What is the recommended regimen for prescribing intravenous (IV) iron?

IV Iron Administration Guidelines

For optimal patient outcomes, IV iron should be administered according to specific regimens based on the iron preparation used, with test doses required for iron dextran and strongly recommended for other preparations in patients with previous sensitivities. 1

Iron Preparation Options

• Three main parenteral iron preparations are used clinically: iron dextran, ferric gluconate, and iron sucrose 1
• If using iron dextran, low-molecular-weight iron dextran (INFed) is recommended over high-molecular-weight iron dextran (Dexferrum) due to fewer adverse events 1
• Patients with active infection should not receive IV iron therapy 1

Administration Protocols by Preparation

Iron Dextran

• Test dose: 25 mg slow IV push and wait 1 hour before giving main dose (required) 1
• Dosage: 100 mg IV over 5 minutes 1
• Regimen options:
  • Repeated weekly dosing for 10 doses to achieve total dose of 1 g 1
  • Total dose infusion given over several hours 1
• Maximum total dose: 1000 mg 1
• For CKD, home hemodialysis, or PD patients: Can administer single doses of 500-1000 mg diluted in 250 mL normal saline infused over 1 hour 1

Ferric Gluconate (Ferrlecit)

• Test dose: 25 mg slow IV push or infusion (at physician discretion, but strongly recommended for patients with previous sensitivities) 1
• Adult dosage: 125 mg IV over 60 minutes 1, 2
• FDA-approved administration: 10 mL (125 mg elemental iron) diluted in 100 mL of 0.9% sodium chloride administered by IV infusion over 1 hour per dialysis session 2
• Alternative: Undiluted as slow IV injection (up to 12.5 mg/min) 2
• Repeated dosing given once weekly for 8 doses 1
• Individual doses above 125 mg are not recommended 1, 2
• Maximum total dose: 1000 mg 1

Iron Sucrose

• Test dose: 25 mg slow IV push (at physician discretion, but strongly recommended for patients with previous sensitivities) 1
• Dosage: 200 mg IV over 60 minutes 1
• Alternative: 200 mg IV over 2-5 minutes 1, 3
• Repeated dosing given every 2-3 weeks 1
• Individual doses above 300 mg are not recommended 1
• For CKD patients not on dialysis: 200 mg IV push over 5 minutes weekly has been shown to be effective 4

Special Populations

Pediatric Dosing

• Iron dextran for pediatric hemodialysis patients (10-dose course): 1

  • ≤10 kg: 25 mg per dose
  • 10-20 kg: 50 mg per dose
  • ≥20 kg: 100 mg per dose

• Iron dextran for pediatric predialysis and PD patients: 1

  • ≤10 kg: 125 mg in 75 mL saline
  • 10-20 kg: 250 mg in 125 mL saline
  • ≥20 kg: 500 mg in 250 mL saline

• Ferric gluconate for pediatric patients (≥6 years): 0.12 mL/kg (1.5 mg/kg elemental iron) diluted in 25 mL 0.9% sodium chloride administered by IV infusion over 1 hour per dialysis session 2

• Iron sucrose for pediatric patients with IDA: 100-200 mg doses (median 200 mg) given on alternate days up to three times per week 5

Monitoring and Maintenance

• For hemodialysis patients: Maintenance IV iron can be given thrice weekly, twice weekly, weekly, or every other week, providing 250-1000 mg within 12 weeks 1
• Monitor iron status by measuring transferrin saturation (TSAT) and serum ferritin every 3 months during maintenance phase 1
• Target iron levels: TSAT ≥20% and serum ferritin ≥100 ng/mL 1
• Avoid measuring iron parameters within 7-14 days after IV iron administration for accurate results 1

Safety Considerations

• Common adverse events include hypotension, hypertension, nausea, vomiting, diarrhea, pain, fever, dyspnea, pruritus, headaches, and dizziness 1
• Iron dextran carries risk of anaphylactic reactions; other preparations have lower risk but still require monitoring 6
• Monitor patients for signs of hypersensitivity during and after administration 2
• For iron sucrose, metallic taste is common (17.9% of injections) but typically mild and transient 3
• Do not mix IV iron preparations with other medications 2
• Avoid iron therapy in patients with iron overload; monitor hematologic responses regularly 2

Practical Considerations

• IV iron is preferable for hemodialysis patients and may be appropriate for some peritoneal dialysis and CKD patients not on dialysis 1
• For primary care settings, iron gluconate (62.5 mg in 150 mL normal saline over 30 min) and iron sucrose (100 mg in 150 mL normal saline over 30 min) have been used safely 7
• Rapid administration of iron sucrose (200 mg over 2 minutes) has been shown to be safe and practical in CKD patients, saving time and resources 3