses separated by at least 7 days per course Recommended Dosage in Patients with Iron Deficiency with Heart Failure See Table 1 for recommended dosage for treatment of iron deficiency in patients with heart failure and New York Heart Association class II/III to improve exercise capacity Table 1: Recommended Dosage in Patients with Iron Deficiency with Heart Failure Weight less than 70 kg Weight 70 kg or more Hb (g/dL) Hb (g/dL) < 10 < 10 10 to 14 10 to 14
14 to < 15 > 14 to < 15 Day 1 Day 1 1,000 mg 1,000 mg 1,000 mg 1,000 mg 500 mg 500 mg Week 6 Week 6 500 mg No dose No dose No dose 1,000 mg 500 mg 500 mg No dose Administer a maintenance dose of 500 mg at 12,24 and 36 weeks if serum ferritin <100 ng/mL or serum ferritin 100-300 ng/mL with transferrin saturation <20%. There are no data available to guide dosing beyond 36 weeks or with Hb ≥15 g/dL.
To treat Iron Deficiency Anemia (IDA) in patients with Chronic Heart Failure (CHF), the recommended dosage of ferric carboxymaltose (IV) is outlined in Table 1, which takes into account the patient's weight and hemoglobin (Hb) levels.
- For patients weighing less than 70 kg with Hb < 10 g/dL, the recommended dose is 1,000 mg on Day 1 and 500 mg at Week 6.
- For patients weighing 70 kg or more with Hb < 10 g/dL, the recommended dose is 1,000 mg on Day 1 and no dose at Week 6.
- Maintenance doses of 500 mg may be administered at 12,24, and 36 weeks if certain conditions are met, such as low serum ferritin or transferrin saturation levels 2. Monitoring for response to treatment should include regular checks of hemoglobin levels, serum ferritin, and transferrin saturation to assess the effectiveness of the treatment and the need for maintenance doses. Additionally, patients should be monitored for potential adverse reactions, such as hypersensitivity reactions and hypophosphatemia, and treated accordingly 2.
From the Research
Treatment of Iron Deficiency Anemia (IDA) in Congestive Heart Failure (CHF)
- Intravenous iron therapy has been shown to be effective in treating IDA in patients with CHF, with studies suggesting that a cumulative dose of 1500 mg of IV iron may be more effective than a dose of 1000 mg 3.
- Treatment of anemia in patients with CHF with erythropoiesis-stimulating agents has been evaluated, but these agents did not improve outcomes and were associated with a higher risk of adverse events 4.
- Iron deficiency in patients with CHF can be absolute or functional, and iron replacement is appropriate in patients with anemia resulting from absolute iron deficiency 4.
- Intravenous iron has been shown to improve symptoms and exercise capacity in patients with CHF and absolute or functional iron deficiency, with or without anemia 4, 5.
Monitoring for Response to IDA Treatment in CHF
- Hemoglobin levels should be monitored to assess response to IDA treatment, with significant increases in hemoglobin observed in patients treated with intravenous iron 6.
- Echocardiographic parameters, such as left ventricular ejection fraction and left ventricular mass index, should also be monitored to assess improvements in cardiac remodeling 6.
- New York Heart Association (NYHA) classification should be monitored to assess improvements in clinical status, with studies showing that intravenous iron can improve NYHA classification in patients with CHF 6.
- Patient preference and satisfaction with treatment should also be considered, with studies suggesting that patients may prefer intravenous iron therapy due to its ease of administration and fewer side effects 7.
Administration of Iron Therapy
- Intravenous iron can be administered to patients with IDA and CHF, with studies suggesting that this route of administration may be more effective than oral iron supplements 3, 7.
- Oral iron supplements can also be used, but patients may experience difficulties with swallowing and remembering to take the tablets, and may be less satisfied with this route of administration 7.