Iron Sucrose Dosing for Iron Deficiency Anemia
The maximum single dose of iron sucrose is 200 mg, administered either as an undiluted IV push over 2-5 minutes or diluted in up to 100 mL of 0.9% normal saline infused over 15-60 minutes, with a maximum weekly dose of 500 mg. 1, 2
Standard Dosing Protocol
Single Dose Administration:
- Maximum 200 mg per individual dose 3, 1, 2
- Administer as undiluted IV push over 2-5 minutes, OR 1, 4
- Dilute in 100 mL of 0.9% normal saline and infuse over 15-60 minutes 1
- For the faster 10-minute bolus administration, 200 mg undiluted is licensed and more convenient than longer infusions 1, 5
Weekly Dosing Limits:
- Do not exceed 500 mg per week 1, 2
- Multiple infusions are required to achieve complete iron repletion, typically requiring 4-7 visits 5
Higher Dose Considerations:
- For doses of 300-500 mg, dilute in a maximum of 250 mL of 0.9% NaCl 1
- Individual doses above 300 mg are not recommended due to increased risk of infusion reactions 2
- Iron sucrose releases more labile free iron than newer formulations, causing unacceptable reactions at doses above 200-250 mg 5
Administration Safety Protocol
Pre-Administration Requirements:
- No test dose is required for iron sucrose (unlike iron dextran) 1, 6
- However, consider a 25 mg test dose over 5 minutes for patients with history of IV iron sensitivities or multiple drug allergies 1, 2
- Ensure resuscitation facilities and trained personnel are immediately available 1
- Have IV epinephrine, diphenhydramine, and corticosteroids readily accessible 1
During Infusion Monitoring:
- Start the infusion slowly for the first 5 minutes to monitor for reactions 1
- Monitor vital signs during and after infusion 1, 2
- Observe patient for 15-60 minutes after administration 1
Absolute Contraindications
Active Infection:
- Do not administer iron sucrose to patients with active bacteremia 1, 2
- Chronic infection alone is not an absolute contraindication if risk/benefit favors treatment 3, 1
- Withhold therapy in ongoing bacteremia but not necessarily in all infections 3
Expected Response and Total Dosing
Clinical Response:
- Hemoglobin should increase by 1-2 g/dL within 4-8 weeks of treatment 5
- Significant hemoglobin increase typically evident after three doses 6
- The median cumulative dose for complete repletion is approximately 1,000 mg (range 100-5,000 mg) 4
Calculation Approach:
- Total iron deficit should be calculated based on patient's weight and hemoglobin deficit 7
- Administer 200 mg weekly until hemoglobin is corrected or total calculated dose is reached 7
Adverse Effects Profile
Common Reactions (Well-Tolerated):
- Hypotension, nausea, vomiting, and diarrhea are most frequently reported 1
- Flushing, abdominal cramps, and arthralgias/myalgias may occur 1
- Hypersensitivity-type reactions occur in approximately 0.5% of patients 3, 1
Metabolic Complications:
- Hypophosphatemia occurs in only 1% of iron sucrose patients (compared to 58% with ferric carboxymaltose) 3, 1, 5
- Monitor serum phosphate in patients receiving long-term or multiple high-dose infusions if risk factors exist 3, 1
Management of Infusion Reactions
Minor Reactions:
- Stop the infusion immediately 1
- Switch to hydration fluid to keep vein open 1
- Most reactions are self-limiting and resolve spontaneously with monitoring 1
- After 15 minutes of symptom resolution, rechallenge may be considered with careful monitoring 1
- If symptoms persist or worsen after 15 minutes, administer IV hydrocortisone 1
Severe Reactions:
- Treat anaphylaxis with IV epinephrine, diphenhydramine, and corticosteroids 1
- Symptoms include dyspnea, wheezing, hypotension, and chest pain 1
Key Clinical Pitfalls to Avoid
- Never exceed 200 mg per single dose in routine practice to minimize anaphylactoid reactions 1, 2
- Never administer during active bacteremia 1, 2
- Do not give test doses routinely as they are not required and delay treatment 1, 6
- Recognize that iron sucrose requires multiple visits (4-7 typically) compared to newer total-dose formulations that can replenish iron stores in 1-2 infusions over 15-40 minutes 3, 5