How to Administer Iron Sucrose
Iron sucrose should be administered as a slow intravenous infusion at a maximum individual dose of 200 mg, given over at least 10-30 minutes, without requiring a test dose. 1
Dosing Protocol
Standard Adult Dosing
- Maximum single dose: 200 mg of elemental iron 1
- Infusion time: Minimum 10 minutes for bolus dosing, though 30 minutes is safer and commonly used 1
- Frequency: Can be administered 2-3 times per week until total iron deficit is corrected 1, 2
- Total induction dose: Typically 1,000-1,200 mg given as divided doses over several weeks 1
Calculating Total Dose Needed
The total iron deficit should be calculated based on the patient's hemoglobin level and body weight, though the evidence does not provide a specific formula. 3, 4 In clinical trials, patients received between 200-1,200 mg total dose depending on severity of anemia. 2, 3
Administration Technique
Preparation and Infusion
- Dilution: 200 mg iron sucrose in 100-150 mL normal saline 5
- Infusion rate: Administer over 10-30 minutes 1, 5
- No test dose required - this is a key safety advantage over iron dextran 1
- Can be given undiluted as IV push over 5 minutes in dialysis settings, though slower infusion is generally preferred 6
Monitoring During Administration
- Resuscitation facilities must be available as anaphylaxis can occur, though rare (approximately 0.5% incidence) 1
- Monitor blood pressure during and after infusion 6
- Observe for infusion reactions: flushing, paresthesias, hypotension 5
- If reactions occur, slow the infusion rate - this typically resolves symptoms 5
Clinical Indications
Iron sucrose is appropriate when:
- Oral iron is not tolerated (GI side effects) 1
- Oral iron is ineffective (malabsorption, inflammation, hepcidin upregulation) 1
- Rapid iron repletion is needed 1
- Patient has chronic kidney disease with iron deficiency anemia 1, 7
- Ongoing blood loss exceeds oral replacement capacity 5
Response Monitoring
Expected Hemoglobin Response
- Significant Hb increase evident after 3 doses (approximately 1-2 weeks) 6
- Mean Hb increase: 3.3-4.6 g/dL after completing therapy 3
- Response rate: 84-94% of patients achieve ≥2 g/dL Hb increase 3
- Time to correction: 31-42 days from first infusion 2
Laboratory Monitoring
- Baseline: Hemoglobin, ferritin, transferrin saturation (TSAT) 1, 3
- Post-treatment assessment at 4 weeks: Expect ferritin increase from ~8-10 ng/mL to ~100-224 ng/mL 3, 4
- TSAT should increase by approximately 7-22% from baseline 1
- Continue monitoring every 4 weeks until Hb normalizes 1
Safety Considerations
Contraindications and Cautions
- Withhold during active bacteremia (though infection is not an absolute contraindication if benefit outweighs risk) 1
- Monitor serum phosphate in patients receiving multiple or high-dose infusions, as hypophosphatemia occurs in ~1% of iron sucrose patients (much lower than ferric carboxymaltose at 58%) 1
- Use caution in patients with known hypersensitivity, though iron sucrose does not require test dosing unlike iron dextran 1
Common Side Effects
- Injection site reactions (mild, self-limited) 2
- Transient taste perversion 2
- Flushing and paresthesias (resolve with slower infusion) 5
- Hypotension (rare, treat with IV fluids) 5
- No serious adverse reactions reported in most clinical series 3, 5, 6
Special Populations
Chronic Kidney Disease Patients
- Iron sucrose is specifically approved for CKD patients with IDA 1
- Can be administered during hemodialysis sessions 6
- Maintenance dosing: 2 mg/kg once or twice monthly after initial repletion 1
Pediatric Patients (Ages 1-16 years)
- Dose: 7 mg/kg (maximum 200 mg per dose) 7
- Administer 2-6 infusions depending on severity 2
- Total doses: 200-1,200 mg over treatment course 2
- Safety profile similar to adults 2
Key Advantages Over Other IV Iron Preparations
- No test dose required (unlike iron dextran) 1
- Lower cost than newer agents (ferric carboxymaltose, iron derisomaltose) 1
- Very low hypophosphatemia risk (1% vs 58% with ferric carboxymaltose) 1
- Extensive safety data spanning over 50 years of use 6
- Can be given in primary care settings safely 5
Common Pitfall to Avoid
Do not exceed 200 mg per individual dose - this is the maximum licensed single dose and exceeding it increases risk of adverse reactions without improving efficacy. 1 Multiple smaller doses are safer and equally effective for total iron repletion.