Would you recommend an iron transfusion for a patient with low ferritin (iron deficiency) levels without anemia who is intolerant to oral iron medication?

From the Guidelines

I would strongly recommend an iron transfusion for a patient with a ferritin level of 14 without anemia who is intolerant to oral iron medication. This recommendation is based on the most recent and highest quality study available, which suggests that intravenous iron should be used if the patient does not tolerate oral iron, ferritin levels do not improve with a trial of oral iron, or the patient has a condition in which oral iron is not likely to be absorbed 1. Iron transfusions, such as iron sucrose (Venofer), ferric carboxymaltose (Injectafer), or iron dextran (INFeD), can effectively replenish iron stores when oral supplements cause intolerable side effects like nausea, constipation, or abdominal pain.

The typical dosing regimen involves 1-2 infusions depending on the specific product and severity of deficiency, administered in a monitored setting due to the small risk of hypersensitivity reactions 1. Before proceeding, it is essential to confirm iron deficiency with comprehensive testing, including serum ferritin, transferrin saturation, and complete blood count. While not having anemia means this isn't an emergency, treating iron deficiency is still crucial as it can cause fatigue, hair loss, restless legs syndrome, and cognitive issues even without anemia.

Key points to consider in the management of iron deficiency without anemia include:

• The importance of confirming iron deficiency through comprehensive testing
• The role of intravenous iron in replenishing iron stores when oral supplements are not tolerated
• The potential side effects and risks associated with intravenous iron therapy, such as hypersensitivity reactions
• The need for ongoing monitoring and potential re-treatment with intravenous iron if serum ferritin levels drop below 100 mg/L or hemoglobin levels fall below 12 or 13 g/dL, depending on gender 1.

Overall, the benefits of treating iron deficiency with intravenous iron transfusion in a patient who is intolerant to oral iron medication outweigh the risks, and this approach can significantly improve the patient's quality of life by rapidly restoring iron levels and alleviating symptoms associated with iron deficiency.

From the FDA Drug Label

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. There are no data available to guide dosing beyond 36 weeks or with Hb ≥15 g/dL.

The patient has low ferritin levels without anemia and is intolerant to oral iron medication. Iron transfusion may be considered for patients with iron deficiency. However, the provided drug label does not explicitly address the treatment of patients with low ferritin levels without anemia.

• The label recommends Injectafer for the treatment of iron deficiency anemia.
• It does not provide guidance on the treatment of patients with low ferritin levels without anemia. Given the lack of direct evidence, a conservative clinical decision would be to not recommend an iron transfusion for a patient with a ferritin level of 14 without anemia, as the label does not provide clear guidance on this specific scenario 2.

From the Research

Iron Transfusion for Low Ferritin Levels Without Anemia

• The decision to perform an iron transfusion for a patient with a ferritin level of 14 without anemia, who is intolerant to oral medication, depends on various factors, including the patient's overall health and the presence of any underlying conditions 3, 4.
• Studies have shown that intravenous iron supplementation, such as ferric carboxymaltose, can be effective in treating iron deficiency anemia, even in patients without anemia, by replenishing depleted iron stores and improving health-related quality of life 3, 5.
• Ferric carboxymaltose has been shown to be well tolerated, with a low risk of adverse events, and can be administered in a single session, making it a convenient option for patients who are intolerant to oral iron medication 4, 6.

Considerations for Iron Transfusion

• The patient's ferritin level of 14 indicates iron deficiency, which can have negative effects on overall health, even in the absence of anemia 5.
• The fact that the patient is intolerant to oral iron medication makes intravenous iron supplementation a viable alternative 3, 4.
• The potential benefits of iron transfusion, including improved iron stores and health-related quality of life, should be weighed against the potential risks and costs of the procedure 6, 7.

Evidence for Iron Transfusion

• Studies have demonstrated the efficacy and safety of intravenous iron supplementation, including ferric carboxymaltose, in treating iron deficiency anemia and replenishing depleted iron stores 3, 4, 6.
• A study published in 2021 found that in-hospital intravenous iron supplementation with ferric carboxymaltose reduced the number of red blood cell transfusions required during hospitalization and within 3 months of discharge 7.
• Another study published in 2016 noted that intravenous iron therapy is underutilized and should be considered a viable option for patients with iron deficiency anemia, including those without anemia 5.