Can iron be administered as an intravenous (IV) push?

Administration of Intravenous Iron

Iron dextran can be administered by slow IV push at a rate not exceeding 1.0 mL (50 mg, if undiluted) per minute, while other IV iron formulations have specific administration requirements that generally do not include IV push. 1

IV Iron Administration Methods by Formulation

Different IV iron formulations have varying administration requirements:

Iron Dextran

• Can be administered by slow IV push at a rate not exceeding 1.0 mL (50 mg) per minute 1
• For in-center hemodialysis patients, recommended dose is no more than 100 mg per dose to minimize dose-related arthralgias/myalgias 1
• Requires a test dose of 25 mg in adults before initiating therapy 1

Ferric Sodium Gluconate (Ferrlecit)

• Test dose should be diluted in 50 mL 0.9% sodium chloride and administered over 60 minutes 1
• Infusion of more than 125 mg as a bolus or infusion is not recommended by the manufacturer 1
• Doses of 62.5 mg and 125 mg can be mixed in 50 or 100 mL of saline and infused over 30 or 60 minutes 1

Ferric Carboxymaltose (Injectafer)

• Can be administered as an undiluted slow intravenous push or by infusion 2
• When given as slow IV push, administer at approximately 100 mg (2 mL) per minute 2
• For 1,000 mg dose, administer as slow IV push over 15 minutes 2
• For infusion, dilute up to 1,000 mg in no more than 250 mL of sterile 0.9% sodium chloride (minimum concentration 2 mg/mL) and administer over at least 15 minutes 2

Safety Considerations

Test Dose Requirements

• Iron dextran: 25 mg test dose required before initiating therapy 1
• Ferric sodium gluconate: 25 mg test dose required 1
• Modern formulations: The EMA no longer recommends administration of a test dose to predict/prevent allergic reactions 1

Monitoring for Reactions

• Patients should be monitored for at least 30 minutes after infusion for hypersensitivity reactions 3, 4
• IV iron should only be administered by staff trained to evaluate and manage anaphylactic reactions 1, 4
• Immediate access to medications needed for treatment of serious allergic reactions should be available 1

Adverse Reactions

• Anaphylaxis-like reactions occur in fewer than 1% of iron dextran or iron gluconate administrations 1
• Modern iron formulations have a low risk of severe infusion reactions (<1:250,000 administrations) 4
• Minor infusion reactions are self-limited and due to labile iron, not hypersensitivity 4
• Aggressively treating minor infusion reactions with H1-antihistamines or vasopressors should be avoided 4

Clinical Pearls and Pitfalls

• Do not administer IV iron on the same day as anthracycline chemotherapy due to potential increased cardiotoxicity 3
• Avoid IV iron during periods of neutropenia as it may increase infection risk 3
• Extravasation should be avoided as it can cause long-lasting brown discoloration at the site 2
• Routine prophylactic premedication is not justified for newer IV iron formulations but may be considered in high-risk patients 5
• IV iron should not be given to patients with an active infection 1

In summary, while iron dextran can be administered as an IV push, other formulations have specific administration requirements that generally involve slower infusion rates. The choice of administration method should be based on the specific iron formulation being used, with careful attention to the manufacturer's recommendations for dosing and administration.