Can IV Iron Be Given to Patients with PVD and Anemia?
Yes, intravenous iron can be safely administered to patients with peripheral vascular disease (PVD) and iron deficiency anemia—there are no specific contraindications related to PVD itself for IV iron therapy. The decision to use IV iron should be based on standard indications for iron deficiency anemia treatment, not on the presence of PVD 1.
Key Indications for IV Iron in This Population
IV iron should be considered first-line therapy when:
- Hemoglobin is below 10 g/dL (100 g/L) 1
- Previous intolerance to oral iron exists 1
- Oral iron has failed to improve ferritin levels after an adequate trial 1
- Active inflammation is present (which may impair oral iron absorption) 1
- Rapid correction of iron deficit is required 2, 3
The 2024 AGA guidelines emphasize that IV iron should be used when patients have conditions where oral iron is unlikely to be absorbed or when oral iron is not tolerated 1. This is particularly relevant for patients with PVD who may have comorbid inflammatory conditions or chronic disease states.
Practical Dosing Approach
Use weight and hemoglobin-based dosing:
For patients with hemoglobin 10-12 g/dL (women) or 10-13 g/dL (men):
- Body weight <70 kg: 1000 mg total
- Body weight ≥70 kg: 1500 mg total 1
For patients with hemoglobin 7-10 g/dL:
- Body weight <70 kg: 1500 mg total
- Body weight ≥70 kg: 2000 mg total 1
Prefer formulations allowing 1-2 total dose infusions (ferric carboxymaltose, ferric derisomaltose, low-molecular-weight iron dextran, or ferumoxytol) over those requiring multiple visits 1, 4.
Safety Considerations Specific to IV Iron
The primary safety concerns are NOT related to PVD but to the infusion itself:
- True anaphylaxis is exceedingly rare (<1:200,000 administrations) 1, 4
- Most reactions are complement activation-related pseudo-allergy (CARPA), which resolve without intervention 1, 4
- Avoid iron dextran preparations that require test doses due to higher anaphylactic risk; modern formulations do not require test dosing 1
- Monitor for hypophosphatemia, particularly with ferric carboxymaltose, which can affect 50-74% of patients 2, 5
Important Caveats
Do not exceed these upper safety limits:
- Transferrin saturation >50%
- Serum ferritin >800 μg/L 1
Ensure stable IV access to avoid extravasation, which can cause injection site discoloration 6. This is particularly important in patients with PVD who may have compromised peripheral vasculature.
Monitor response appropriately:
- Expect hemoglobin increase of at least 2 g/dL within 4 weeks 1
- Recheck iron studies 2-7 days after last dose (not within 14 days if single dose ≥1000 mg was given) 1
When to Choose Oral vs. IV Iron
Oral iron may be acceptable only if:
- Anemia is mild (Hgb 11.0-11.9 g/dL in women, 11.0-12.9 g/dL in men)
- No active inflammation present
- No prior oral iron intolerance
- Patient can tolerate waiting 8-12 weeks for correction 1
Otherwise, IV iron is superior with faster response, better tolerability, and higher efficacy 1.
The presence of PVD does not alter these treatment algorithms—focus on the severity of anemia, presence of inflammation, and prior response to oral iron when making treatment decisions 1.