Should I give intravenous (IV) iron if a patient has low iron saturation and a ferritin level indicating iron deficiency?

From the Guidelines

Yes, you should consider giving intravenous (IV) iron to a patient with low iron saturation and ferritin levels indicating iron deficiency, especially if oral iron has failed or isn't tolerated, or if rapid repletion is needed. According to the most recent and highest quality study 1, IV iron is indicated if a patient cannot tolerate oral iron or if blood counts or iron stores do not improve with oral iron supplementation. In this case, the patient's ferritin level is 23, which is below the normal range, indicating iron deficiency.

The study 1 also suggests that IV iron should be used in situations where oral iron is likely to be ineffective due to impaired absorption. Although the patient's specific condition is not mentioned, the low ferritin level and iron saturation suggest that IV iron may be necessary to quickly restore iron stores and raise hemoglobin levels.

Some key points to consider when administering IV iron include:

• Verifying the diagnosis with laboratory testing and assessing for contraindications such as active infection or first trimester pregnancy
• Monitoring patients during infusion for hypersensitivity reactions, which are more common with older iron dextran formulations
• Choosing an IV iron preparation that can replace iron deficits with 1 to 2 infusions, such as iron sucrose (Venofer) or ferric carboxymaltose (Injectafer)
• Being aware that true allergies to IV iron are rare, and most reactions are complement activation-related pseudo-allergy, which can be managed with slowing the infusion rate or using corticosteroids.

Overall, the decision to use IV iron should be based on the severity of deficiency, underlying cause, comorbidities, and the patient's ability to tolerate oral supplementation, as suggested by the study 1.

From the FDA Drug Label

Inclusion criteria prior to randomization included hemoglobin (Hb) <12 g/dL, ferritin ≤100 ng/mL or ferritin ≤300 ng/mL when transferrin saturation (TSAT) ≤30%.

Iron deficiency was defined as serum ferritin <100 ng/mL or 100 to 300 ng/mL with TSAT <20%.

Decision to give IV iron: Based on the provided ferritin level of 23 ng/mL, which is below the threshold of 100 ng/mL, and assuming the patient has low iron saturation, yes, IV iron can be considered. The patient's ferritin level indicates iron deficiency, and IV iron supplementation may be necessary to replenish iron stores. However, it is essential to evaluate the patient's overall clinical condition, medical history, and other laboratory results to determine the best course of treatment 2.

From the Research

Iron Deficiency and IV Iron Therapy

• Iron deficiency is a common condition that can cause symptoms such as fatigue, exercise intolerance, and difficulty concentrating 3.
• A patient with low iron saturation and a ferritin level of 23 is likely to have iron deficiency, as ferritin levels <30 ng/mL are indicative of iron deficiency in individuals without inflammatory conditions 3.
• The decision to give intravenous (IV) iron should be based on the patient's overall clinical picture, including the presence of symptoms, underlying causes of iron deficiency, and ability to tolerate oral iron therapy.

Indications for IV Iron Therapy

• IV iron is indicated for patients with oral iron intolerance, poor absorption, chronic inflammatory conditions, ongoing blood loss, and during the second and third trimesters of pregnancy 3.
• Patients with low iron saturation and ferritin levels <30 ng/mL may benefit from IV iron therapy, especially if they have underlying conditions such as chronic kidney disease, heart failure, or inflammatory bowel disease 4.
• However, the use of IV iron should be individualized, and the decision to initiate therapy should be based on a thorough evaluation of the patient's iron status and overall health.

Alternative Treatment Options

• Oral iron therapy is typically first-line therapy for iron deficiency, and IV iron is reserved for patients who do not respond to or cannot tolerate oral iron 3, 5.
• Ferric maltol is a new oral iron replacement therapy that has been shown to be effective and well-tolerated in patients with iron-deficiency anemia, including those with chronic kidney disease 5, 6.
• The choice of treatment should be based on the patient's specific needs and circumstances, and IV iron should only be used when necessary and under close medical supervision.