What dose of Venofer (iron sucrose) should be given to a patient with iron deficiency anemia and a ferritin level of 12 who is not responding to oral iron?

Venofer (Iron Sucrose) Dosing for Iron Deficiency Anemia with Low Ferritin and Non-Response to Oral Iron

For a patient with iron deficiency anemia (ferritin 12 ng/mL) who is not responding to oral iron therapy, administer Venofer (iron sucrose) 200 mg intravenously either as an undiluted slow injection over 2-5 minutes or as an infusion of 200 mg diluted in a maximum of 100 mL of 0.9% NaCl over 15 minutes, given on 5 different occasions over a 14-day period, for a total dose of 1000 mg. 1

Rationale for IV Iron Therapy

When patients fail to respond to oral iron therapy, intravenous iron is clearly indicated:

• The American Gastroenterological Association (AGA) recommends intravenous iron when:

  • Patients do not tolerate oral iron
  • Ferritin levels do not improve with oral iron trial
  • Patient has conditions where oral iron absorption is impaired 2

• A ferritin level of 12 ng/mL confirms severe iron deficiency (below the threshold of 30 ng/mL) 3

Specific Dosing Protocol for Venofer

The FDA-approved dosing for Venofer in non-dialysis dependent patients is:

• 200 mg per dose
• Administered on 5 different occasions over a 14-day period
• Total cumulative dose: 1000 mg 1

Administration options:

1. Undiluted as slow IV injection over 2-5 minutes, OR
2. Diluted in maximum 100 mL of 0.9% NaCl over 15 minutes 1

Expected Response

• Hemoglobin typically increases by 3-4 g/dL following IV iron sucrose therapy 4, 5
• Ferritin levels can increase from baseline levels around 10 ng/mL to >200 ng/mL after one month of treatment 5
• Most patients (84-94%) respond with hemoglobin increases of at least 2 g/dL 4

Safety Considerations

• Iron sucrose has a well-established safety profile with over 70 years of clinical experience 6
• Most adverse events are mild to moderate and include:
  • Headache, dizziness, nausea
  • Abdominal pain, constipation, diarrhea
  • Rash and injection-site reactions 7
• True anaphylaxis is very rare; most reactions are complement activation-related pseudo-allergy (infusion reactions) 2
• Resuscitation facilities should be available when administering IV iron 2

Follow-up Monitoring

After IV iron therapy:

• Monitor complete blood count 3 months after treatment
• Continue monitoring every 3 months for 12 months
• Then every 6 months for 2-3 years 3

Alternative IV Iron Options

While Venofer requires multiple administrations, other IV iron formulations that can replace iron deficits with fewer infusions include:

• Ferric carboxymaltose (Ferinject/Injectafer): Can deliver up to 1000 mg in a single 15-minute infusion 8, 7
• Iron dextran (Cosmofer): Can replenish iron in a single infusion but requires 6 hours administration time and carries higher risk of serious reactions 2

The AGA recommends IV iron formulations that can replace iron deficits with 1-2 infusions over those requiring more than 2 infusions 2, but Venofer has the longest safety record and remains a standard option 6.

Pitfalls to Avoid

1. Failing to investigate the underlying cause of iron deficiency
2. Not continuing treatment long enough to replenish iron stores
3. Inadequate monitoring for recurrence of iron deficiency
4. Not addressing ongoing sources of blood loss if present

Following this protocol will effectively treat iron deficiency anemia in patients who have failed oral iron therapy, with an excellent safety profile.