Contraindications to Intravenous Iron
The absolute contraindications to IV iron are: known hypersensitivity to the active iron compound or its excipients, known serious hypersensitivity to other parenteral iron products, anemia not caused by iron deficiency, and evidence of iron overload or disturbances in iron utilization. 1, 2
Absolute Contraindications
Known hypersensitivity to the specific IV iron formulation (e.g., ferric carboxymaltose, iron sucrose) or any of its excipients 1, 2
Previous serious hypersensitivity reaction to any parenteral iron product 1
Anemia not attributed to iron deficiency (e.g., other microcytic anemias such as thalassemia or sideroblastic anemia) 1
Evidence of iron overload or disturbances in iron utilization (e.g., hemochromatosis, elevated ferritin with normal/high transferrin saturation suggesting iron overload rather than deficiency) 1, 2
High-Risk Situations Requiring Extreme Caution or Avoidance
Active Infection and Bacteremia
Treatment must be stopped in patients with ongoing bacteremia 1, 3
IV iron should be avoided during active infection and neutropenia due to a 26% increased risk of infection (RR 1.26,95% CI 1.09-1.44) 4
Use with extreme caution in patients with acute or chronic infection, and only after careful risk-benefit assessment by the treating physician 1
Severe Allergic History
Patients with multiple drug allergies, severe asthma, eczema, or other atopic allergies are at significantly increased risk of hypersensitivity reactions 1, 5, 6
Patients with immune or inflammatory conditions (systemic lupus erythematosus, rheumatoid arthritis) have increased risk of hypersensitivity reactions to parenteral iron 1
High-molecular weight iron dextran should be avoided entirely due to higher anaphylaxis risk; use low-molecular weight iron dextran, ferric carboxymaltose, ferric derisomaltose, or iron sucrose instead 7, 4
Concurrent Cardiotoxic Chemotherapy
Never administer IV iron on the same day as anthracyclines or other cardiotoxic chemotherapy due to theoretical risk of potentiating cardiotoxicity 7
Administer IV iron either before chemotherapy, after chemotherapy, or at the end of a treatment cycle—never concurrently 7
Situations Where Safety/Efficacy Not Established
Hemoglobin levels >15 g/dL: efficacy and safety of IV iron have not been evaluated in this population 1
Early pregnancy: considered a contraindication to iron infusions due to lack of safety data 6
Heart failure with preserved ejection fraction (HFpEF, LVEF ≥50%): no clinical evidence for IV iron in this population 1
Critical Safety Requirements for All IV Iron Administration
Mandatory Infrastructure
Only administer when personnel trained to evaluate and manage anaphylactic reactions are immediately available 1, 4, 3, 2
Resuscitation facilities must be immediately available at the administration site 1, 4, 3, 2
Monitoring Requirements
Observe patients for at least 30 minutes following each IV iron administration for hypersensitivity reactions 1, 7, 3, 2
Monitor vital signs during the first 10 minutes, as immediate infusion reactions occur during the first minute 1
Initiate infusion at slow rate, as slower infusion rates are associated with lower infusion reaction rates 1
Common Pitfalls to Avoid
Do not confuse functional iron deficiency with iron overload: patients with high ferritin (>800 ng/mL) but low TSAT may have inflammation rather than true iron deficiency 7
Do not perform serum iron measurements for at least 48 hours after IV dosing, as transferrin saturation values increase rapidly after IV iron administration 2
Do not use IV iron in patients with Porphyria Cutanea Tarda, as iron overload worsens this condition by disrupting uroporphyrinogen decarboxylase activity 3
Avoid high-molecular weight iron dextran formulations due to significantly higher rates of severe anaphylactoid reactions compared to non-dextran formulations 4, 6