What is the recommended dose of Desferoxamine (Deferoxamine) for a patient with iron overload?

Deferoxamine Dosing for Iron Overload

For chronic iron overload from transfusion-dependent conditions like β-thalassemia, administer deferoxamine subcutaneously at 20-50 mg/kg/day via continuous infusion over 8-12 hours for 5-7 days per week, with a typical daily dose of 1000-2000 mg (not exceeding 60 mg/kg/day in adults or 40 mg/kg/day in children). 1, 2

Dosing by Clinical Context

Chronic Transfusional Iron Overload (Standard Maintenance)

• Subcutaneous route (preferred): 20-40 mg/kg/day administered over 8-24 hours using a portable infusion pump 1, 2
• Typical adult dose: 40-50 mg/kg/day over 8-12 hours for 5-7 days per week 1
• Pediatric dose: Should not exceed 40 mg/kg/day on average until growth has ceased 2
• Maximum adult dose: Do not exceed 60 mg/kg/day on average 2
• Infusion duration: 8-12 hours is standard, though some patients may require up to 24 hours depending on individual iron excretion patterns 2

Cardiac Iron Overload (Intensive Chelation)

• Continuous intravenous infusion: When intensive chelation is needed for cardiac siderosis, deferoxamine can be given as continuous IV infusion 1
• Cardiac iron clearance: Continuously administered deferoxamine clears cardiac iron at nearly 5% per month, compared to only 1.1-2.2% per month with standard intermittent subcutaneous infusions 1
• Combination therapy for severe cardiac disease: For patients with depressed left ventricular ejection fraction and severe cardiac iron, combine subcutaneous deferoxamine with oral deferiprone 75 mg/kg/day for 7 days per week 1
• Intravenous rate limit: The infusion rate should not exceed 15 mg/kg/hour 2

Acute Iron Toxicity

• Intramuscular route (preferred for stable patients): Initial dose of 1000 mg, followed by 500 mg every 4 hours for two doses, then 500 mg every 4-12 hours as needed 2
• Intravenous route (only for cardiovascular collapse): Initial dose of 1000 mg at a rate NOT exceeding 15 mg/kg/hr, followed by 500 mg over 4 hours for two doses 2
• Maximum daily dose: Do not exceed 6000 mg in 24 hours 2
• Transition: Switch from IV to IM administration as soon as the patient's clinical condition permits 2

Alternative Dosing Strategies

Bolus Injection Method

• Subcutaneous bolus: Twice-daily subcutaneous bolus injections achieve similar urinary iron excretion as 12-hour continuous infusions 3
• Patient preference: 96.3% of patients chose to continue with bolus injection over continuous infusion due to convenience 3
• Efficacy: Ferritin decreased to below 1000 μg/L in 73% of patients and normalized in 26% over 20 months of follow-up 3

Hemodialysis Patients

• Weekly dosing: 2 grams administered intravenously during the last hour of dialysis session once weekly 4
• Dual benefit: This regimen chelates both aluminum and excessive iron, with mean serum ferritin decreasing from 1,563 μg/L to 487 μg/L within 2 years 4

Monitoring Requirements

• Ophthalmologic and audiological testing: Perform baseline and annual examinations due to risk of sensorineural deafness and visual disturbances 1, 5
• Growth monitoring: Essential in pediatric patients, as skeletal abnormalities and growth retardation can occur, particularly when doses are high relative to iron burden 1, 5
• Infection surveillance: Watch for Yersinia and Klebsiella infections, which have been reported in deferoxamine-treated patients 1, 5
• Renal function: Monitor for renal toxicity, especially after high intravenous doses 1
• Target ferritin: Aim for serum ferritin <1000 ng/mL, with chelation continuing until ferritin reaches 50-100 μg/L in hereditary hemochromatosis 1, 6

Critical Clinical Pitfalls

Avoid excessive dosing relative to iron burden: Serious adverse events (ophthalmologic, audiological, skeletal abnormalities) occur particularly when deferoxamine doses are high relative to the patient's actual iron burden 1, 5. This is especially critical in pediatric patients where growth retardation can occur.

Do not exceed infusion rate limits: For IV administration, never exceed 15 mg/kg/hr for the first 1000 mg, and subsequent dosing must not exceed 125 mg/hr to avoid acute respiratory distress syndrome 2.

Recognize deferoxamine's limitations for cardiac iron: Standard intermittent subcutaneous deferoxamine is relatively ineffective for cardiac iron clearance compared to continuous administration or deferiprone 1. For patients with cardiac T2* <20 ms or established heart failure, deferiprone at 75-100 mg/kg/day is superior 1, 7.

Avoid vitamin C supplementation: Pharmacological doses of vitamin C accelerate iron mobilization to levels that may saturate transferrin, resulting in increased pro-oxidant activity and risk of sudden death in patients with cardiac involvement 1.

Poor compliance undermines efficacy: The short 20-30 minute half-life of deferoxamine means labile iron rebounds quickly when infusions are stopped, so anything short of excellent compliance places the heart at risk 1. Consider switching to oral agents (deferasirox or deferiprone) if compliance is poor 1.