What is the recommended dosing schedule for intravenous (IV) iron therapy over 2 weeks?

IV Iron Dosing Schedule Over 2 Weeks

For a 2-week IV iron administration schedule, the recommended approach depends on the specific iron preparation used, with iron sucrose allowing for 200-300 mg doses every 2-3 days, ferric gluconate at 125 mg weekly doses, and iron dextran at 100 mg weekly doses. 1, 2

Iron Preparation Options and Dosing Schedules

Iron Sucrose (Venofer)

• For non-dialysis dependent chronic kidney disease (NDD-CKD) patients: 200 mg undiluted as slow IV injection over 2-5 minutes or as infusion of 200 mg in 100 mL of 0.9% NaCl over 15 minutes, administered on 5 different occasions over a 14-day period 3
• Alternative dosing: 300 mg by 2-hour infusion is safe and effective with no significant adverse reactions 4
• Can also be administered as 200 mg over 2 minutes, which has been shown to be safe in a study of 2,297 injections 5

Ferric Gluconate (Ferrlecit)

• Dosage: 125 mg IV over 60 minutes 2
• Schedule: Once weekly for 8 doses (can fit 2 doses within a 2-week period) 2
• Individual doses above 125 mg are not recommended based on published trial results 2

Iron Dextran

• Test dose required: 25 mg slow IV push and wait 1 hour before giving main dose 2, 1
• Dosage: 100 mg IV over 5 minutes 2, 1
• Schedule: Once weekly for 10 doses (can fit 2 doses within a 2-week period) 2, 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 2, 1

Special Considerations

Safety Considerations

• Higher doses (400-500 mg) of iron sucrose administered as a 2-hour infusion have shown increased adverse events and are not recommended for routine use 4
• Common adverse events with IV iron include hypotension, hypertension, nausea, vomiting, diarrhea, pain, fever, dyspnea, pruritus, headaches, and dizziness 2
• Test doses are required for iron dextran and strongly recommended for ferric gluconate and iron sucrose if patients have exhibited previous sensitivities to IV iron preparations or have multiple drug allergies 2, 1
• Patients with active infection should not receive IV iron therapy 2, 1

Monitoring Recommendations

• For doses of 200-500 mg, wait at least 7 days before measuring iron parameters 6
• For doses of 1000 mg or larger, wait at least 2 weeks before accurate assessment of iron parameters 6
• Target iron levels: Transferrin saturation (TSAT) ≥20% and serum ferritin ≥100 ng/mL 2, 1

Population-Specific Considerations

• For pediatric patients, iron sucrose has been shown to be safe and effective at doses of 100-200 mg (median 200 mg) given on alternate days up to three times per week 7
• For patients with inflammatory conditions, IV iron may be more effective than oral iron due to hepcidin-mediated inhibition of oral iron absorption 6
• Avoid IV iron administration in patients with iron overload (TSAT >50% and/or serum ferritin >800 ng/mL) 2, 6

Preferred Regimen for 2-Week Administration

• For most patients, iron sucrose offers the most efficient dosing schedule within a 2-week timeframe, allowing for 5 doses of 200 mg (total 1000 mg) 3
• This regimen has been shown to be more effective than iron sucrose in achieving rapid improvement in hemoglobin levels 8