Can a patient receive iron and epoetin alfa (Procrit) on the same day?

Can Iron and Procrit Be Given on the Same Day?

Yes, iron and Procrit (epoetin alfa) can and should be administered on the same day, as iron supplementation is essential to support the erythropoietic response to ESA therapy. 1

Rationale for Concurrent Administration

The majority of patients with chronic kidney disease will require supplemental iron during the course of ESA therapy, as erythropoiesis requires both iron and erythropoietin. 1, 2 Iron absorption is increased as erythropoiesis increases with epoetin therapy, and iron needed for new hemoglobin production may outstrip available body iron stores during acute correction of anemia. 1, 3

Route-Specific Considerations

Intravenous Iron with ESAs

• IV iron is the preferred route for hemodialysis patients and may be appropriate for some peritoneal dialysis and non-dialysis CKD patients. 1
• IV iron supplementation (total doses in the range of 1000 mg) significantly improved the hematological response to ESA treatment versus ESA alone in controlled clinical trials. 1
• IV iron should either be given before or after administration of chemotherapy or at the end of a treatment cycle in cancer patients receiving cardiotoxic chemotherapy. 1
• No increased risk of infection or cardiovascular morbidity has been observed with IV iron when given with ESAs. 1

Oral Iron with ESAs

• When oral iron is used, it should be given as 200 mg of elemental iron per day in 2 to 3 divided doses in adults. 1
• Oral iron is best absorbed when ingested without food or other medications. 1
• In cancer patients, oral iron did not result in better outcomes compared with no iron at all, whereas IV iron benefits were substantial. 1
• In non-iron-deficient orthopedic surgery patients, there was comparable erythropoietic response to epoetin alfa irrespective of the route of iron administration (oral vs IV). 4

Timing and Administration Protocol

For Hemodialysis Patients

• The recommended frequency of maintenance IV iron therapy can be thrice weekly (with every hemodialysis), twice weekly, weekly, or every other week, providing 250 to 1,000 mg of iron within 12 weeks. 1
• No more than 100 mg per dose of iron dextran IV should be given to in-center hemodialysis patients to minimize dose-related arthralgias and myalgias. 1

For Surgery Patients

• All patients in orthopedic surgery studies received oral iron along with epoetin alfa (300-600 Units/kg) administered subcutaneously for 10 days before surgery, on the day of surgery, and for 4 days after surgery. 5

Monitoring Requirements

• Iron status during the maintenance phase of epoetin treatment should be monitored by measuring transferrin saturation (TSAT) and serum ferritin every 3 months. 1
• Intravenous iron is typically required to achieve and maintain adequate iron stores in CKD patients receiving ESAs. 2
• Markers of iron status that may indicate a need for IV iron include serum ferritin <100 µg/L, TSAT <20%, and percentage of hypochromic red cells >10%. 6

Safety Considerations

• Patients should be observed closely for symptoms of hypersensitivity reactions for at least 30 minutes following each IV iron administration. 1
• IV iron should not be given to patients with an active infection. 1
• Care should be taken to prevent serum ferritin rising above 800-1000 µg/L and TSAT above 50%. 6
• Concomitant administration of IV iron and cardiotoxic chemotherapy should be avoided in cancer patients. 1

Common Pitfalls to Avoid

• Failure to provide adequate iron supplementation during ESA therapy can convert the anemia of chronic renal failure to iron deficiency anemia, impairing ESA efficacy. 3
• Measuring transferrin saturation and serum ferritin may be inaccurate if performed within 14 days of receiving a single dose of 1 gram or more of iron intravenously. 1
• When food is eaten within 2 hours before or 1 hour after an oral iron supplement, food will reduce iron absorption by as much as one half. 1