What is the comparison between ferric carboxymaltose (iron(III)-oxyhydroxide) and monoferric (iron isomaltoside) for intravenous iron supplementation?

Comparison of Ferric Carboxymaltose vs. Monoferric for IV Iron Supplementation

Ferric derisomaltose (Monoferric) is superior to ferric carboxymaltose (Injectafer) for intravenous iron supplementation due to its higher maximum single dose capability (up to 1500 mg vs. 750 mg in US) and significantly lower risk of hypophosphatemia. 1

Dosing Capabilities

Monoferric (Ferric Derisomaltose/Iron Isomaltoside)

• Maximum single dose: 20 mg/kg up to 1500 mg
• Administration time: 15-30+ minutes
• Can often achieve complete iron repletion in a single infusion

Ferric Carboxymaltose (Injectafer)

• Maximum single dose: 750 mg in US (1000 mg in EU)
• Administration time: 15 minutes
• Often requires two administrations separated by at least 7 days 2

Safety Profile Comparison

Hypophosphatemia Risk

• Major difference: Ferric carboxymaltose causes significantly more hypophosphatemia than ferric derisomaltose 1
• Mechanism: Both can increase FGF-23 (fibroblast growth factor-23), which increases renal phosphate excretion, but this effect is much more pronounced with ferric carboxymaltose
• Clinical impact: Repeated use of ferric carboxymaltose may lead to severe osteomalacia, characterized by bone pain, pseudofractures, and low-trauma fractures 1

Hypersensitivity Reactions

• Both formulations have similar rates of hypersensitivity reactions (<1% in clinical trials) 1
• Both are non-dextran formulations with better safety profiles than older iron dextran products

Efficacy Comparison

Both medications are highly effective at:

• Rapidly increasing hemoglobin levels
• Replenishing iron stores
• Improving quality of life measures in iron deficiency anemia 3

Clinical Considerations for Selection

Choose Monoferric when:

• Complete iron repletion in a single visit is desired
• Patient has risk factors for hypophosphatemia
• Higher total iron dose is needed (>1500 mg)
• Patient has a history of adverse reactions to ferric carboxymaltose

Choose Ferric Carboxymaltose when:

• Extensive clinical trial data is preferred (more published studies)
• Specific patient populations where it has been extensively studied (heart failure, IBD, etc.) 4
• Shorter infusion time is prioritized (15 minutes vs. potentially longer for Monoferric)

Practical Administration

Both medications:

• Require monitoring for at least 30 minutes post-infusion for hypersensitivity reactions 3
• Do not require a test dose (unlike older iron dextran formulations)
• Can be administered in outpatient settings
• Are indicated when oral iron is ineffective, not tolerated, or contraindicated 3

Cost Considerations

Ferric carboxymaltose has historically been more expensive than other IV iron formulations, with a cost of approximately $217.50 per gram compared to lower costs for other formulations 4.

Conclusion

While both medications are effective for treating iron deficiency anemia, ferric derisomaltose (Monoferric) offers advantages in terms of higher single-dose capability and significantly lower risk of hypophosphatemia, making it the preferred option for most patients requiring IV iron supplementation.