What is the protocol for ordering IV Venofer (iron sucrose) for a patient at an outpatient facility?

How to Order IV Venofer for Outpatient Administration

Order iron sucrose (Venofer) 200 mg IV, administered either as a slow push over 2-5 minutes undiluted, or diluted in 100 mL of 0.9% NaCl infused over 15 minutes, with resuscitation equipment immediately available. 1

Pre-Administration Requirements

Patient Screening

• Do not administer if the patient has active infection or bacteremia - this is an absolute contraindication 2, 3
• Screen for history of IV iron sensitivities or multiple drug allergies; if present, strongly consider a 25 mg test dose over 5 minutes before proceeding with the full dose 2, 3
• Verify iron deficiency with appropriate labs (ferritin, transferrin saturation) 4

Facility Requirements

• Resuscitation facilities must be available during administration due to potential anaphylaxis risk, though this occurs in only ~0.5% of patients 2
• Ensure capability for vital sign monitoring during and after infusion 2, 3

Dosing Parameters

Maximum Dose Limits

• Single dose maximum: 200 mg 2, 3
• Weekly maximum: 500 mg 2, 3
• Individual doses above 300 mg are not recommended 3

Administration Options (per FDA label)

Option 1 (Preferred for convenience): 200 mg undiluted as slow IV push over 2-5 minutes 1

Option 2: 200 mg diluted in maximum 100 mL of 0.9% NaCl, infused over 15 minutes 1

Administration Protocol

Infusion Monitoring

• Start infusion slowly for the first 5 minutes to monitor for reactions 2
• Monitor vital signs during and after infusion 2, 3
• Common minor reactions include hypotension, flushing, abdominal cramps, and arthralgias 2

Management of Minor Infusion Reactions

If minor reactions occur:

1. Stop the infusion immediately 2
2. Switch to hydration fluid to keep vein open 2
3. Monitor patient - most reactions are self-limiting and resolve spontaneously 2
4. After 15 minutes of symptom resolution, consider rechallenge with careful monitoring 2
5. If symptoms persist or worsen after 15 minutes, administer IV hydrocortisone 2

Severe Reaction Warning Signs

Watch for dyspnea, wheezing, hypotension, or chest pain - these indicate severe reactions requiring immediate intervention 2

Ordering Specifics for Outpatient Facility

Written Order Should Include:

• Drug: Iron sucrose (Venofer) 200 mg IV
• Route: Slow IV push over 2-5 minutes OR diluted in 100 mL 0.9% NaCl over 15 minutes
• Frequency: Not to exceed 500 mg per week 2, 3
• Special instructions: Resuscitation equipment at bedside, vital signs during and post-infusion
• Hold parameters: Active infection present 2, 3

Repeat Dosing Schedule

• For non-dialysis patients: typically 200 mg on 5 different occasions over 14 days (total 1000 mg course) 1
• May repeat entire treatment course if iron deficiency recurs 1
• Recheck iron studies 3-4 weeks after last dose 4

Key Clinical Pitfalls to Avoid

• Never exceed 200 mg per single dose in routine outpatient practice - higher doses increase anaphylactoid reaction risk 2, 3
• Never administer during active infection - defer until infection resolves 2, 3
• Do not confuse with iron dextran - test doses are NOT routinely required for iron sucrose unless patient has prior IV iron sensitivity 2, 3
• Avoid rapid administration - the 2-5 minute push is the minimum time, not a target 1

Special Populations

Cancer Patients

• For cancer patients with iron deficiency anemia, some guidelines recommend lower doses (125 mg weekly for up to 8 doses, max 1000 mg total) 4
• This is particularly relevant for patients on chemotherapy with ongoing blood loss 4

Pediatric Patients (≥2 years)

• Dose: 0.5 mg/kg, not to exceed 100 mg per dose 1
• Can be given undiluted over 5 minutes or diluted to 1-2 mg/mL concentration 1