When Iron Therapy is Not Indicated for Iron Deficiency Anemia
Iron therapy is contraindicated in patients with iron overload conditions such as hemochromatosis, and should be used with caution in patients with active infections, chronic inflammatory conditions with functional iron deficiency, and when transferrin saturation exceeds 50% or serum ferritin exceeds 800 ng/mL. 1
Specific Conditions Where Iron Therapy Should Be Avoided or Used with Caution
Iron Overload Conditions
- Hereditary hemochromatosis patients require phlebotomy rather than iron supplementation as the primary treatment to reduce excess iron stores 1
- Even with normal dietary iron intake, patients with hemochromatosis will accumulate excess iron and require regular phlebotomy 1
- Caution: Patients with hemochromatosis who undergo excessive therapeutic phlebotomy may paradoxically develop iron deficiency requiring brief, controlled iron supplementation 2
Elevated Iron Parameters
- Iron therapy should be withheld when transferrin saturation is >50% and/or serum ferritin is >800 ng/mL 1
- In hemodialysis patients, IV iron should be withheld for up to 3 months when these thresholds are exceeded, with parameters re-measured before resuming therapy 1
- When iron parameters return below these thresholds, iron therapy can be resumed at reduced doses (one-third to one-half of previous dose) 1
Active Infections
- Experimental studies suggest intravenous iron may be harmful in the presence of severe infection 1
- Iron should be used with caution, if at all, in patients with active infections as it may potentially exacerbate the infectious process 1
- Several observational studies in hemodialysis patients have shown associations between very high ferritin levels (>4500 ng/mL) and infections 1
Chronic Inflammatory Conditions with Functional Iron Deficiency
- In conditions like cancer, chronic kidney disease, and inflammatory bowel disease, iron sequestration due to inflammation may cause functional iron deficiency 1
- Standard oral iron therapy may be ineffective in these cases due to upregulation of hepcidin, which blocks iron absorption 1
- In such cases, intravenous iron rather than oral iron may be more appropriate, or iron therapy may need to be combined with erythropoiesis-stimulating agents 1
Hypersensitivity to Iron Preparations
- Serious hypersensitivity reactions, including anaphylactic-type reactions (some life-threatening and fatal), have been reported with parenteral iron products 3
- Patients with previous hypersensitivity reactions to iron preparations should not receive the same formulation again 3
Special Considerations
Anemia of Chronic Disease vs. Iron Deficiency
- In chronic inflammatory states, ferritin may be falsely elevated as an acute phase reactant 1
- Traditional laboratory thresholds for iron deficiency may not apply; transferrin saturation <20% should be used as an additional diagnostic criterion 4
- When absolute iron deficiency is ruled out, treating the underlying disease should be prioritized over iron supplementation 1
Non-Iron Deficiency Causes of Anemia
- Before initiating iron therapy, other causes of anemia should be ruled out, including hemorrhage, hemolysis, nutritional deficiencies (B12, folate), inherited disorders, and renal insufficiency 1
- Iron therapy is not indicated as primary treatment when anemia is primarily due to these other causes 1
Full-Term Infants Under 6 Months
- Iron screening and supplementation is of little value before age 6 months for full-term infants of normal or high birthweight, as their iron stores can meet body requirements up to this age 1
Remember that the decision to withhold iron therapy should be based on accurate diagnosis of the underlying cause of anemia, appropriate laboratory testing, and consideration of the patient's overall clinical condition.