What is the administration protocol for intravenous (IV) iron infusion?

IV Iron Infusion Administration Protocol

IV iron infusion should be administered based on the specific iron formulation, with dosing tailored to the underlying condition and administered over appropriate timeframes to minimize adverse reactions while ensuring optimal iron repletion. 1, 2

Administration Methods by Formulation

Ferric Gluconate (Ferrlecit)

• For adults, the recommended dose is 125 mg (10 mL) of elemental iron per dialysis session 2
• Can be administered either:
  • Diluted in 100 mL of 0.9% sodium chloride and infused over 1 hour 2
  • Undiluted as a slow IV injection at a rate up to 12.5 mg/min 2
• For repletion treatment, most patients require a cumulative dose of 1000 mg administered over 8 dialysis sessions 2
• Individual doses exceeding 125 mg may be associated with higher incidence of adverse events 2

Iron Dextran

• For in-center hemodialysis patients: No more than 100 mg per dose given as IV "push" over 2 minutes to minimize arthralgias/myalgias 1
• For CKD, home hemodialysis, or peritoneal dialysis patients: 500-1000 mg diluted in 250 mL normal saline and infused over 1 hour 1
• A test dose of 25 mg should be administered before the first therapeutic dose 1

Iron Sucrose

• Typically administered in doses of 100 mg diluted in 150 mL normal saline over 30 minutes 3
• Has shown excellent safety profile with minimal adverse reactions 3

Ferumoxytol

• Can be administered as a 1020 mg total dose infusion over 15 minutes 4
• Provides excellent efficacy with complete iron repletion in a single visit 4

Iron Isomaltoside (Monofer)

• Can be administered in high doses with maximum single dosage of 20 mg/kg body weight 5
• Doses up to 1000 mg administered over more than 15 minutes; doses exceeding 1000 mg over 30 minutes or more 5

Pediatric Dosing

• For hemodialysis patients:
  • Weight <10 kg: 25 mg (0.5 mL) per dose 1
  • Weight 10-20 kg: 50 mg (1.0 mL) per dose 1
  • Weight >20 kg: 100 mg (2.0 mL) per dose 1
• For predialysis and peritoneal dialysis patients:
  • Weight <10 kg: 125 mg in 75 mL saline 1
  • Weight 10-20 kg: 250 mg in 125 mL saline 1
  • Weight >20 kg: 500 mg in 250 mL saline 1
• For ferric gluconate (Ferrlecit): 0.12 mL/kg (1.5 mg/kg) diluted in 25 mL saline over 1 hour, not exceeding 125 mg per dose 2

Monitoring and Safety Considerations

• Monitor patients for signs of hypersensitivity during and after infusion for at least 30 minutes 2
• Common adverse reactions include hypotension, flushing, arthralgias, myalgias, and headache 1, 2
• Serious hypersensitivity reactions, including anaphylaxis, have been reported but are rare 2
• Newer IV iron formulations have lower risk of adverse reactions compared to older preparations 1, 3
• Do not mix IV iron with other medications or add to parenteral nutrition solutions 2

Timing of Laboratory Assessment

• If IV iron is given in amounts of 100-125 mg or less per week, iron parameters can be measured without interrupting therapy 1
• For doses of 200-500 mg, wait at least 7 days before measuring iron parameters 1
• For doses of 1000 mg or larger, wait at least 2 weeks before accurate assessment of iron parameters 1

Frequency of Administration

• For hemodialysis patients: Weekly administration of 100-125 mg for 8-10 doses is recommended when TSAT <20% and/or ferritin <100 ng/mL 1
• For maintenance therapy: 25-125 mg weekly once target levels are achieved 1
• For non-dialysis patients: Higher individual doses (500-1000 mg) may be more cost-effective and equally efficacious as multiple smaller doses 6

Special Considerations

• In inflammatory conditions like inflammatory bowel disease, IV iron may be more effective than oral iron due to hepcidin-mediated inhibition of oral iron absorption 1
• Avoid IV iron administration in patients with iron overload (TSAT >50% and/or ferritin >800 ng/mL) 1
• For patients with anemia of chronic disease, IV iron can overcome the limited absorption of oral iron 1

By following these administration protocols, IV iron infusion can effectively treat iron deficiency anemia while minimizing the risk of adverse events and improving patient outcomes.