What is the management for an allergic reaction to Venofer (iron sucrose)?

Management of Allergic Reactions to Venofer (Iron Sucrose)

For allergic reactions to Venofer (iron sucrose), immediately stop the infusion, assess severity, and administer epinephrine 0.3-0.5 mg IM for severe reactions/anaphylaxis as first-line treatment, followed by appropriate supportive care based on symptom severity. 1

Classification and Initial Management

Mild Reactions

• Symptoms: Flushing, pruritus, mild urticaria, mild discomfort
• Management:
  • Stop the infusion immediately
  • Monitor vital signs for at least 15 minutes
  • Consider H1 antihistamines (diphenhydramine 25-50 mg IV) for symptom relief
  • If symptoms resolve completely, consider rechallenge at 50% of the initial infusion rate 1

Moderate Reactions

• Symptoms: More extensive urticaria, angioedema without airway compromise, mild hypotension, mild bronchospasm
• Management:
  • Stop the infusion immediately
  • Maintain IV access 2
  • Administer H1 antihistamines (diphenhydramine 50 mg IV)
  • Consider adding H2 antagonists (ranitidine 50 mg IV)
  • Consider IV corticosteroids (methylprednisolone 1-2 mg/kg)
  • Provide oxygen by mask or nasal cannula if hypoxemia present
  • Monitor vital signs every 15 minutes until resolution 2, 1

Severe Reactions/Anaphylaxis

• Symptoms: Hypotension, tachycardia, bronchospasm, laryngeal edema, widespread urticaria, angioedema with airway compromise
• Management:
  1. Stop the infusion immediately
  2. Call for emergency assistance
  3. Administer epinephrine 0.3-0.5 mg (0.3-0.5 mL of 1:1000) IM in anterolateral thigh 1, 3
     • May repeat every 5-15 minutes as necessary
     • For children <30 kg: 0.01 mg/kg (0.01 mL/kg) up to 0.3 mg maximum 3
  4. Position patient appropriately (supine with legs elevated for hypotension; sitting up for respiratory distress) 2
  5. Administer IV fluids: 1-2 L normal saline at 5-10 mL/kg in first 5 minutes 2
  6. Administer H1/H2 antagonists: diphenhydramine 50 mg IV plus ranitidine 50 mg IV 2
  7. Administer corticosteroids: methylprednisolone 1-2 mg/kg IV 2
  8. For persistent hypotension:
     • Consider vasopressors (dopamine 400 mg in 500 mL at 2-20 μg/kg/min) 2
     • For patients on beta-blockers: glucagon 1-5 mg IV infusion over 5 minutes 2
  9. For bronchospasm: consider inhaled bronchodilators 2

Post-Reaction Management

Observation

• Monitor vital signs until complete resolution of symptoms
• For severe reactions: observe for at least 24 hours 2
• For mild-moderate reactions: observe for at least 1-2 hours after symptom resolution 2

Documentation and Follow-up

• Document detailed reaction information:
  • Symptoms and timing
  • Interventions provided and response
  • Vital signs throughout the event 1
• Consider tryptase level measurement (optimal timing: 15 minutes to 3 hours after symptom onset) 2

Future Iron Administration

• For patients with previous severe reactions to Venofer:
  1. Consider alternative iron formulations 1
  2. Consider desensitization protocols under specialist supervision 4
  3. Avoid rechallenge in patients with severe reactions 2

Prevention Strategies

• Screen for risk factors before administration:
  • Previous reaction to IV iron
  • Multiple drug allergies
  • Severe atopy
  • Systemic inflammatory diseases
  • Asthma
  • Mastocytosis 1
• Ensure resuscitation equipment and medications are readily available
• Ensure staff are trained in recognition and management of infusion reactions 1

Important Caveats

• Even "safer" iron preparations like iron sucrose can cause severe anaphylaxis and cardiac arrest 5
• Do not administer repeated epinephrine injections at the same site to prevent tissue necrosis 3
• Normal tryptase levels do not rule out anaphylaxis 2
• Patients allergic to one iron formulation may tolerate a different formulation 6