IV Iron Dosing Guidelines
For patients with iron deficiency anemia, IV iron should be dosed according to patient-specific factors including weight, severity of anemia, and clinical setting, with hemodialysis patients typically receiving 100 mg per dose and non-dialysis patients receiving larger single doses of 500-1000 mg to reduce healthcare visits. 1
Adult Dosing by Clinical Setting
Hemodialysis Patients
In-center hemodialysis patients:
- 100 mg iron dextran IV per dialysis session (given as IV push over 2 minutes)
- Total cumulative dose: 1000 mg (typically over 10 sessions)
- This smaller dosing minimizes dose-related arthralgias/myalgias 1
For ferric sodium gluconate (Ferrlecit):
- 125 mg elemental iron (10 mL) per dialysis session
- Dilute in 100 mL of 0.9% sodium chloride and infuse over 1 hour
- Or administer undiluted as slow IV injection (up to 12.5 mg/min)
- Most patients require cumulative dose of 1000 mg over 8 dialysis sessions 2
Home Hemodialysis, Peritoneal Dialysis, or CKD Patients
- Single larger doses:
- 500-1000 mg iron dextran diluted in 250 mL normal saline
- Infuse over 1 hour
- Repeat as necessary to maintain adequate iron stores
- Patients should be informed of increased risk of myalgias/arthralgias with larger doses 1
Cancer-Related Anemia
- Typical dosing regimens:
Inflammatory Bowel Disease
- Simplified dosing scheme based on weight and hemoglobin:
| Hemoglobin g/dL | Body weight <70 kg | Body weight ≥70 kg |
|---|---|---|
| 10-12 [women] 10-13 [men] | 1000 mg | 1500 mg |
| 7-10 | 1500 mg | 2000 mg |
- First-line treatment for patients with clinically active IBD, previous intolerance to oral iron, or hemoglobin below 10 g/dL 1
Pediatric Dosing
Pediatric Hemodialysis Patients
Iron dextran dosing per session in a 10-dose course:
- Weight <10 kg: 25 mg (0.5 mL)
- Weight 10-20 kg: 50 mg (1.0 mL)
- Weight >20 kg: 100 mg (2.0 mL) 1
Pediatric Predialysis and PD Patients
Single dose of iron dextran:
- Weight <10 kg: 125 mg in 75 mL saline
- Weight 10-20 kg: 250 mg in 125 mL saline
- Weight >20 kg: 500 mg in 250 mL saline 1
Ferric Gluconate in Pediatric Patients
- 0.12 mL/kg (1.5 mg/kg elemental iron)
- Dilute in 25 mL 0.9% sodium chloride
- Administer by IV infusion over 1 hour per dialysis session
- Maximum dose: 125 mg per dose 2
Monitoring Parameters
Measure TSAT and serum ferritin 2-7 days after last dose of IV iron
- For doses of 100-125 mg, wait at least 7 days
- For doses >1000 mg, wait at least 14 days 1
Target parameters:
- TSAT ≥20%
- Serum ferritin ≥100 ng/mL
- Hemoglobin 11-12 g/dL 1
Monitor for iron overload:
Safety Considerations
Hypersensitivity reactions:
- Monitor patients for at least 30 minutes after administration
- Have personnel and therapies available for treating anaphylaxis 2
Hypotension:
- May occur during or after administration
- Monitor vital signs during and after infusion 2
Test dose:
- Required for iron dextran preparations due to risk of anaphylactic reactions
- Not required for newer preparations like ferric carboxymaltose, iron sucrose, or ferric gluconate 1
Avoid in iron overload:
- Do not administer to patients with evidence of iron overload 2
Practical Considerations
- Recent research suggests that the actual iron deficit in most patients with iron deficiency anemia is closer to 1500 mg rather than the traditional 1000 mg 3
- Lower retreatment rates (5.6% vs 11.1%) were observed with 1500 mg cumulative dose compared to 1000 mg 3
- For maintenance therapy in hemodialysis patients, provide 250-1000 mg of iron within 12 weeks 1
- Oral iron is not recommended when IV iron is required due to inconvenience, cost, and side effects 1
IV iron administration should be tailored to the specific clinical scenario, with appropriate monitoring for efficacy and safety to optimize outcomes related to morbidity, mortality, and quality of life.