What is the recommended iron infusion medication for an elderly patient with heart failure and severe iron deficiency anemia?

Ferric Carboxymaltose (Injectafer) for Iron Deficiency in Heart Failure

This elderly man with heart failure and severe iron deficiency (transferrin saturation 7%, ferritin 170 ng/mL) should receive intravenous ferric carboxymaltose (Injectafer), which is the evidence-based treatment specifically indicated for iron deficiency in heart failure patients. 1, 2

Why Ferric Carboxymaltose is the Correct Choice

Ferric carboxymaltose is FDA-approved specifically for iron deficiency in adult patients with heart failure and NYHA class II/III to improve exercise capacity. 2 This patient meets diagnostic criteria for iron deficiency with transferrin saturation <20% (his is 7%), even though ferritin is between 100-299 ng/mL. 1, 3

Key Clinical Evidence Supporting This Choice

• The European Society of Cardiology specifically recommends intravenous ferric carboxymaltose for symptomatic heart failure patients with reduced ejection fraction who have iron deficiency, as it improves functional capacity, quality of life, and reduces heart failure hospitalizations. 1

• Ferric carboxymaltose demonstrated superior clinical outcomes in landmark trials (FAIR-HF, CONFIRM-HF), improving NYHA functional class, 6-minute walk test distance, and quality of life measures. 4, 3, 5

• Oral iron is NOT recommended and has been proven ineffective in heart failure patients due to hepcidin upregulation, GI mucosal edema, and impaired absorption. 1, 3

Dosing Regimen for This Patient

Based on the patient's hemoglobin of 9.7 g/dL and assuming weight ≥70 kg (typical for elderly men):

• Day 1: Administer 1,000 mg IV ferric carboxymaltose 2
• Week 6: Administer 1,000 mg IV ferric carboxymaltose 2
• Maintenance doses: 500 mg at 12,24, and 36 weeks if serum ferritin remains <100 ng/mL or ferritin 100-300 ng/mL with transferrin saturation <20% 2

If the patient weighs <70 kg, adjust to 1,000 mg on Day 1 and 500 mg at Week 6. 2

Administration Details

• Can be given as undiluted slow IV push (approximately 100 mg per 2 mL per minute) or as IV infusion over at least 15 minutes. 2
• For 1,000 mg dose as slow IV push, administer over 15 minutes. 2
• Maximum weekly dose is 1,000 mg iron per week. 1
• Monitor the patient for at least 30 minutes post-administration for hypersensitivity reactions. 1, 2

Critical Safety Considerations

Absolute Contraindications

• Hypersensitivity to ferric carboxymaltose or its excipients 2
• Known serious hypersensitivity to other parenteral iron products 3
• Hemoglobin >15 g/dL 1

Important Warnings

• Serious anaphylactic/anaphylactoid reactions occur in 0.1% of patients; other serious hypersensitivity reactions in 1.5%. 2
• Must be administered where personnel and therapies are immediately available to treat serious hypersensitivity reactions. 2
• Monitor serum phosphate levels in patients requiring repeat courses, especially if within 3 months, as symptomatic hypophosphatemia can occur. 2
• Avoid extravasation as brown discoloration may be long-lasting. 2

Why NOT Other IV Iron Preparations

• Iron dextran (Infed) carries a boxed warning for anaphylaxis risk and requires test dosing, making it less desirable despite lower cost. 4
• Iron sucrose and ferric gluconate are approved only for CKD patients with IDA, not specifically for heart failure, and require multiple smaller doses (200 mg and 125 mg maximum per dose, respectively). 4
• Ferumoxytol requires slower infusion after postmarketing surveillance documented reactions with rapid infusion. 4
• Iron isomaltoside is not FDA-approved in the USA (only in Europe and 45 other countries). 4

Monitoring Strategy

• Reassess iron parameters (ferritin and transferrin saturation) at 3 months after initial treatment. 1, 3
• Avoid early re-evaluation within 4 weeks as ferritin levels are markedly elevated immediately following IV iron. 3
• Routine follow-up should include re-evaluating iron parameters 1-2 times per year in patients with chronic heart failure. 1
• If no hemoglobin response or hemoglobin decreases, investigate for occult blood loss and other underlying causes. 1

Common Pitfalls to Avoid

• Do not use oral iron in heart failure patients—it is ineffective and unsupported by evidence. 1, 3
• Do not delay treatment waiting for "optimal" ferritin levels—this patient's transferrin saturation of 7% clearly indicates functional iron deficiency despite ferritin of 170 ng/mL. 1, 3
• Do not administer in an unmonitored setting—hypersensitivity reactions require immediate treatment capability. 2, 6
• Do not confuse the dosing regimens for IDA versus heart failure—they differ significantly. 2