What is the proper administration protocol for iron sucrose in patients with iron deficiency, including those with chronic kidney disease or a history of hypersensitivity reactions?

How to Administer Iron Sucrose

Iron sucrose should be administered intravenously at a maximum single dose of 200 mg, either as a slow IV push over 2-5 minutes or as an infusion over 15-30 minutes, with no test dose required, and resuscitation equipment must be immediately available. 1, 2

Dosing Parameters

Maximum Dose Limits

• Maximum single dose: 200 mg 1, 3
• Maximum weekly dose: 500 mg 1, 3
• Concentration: 20 mg elemental iron per mL 2

Administration Methods

Two FDA-approved routes exist:

1. Slow IV push (undiluted):

   • Administer 100-200 mg over 2-5 minutes 2
   • Most practical and time-efficient method 4
   • Bolus administration over 2 minutes has been safely used in 2,297 injections with 97.5% proceeding uneventfully 4

2. IV infusion (diluted):

   • Dilute 100-200 mg in maximum 100 mL of 0.9% NaCl 2
   • Infuse over minimum 15-30 minutes 1, 2
   • For higher doses (300-500 mg), dilute in maximum 250 mL of 0.9% NaCl and infuse over 1.5-4 hours 2

Population-Specific Protocols

Hemodialysis Patients (HDD-CKD)

• Standard dose: 100 mg per dialysis session 2
• Administer early during dialysis (within first hour) 2
• Give undiluted over 2-5 minutes or diluted in 100 mL 0.9% NaCl over 15 minutes 2
• Total treatment course: 1000 mg 2

Non-Dialysis CKD Patients (NDD-CKD)

• Standard dose: 200 mg per administration 2
• Give on 5 different occasions over 14-day period 2
• Alternative: 500 mg diluted in 250 mL 0.9% NaCl over 3.5-4 hours on Day 1 and Day 14 (limited experience) 2

Peritoneal Dialysis Patients (PDD-CKD)

• Three divided doses over 28 days: 2
  • Two infusions of 300 mg over 1.5 hours (14 days apart)
  • One infusion of 400 mg over 2.5 hours (14 days after second dose)
• Dilute in maximum 250 mL 0.9% NaCl 2

Pediatric Patients (≥2 years)

• Maintenance dose: 0.5 mg/kg (maximum 100 mg per dose) 2
• HDD-CKD: Every 2 weeks for 12 weeks 2
• NDD-CKD or PDD-CKD on erythropoietin: Every 4 weeks for 12 weeks 2
• Administer undiluted over 5 minutes or diluted to 1-2 mg/mL concentration over 5-60 minutes 2
• Do not dilute below 1 mg/mL 2

Safety Protocols

Test Dose Requirements

No test dose is required for iron sucrose 3, 5, 6

• This distinguishes iron sucrose from iron dextran, which requires a 25 mg test dose 1
• However, consider a 25 mg test dose in patients with history of IV iron sensitivities or multiple drug allergies 3, 5

Contraindications

Absolute contraindication: Active bacteremia 3, 5

• Withhold during active infection, particularly bacteremia 3
• Chronic infection alone is not an absolute contraindication if risk/benefit favors treatment 3

Emergency Preparedness

Must have immediately available: 1

• Personnel trained in emergency treatment
• IV epinephrine
• Diphenhydramine
• Corticosteroids (hydrocortisone)
• Resuscitation equipment 3

Monitoring During Administration

• Monitor vital signs during and after infusion 3, 5
• Start infusion slowly for first 5 minutes to assess for reactions 3
• Observe patient for 15-60 minutes after administration 1

Adverse Event Management

Common Side Effects (Not Requiring Intervention)

• Metallic taste: 17.9% of injections 4
  • Mild and transient
  • Does not require stopping infusion 4
• Hypotension, nausea, vomiting, diarrhea 3

Minor Infusion Reactions

Management algorithm: 3

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

Serious Reactions

Anaphylaxis risk: Exceedingly rare (<1:200,000 administrations) 5

• Symptoms include dyspnea, wheezing, hypotension, chest pain 3
• Seven anaphylactoid reactions occurred in 2,297 injections (0.3%), all resolved within 30 minutes without hospitalization 4
• Treat with IV epinephrine, diphenhydramine, and corticosteroids 1

Critical Clinical Pitfalls

Dosing Errors to Avoid

• Never exceed 200 mg single dose to minimize anaphylactoid reactions 1, 3
• Never exceed 500 mg weekly dose 1, 3
• Do not dilute pediatric doses below 1 mg/mL concentration 2

Metabolic Complications

• Hypophosphatemia occurs in approximately 1% of iron sucrose patients (compared to 58% with ferric carboxymaltose) 3
• Monitor serum phosphate in patients receiving long-term or multiple high-dose infusions 3

Laboratory Monitoring Pitfall

• Do not evaluate iron parameters within 4 weeks after administration as circulating iron interferes with assay results 5
• Transferrin and ferritin can be reliably measured 48 hours after IV administration 6

Practical Advantages

Iron sucrose offers several clinical benefits:

• No black-box warning 6
• Significantly lower incidence of serious adverse effects compared to iron dextran 3, 6
• Can be safely administered to patients with previous intolerance to iron dextran or iron gluconate 6
• Rapid administration (2-minute push) results in considerable time and cost savings 4
• Terminal half-life of 5-6 hours with distribution into plasma volume 6

Comparison with Other Formulations

Iron sucrose requires multiple visits (4-7) for complete iron repletion 7, whereas newer formulations like ferric carboxymaltose allow 750-1000 mg in single 15-minute infusion 7, 8. However, iron sucrose has the lowest hypophosphatemia risk (1%) among IV iron preparations 3 and maintains an excellent long-term safety profile established over five decades of use 6.