When to administer Iron Dextran (Rogam) for iron deficiency anemia?

Iron Dextran (Rogam) Administration for Iron Deficiency Anemia

Intravenous iron dextran should be administered when oral iron therapy has failed, is not tolerated, or when rapid iron repletion is needed due to severe anemia (hemoglobin <10 g/dL) or active bleeding. 1, 2

Indications for IV Iron Dextran

• Failed oral iron therapy: Patients who show inadequate response (<1 g/dL hemoglobin increase) after 2-4 weeks of oral iron 1
• Intolerance to oral iron: Patients experiencing significant gastrointestinal side effects (nausea, vomiting, constipation) 1
• Malabsorption conditions: Inflammatory bowel disease, postgastrectomy 1
• Active bleeding: Patients with ongoing blood loss where oral iron cannot keep pace with losses 2
• Severe anemia: Hemoglobin <10 g/dL requiring rapid correction 1
• Chronic kidney disease: Especially patients on hemodialysis 1

Pre-Administration Requirements

1. Confirm iron deficiency: Document low ferritin (<30 ng/mL) and/or transferrin saturation <15% 1
2. Test dose required: Administer 0.5 mL test dose before therapeutic dose to assess risk for anaphylaxis 3
3. Exclude active infection: IV iron is contraindicated during active infection 1
4. Resuscitation equipment: Must be readily available during administration 3

Dosing Protocol

Adults:

• Standard dosing: 100 mg per dose for in-center hemodialysis patients 1
• Total dose infusion: 500-1000 mg diluted in 250 mL normal saline infused over 1 hour for non-dialysis patients 1
• Maximum daily dose: Should not exceed 2 mL undiluted iron dextran 3

Pediatric patients:

• Weight <10 kg: 25 mg per dose (hemodialysis) or 125 mg total dose (non-dialysis)
• Weight 10-20 kg: 50 mg per dose (hemodialysis) or 250 mg total dose (non-dialysis)
• Weight >20 kg: 100 mg per dose (hemodialysis) or 500 mg total dose (non-dialysis) 1

Administration Method

1. Test dose: Administer 0.5 mL and observe patient for at least 1 hour 3
2. IV push: For hemodialysis patients, 100 mg given as IV push over 2 minutes 1
3. IV infusion: For larger doses (500-1000 mg), dilute in 250 mL normal saline and infuse over 1 hour 1
4. Monitor: Observe for signs of anaphylaxis during and after administration 3

Monitoring Parameters

• Hemoglobin: Check monthly until stable 2
• Iron parameters: Check ferritin and transferrin saturation every 3 months 2
• Target levels: Aim for hemoglobin 10-12 g/dL, ferritin >100 ng/mL, transferrin saturation >20% 1
• Stop therapy: When hemoglobin stabilizes between 10-12 g/dL 1

Potential Adverse Effects

• Immediate reactions: Anaphylaxis, hypotension, nausea, vomiting, pruritus 3, 4
• Delayed reactions (24-48 hours): Arthralgia, backache, fever, headache, myalgia 3
• Local reactions: Thrombophlebitis at injection site 4

Important Considerations

• Low molecular weight iron dextran (INFeD) is preferred over high molecular weight formulations due to lower risk of adverse reactions 1
• Patients with drug allergies or those on ACE inhibitors may have increased risk for anaphylactic reactions 3
• Avoid in patients with liver impairment or acute infectious kidney disease 3
• Consider newer IV iron formulations (ferric carboxymaltose, ferric derisomaltose) which have lower risk profiles if available 2

Clinical Pearls

• Iron dextran products are not clinically interchangeable with other IV iron formulations 3
• A single total dose infusion may be more convenient than multiple smaller doses for non-dialysis patients 5
• Premedication with diphenhydramine, cimetidine, and dexamethasone may reduce risk of reactions 5
• Pediatric patients generally tolerate IV iron dextran well with appropriate dosing 6