What is the preferred iron replacement therapy, Venofer (iron sucrose) or Monoferric (ferric derisomaltose), in patients with Impaired renal function undergoing dialysis?

Monoferric (Ferric Derisomaltose) is Superior to Venofer (Iron Sucrose) for Iron Replacement in Dialysis Patients

Based on the most recent evidence, Monoferric (ferric derisomaltose/iron isomaltoside) is the preferred iron replacement therapy over Venofer (iron sucrose) for patients with impaired renal function undergoing dialysis due to its superior efficacy in rapidly improving hemoglobin levels and more convenient dosing regimen. 1

Comparison of Efficacy

• Monoferric (ferric derisomaltose) demonstrated faster and greater improvements in hemoglobin levels compared to iron sucrose in patients with iron deficiency anemia 1
• In a randomized trial comparing the two preparations, Monoferric showed a shorter time to achieve hemoglobin increase ≥2 g/dL compared to iron sucrose 1
• Both iron preparations have been shown to effectively maintain hemoglobin concentrations in hemodialysis patients, but Monoferric allows for higher single doses and fewer administrations 2
• Iron isomaltoside 1000 (Monoferric) showed a significant increase in ferritin from baseline compared to iron sucrose at weeks 1,2, and 4 (P < 0.001 for weeks 1 and 2; P = 0.002 for week 4) 2

Dosing Advantages

• Monoferric allows for higher single doses (up to 1000 mg or 20 mg/kg) compared to Venofer's maximum single dose of 200 mg 3
• Venofer requires more frequent administration with a maximum weekly dose of 500 mg, whereas Monoferric can be administered as a single 1000 mg dose 3
• The ability to administer higher doses of Monoferric in fewer infusions reduces the burden on both patients and healthcare resources 1
• Monoferric can be administered over 15 minutes for doses up to 1000 mg, while Venofer requires 30 minutes for its maximum 200 mg dose 3

Safety Considerations

• Both Monoferric and Venofer have demonstrated similar safety profiles in clinical trials 2, 1
• The frequency, type, and severity of adverse events were comparable between the two preparations 2
• Common adverse effects for both preparations include hypotension, flushing, abdominal cramps, and arthralgias/myalgias 4
• Anaphylactic reactions are rare but possible with both IV iron preparations, so resuscitation facilities should be available during administration 4
• Test doses are not required for iron sucrose but may be considered for patients with a history of sensitivities to IV iron preparations or multiple drug allergies 4

Iron Management in Dialysis Patients

• Intravenous iron is preferred over oral iron for hemodialysis patients due to reduced intestinal absorption and greater iron losses in this population 5
• The KDIGO guidelines recommend maintaining ferritin levels <500 μg/L in hemodialysis patients 3
• Regular monitoring of iron status is essential, with transferrin saturation and serum ferritin measurements recommended every 3 months during maintenance therapy 3
• IV iron therapy should be withheld in patients with active infection 4
• Maintenance IV iron therapy should provide 250 to 1,000 mg of iron within a 12-week period 3

Practical Implementation

• For dialysis patients requiring iron replacement, start with Monoferric at a dose of up to 1000 mg administered over 15 minutes 3
• Monitor hemoglobin, transferrin saturation, and ferritin levels to assess response and guide subsequent dosing 3
• If Monoferric is not available, Venofer can be administered at 100-200 mg per dose, with a maximum weekly dose of 500 mg 3
• For Venofer administration, the bolus intravenous dosing of 200 mg over 10 minutes is licensed and more convenient than a 2-hour infusion 3
• Monitor vital signs during and after infusion with either preparation to detect potential reactions 4

Potential Pitfalls and Caveats

• Avoid iron therapy in patients with active infection as it may worsen outcomes 4
• Be cautious about iron overload, especially when ferritin levels exceed 500 μg/L, as recommended by KDIGO guidelines 3
• Measurement of transferrin saturation and serum ferritin may be inaccurate if performed within 14 days of receiving a large dose of intravenous iron 3
• Consider that iron supplementation strategies should balance the need for adequate iron stores against the risk of iron overload, which can lead to oxidative stress and potential organ damage 3
• Remember that the goal of iron therapy is not just to correct anemia but also to replenish iron stores to support ongoing erythropoiesis 3