What is the proper protocol for administering intravenous (IV) iron infusion?

From the Guidelines

Intravenous iron infusion should be administered with careful preparation, monitoring, and follow-up, using formulations that can replace iron deficits with 1 or 2 infusions, such as ferric carboxymaltose (FCM) or low molecular weight iron dextran (LMWID), as they are preferred over those that require more than 2 infusions 1. The proper protocol for administering intravenous (IV) iron infusion requires careful preparation, monitoring, and follow-up. Before administration, patients should undergo laboratory testing including complete blood count, iron studies, and renal function tests to confirm iron deficiency and determine appropriate dosing. Common IV iron preparations include iron sucrose (Venofer), ferric carboxymaltose (Injectafer), and iron dextran (INFeD), each with specific dosing protocols. For example, iron sucrose is typically given as 200-300mg per session over 30 minutes, while ferric carboxymaltose can be administered as 750-1000mg over 15-30 minutes 1. Prior to infusion, vital signs should be recorded as baseline, and a test dose may be required for certain preparations like iron dextran due to higher hypersensitivity risk. The infusion should be administered through a dedicated IV line using an infusion pump to ensure controlled delivery rate. During administration, patients must be monitored for adverse reactions including hypotension, flushing, chest pain, or anaphylaxis, with emergency medications and equipment readily available. The infusion should be slowed or stopped if reactions occur. Post-infusion, patients should be observed for 30 minutes and instructed to report delayed reactions. Follow-up laboratory testing is recommended 4-8 weeks after completion to assess hemoglobin response and iron parameters. This protocol is essential because IV iron bypasses the gastrointestinal absorption limitations of oral iron and can rapidly replenish iron stores, but carries risks of serious adverse reactions that require proper management. The choice of IV iron formulation should be based on the patient's individual needs and medical history, with consideration of factors such as the risk of hypophosphatemia associated with FCM 1 and the potential for infusion reactions with all formulations 1. In general, formulations that can replace iron deficits with 1 or 2 infusions are preferred, as they offer convenience and reduce the risk of adverse reactions associated with multiple infusions 1. Some formulations, such as FCM, have been shown to be safe and efficacious in a variety of clinical settings, including chronic kidney disease, pregnancy, and inflammatory bowel disease 1. However, the use of IV iron should always be individualized and guided by careful monitoring and follow-up to minimize the risk of adverse reactions and optimize patient outcomes.

From the FDA Drug Label

The recommended dosage of Ferrlecit for the repletion treatment of iron deficiency in hemodialysis patients is 10 mL of Ferrlecit (125 mg of elemental iron). Ferrlecit may be diluted in 100 mL of 0.9% sodium chloride administered by intravenous infusion over 1 hour per dialysis session.

The recommended pediatric dosage of Ferrlecit for the repletion treatment of iron deficiency in hemodialysis patients is 0.12 mL/kg Ferrlecit (1.5 mg/kg of elemental iron) diluted in 25 mL 0.9% sodium chloride and administered by intravenous infusion over 1 hour per dialysis session.

The proper protocol for administering intravenous (IV) iron infusion is to dilute Ferrlecit in 0.9% sodium chloride and administer it by intravenous infusion over 1 hour per dialysis session.

• For adults, the recommended dosage is 10 mL of Ferrlecit (125 mg of elemental iron) diluted in 100 mL of 0.9% sodium chloride.
• For pediatric patients, the recommended dosage is 0.12 mL/kg Ferrlecit (1.5 mg/kg of elemental iron) diluted in 25 mL 0.9% sodium chloride. It is also important to monitor patients for signs and symptoms of hypersensitivity during and after Ferrlecit administration for at least 30 minutes and until clinically stable following completion of the infusion 2.

From the Research

Protocol for Administering Intravenous (IV) Iron Infusion

The proper protocol for administering IV iron infusion involves several key considerations, including:

• The type of IV iron formulation used, such as ferric carboxymaltose, ferric derisomaltose, or ferumoxytol 3
• The dose and administration schedule, which may vary depending on the patient's condition and the specific formulation used 4, 5
• Monitoring for potential adverse effects, such as hypersensitivity reactions, hypophosphatemia, and cardiovascular safety 3, 6, 5

Administration Guidelines

Some key guidelines for administering IV iron infusion include:

• Ferric carboxymaltose may be given as a single high-dose, 15-min infusion 4
• The introduction of second-generation IV iron formulations, including iron sucrose and ferric gluconate, has improved the safety and efficacy of IV iron therapy 5
• Newer IV iron preparations, such as ferric carboxymaltose, offer effective and rapid correction of iron deficiency anemia (IDA) and can be safely administered in a single dose of 1000 mg of iron 5

Safety Considerations

Some important safety considerations for IV iron infusion include:

• Immediate infusion reactions can occur with any IV iron and are usually mild, but severe reactions, particularly anaphylaxis, are extremely rare 3
• Severe, persistent hypophosphatemia is a specific side effect of ferric carboxymaltose 3
• No cardiovascular safety signal has been identified for IV iron 3
• Asymptomatic hypophosphatemia was noted in patients receiving both iron sucrose and ferric carboxymaltose infusions 7