Standing Order for Iron Infusion in Iron Deficiency Anemia
For patients requiring IV iron therapy, use ferric carboxymaltose (Injectafer) or low molecular weight iron dextran as single total-dose infusion formulations, administered at 750-1000 mg per dose, with repeat dosing at least 7 days apart if needed. 1, 2
Pre-Infusion Requirements
Patient Eligibility Confirmation
- Documented iron deficiency anemia with ferritin <45 ng/mL (or <100 ng/mL in inflammatory conditions with low transferrin saturation) 1
- One of the following indications must be present: 1, 3
- Intolerance to oral iron (gastrointestinal side effects)
- Inadequate response to oral iron trial (ferritin levels not improving after 8-10 weeks)
- Malabsorption conditions (inflammatory bowel disease with active inflammation, post-bariatric surgery, celiac disease)
- Severe symptomatic anemia requiring rapid correction
- Chronic kidney disease on erythropoietin therapy
Pre-Infusion Assessment
- Baseline laboratory values: hemoglobin, ferritin, transferrin saturation, serum phosphate 1, 2
- Screen for hypersensitivity risk factors: previous reactions to IV iron, multiple drug allergies, active inflammatory conditions 1
- Verify resuscitation equipment and trained personnel are immediately available 1, 3
Dosing Protocol
For Patients ≥50 kg (Ferric Carboxymaltose/Injectafer)
- 750 mg IV on Day 1, repeat 750 mg IV at Day 7 or later (total 1500 mg per course) 2
- Alternative single-dose option: 1000 mg IV as single infusion (15 mg/kg up to 1000 mg maximum) 2
For Patients <50 kg
- 15 mg/kg body weight IV in two doses separated by at least 7 days 2
Administration Method
- Dilute up to 1000 mg in 250 mL normal saline (minimum concentration 2 mg iron/mL) 2
- Infuse over minimum 15 minutes 2
- Alternative: Undiluted slow IV push at 100 mg per minute for doses ≤750 mg; 1000 mg doses given over 15 minutes 2
Safety Monitoring Protocol
During Infusion
- Monitor vital signs at baseline, 15 minutes, and end of infusion 1
- Watch for signs of complement activation-related pseudo-allergy (CARPA): flushing, chest tightness, back pain, hypotension 1
- Monitor infusion site continuously for extravasation (can cause permanent brown discoloration) 2
Post-Infusion Observation
- Observe patient for 60 minutes after first infusion 1, 3
- Subsequent infusions may require shorter observation if first dose tolerated 1
Management of Infusion Reactions
- For mild CARPA reactions (flushing, mild chest discomfort): slow or pause infusion, administer antihistamine, resume at slower rate 1
- For moderate reactions (hypotension, significant chest pain): stop infusion, IV fluids, antihistamines, corticosteroids 1
- True anaphylaxis is exceedingly rare (<1:200,000) but requires standard anaphylaxis management with epinephrine 1
Follow-Up Requirements
Laboratory Monitoring
- Recheck hemoglobin, ferritin, transferrin saturation at 4-6 weeks post-infusion 1, 3
- Check serum phosphate levels 2-4 weeks post-infusion (ferric carboxymaltose causes hypophosphatemia in 50-74% of patients) 2, 4
- Monitor phosphate levels before any repeat course within 3 months 2
Repeat Dosing Criteria
- May repeat course if iron deficiency recurs (ferritin <100 ng/mL or transferrin saturation <20%) 2
- Minimum 7-day interval between doses within same course 2
- Treat hypophosphatemia before repeat dosing if present 2, 4
Special Populations
Chronic Kidney Disease (Hemodialysis)
- Most hemodialysis patients require regular IV iron maintenance 1
- Target: transferrin saturation >20% and ferritin >100 ng/mL 1
- Maintenance dosing: 25-125 mg weekly after initial repletion 1
Inflammatory Bowel Disease
- IV iron is preferred when active inflammation is present (compromises oral absorption) 1
- Treat underlying inflammation concurrently to enhance iron utilization 1
Post-Bariatric Surgery
- IV iron is recommended for IDA in patients with procedures disrupting duodenal absorption (Roux-en-Y gastric bypass, duodenal switch) 1
Critical Safety Considerations
Contraindications
- Known hypersensitivity to ferric carboxymaltose or any component 2
Important Warnings
- History of allergic reactions to IV iron is NOT an absolute contraindication - most reactions are CARPA, not true allergy 1
- All IV iron formulations carry similar overall risk profiles 1
- Avoid extravasation - causes long-lasting brown skin discoloration 2
- Monitor for hypophosphatemia, especially with ferric carboxymaltose - can cause bone pain, osteomalacia, fractures if severe and prolonged 2, 4