Intravenous Iron Is the Treatment of Choice When Oral Iron Cannot Be Taken
When a patient cannot tolerate oral iron due to severe gastrointestinal intolerance, malabsorption, or allergy, intravenous iron formulations are the preferred treatment for iron-deficiency anemia. 1
First-Line IV Iron Recommendation
Use high-dose IV iron formulations that can replace the entire iron deficit in 1 or 2 infusions, such as ferric carboxymaltose (Injectafer) or ferric derisomaltose, rather than formulations requiring multiple visits. 1
For patients ≥50 kg with iron-deficiency anemia, administer ferric carboxymaltose 750 mg IV on day 1 and day 7–14 (total 1,500 mg per course), or as a single 1,000 mg dose if clinically appropriate. 2
For patients <50 kg, dose ferric carboxymaltose at 15 mg/kg body weight IV in two doses separated by at least 7 days. 2
IV iron produces a clinically meaningful hemoglobin rise within one week, making it superior to oral iron in speed of response and should be considered an alternative to blood transfusion in most cases. 3, 4
Specific Clinical Indications for IV Iron
Malabsorption Syndromes
Mandatory use of IV iron in patients with inflammatory bowel disease and active inflammation, as oral iron absorption is severely compromised and may worsen disease activity. 1
Post-bariatric surgery patients (especially procedures disrupting duodenal absorption) require IV iron when iron-deficiency anemia develops without an identifiable source of chronic GI blood loss. 1
Celiac disease patients should first ensure strict adherence to a gluten-free diet; if iron stores do not improve with oral supplementation, switch to IV iron. 1
Chronic Kidney Disease
- IV iron is indicated for non-dialysis-dependent chronic kidney disease patients with iron-deficiency anemia who cannot tolerate or do not respond to oral iron. 2
Heart Failure
- For iron deficiency with heart failure (NYHA class II/III), IV iron improves exercise capacity even in the absence of anemia; dosing is based on body weight and hemoglobin level (see Table 1 in FDA label). 2
Safety Profile of IV Iron
All IV iron formulations have similar safety profiles; true anaphylaxis is very rare. 1
The vast majority of reactions are complement activation–related pseudo-allergy (infusion reactions), not true anaphylaxis, and should be managed accordingly with antihistamines and corticosteroids rather than epinephrine. 1
Patients must be monitored for at least 30 minutes after infusion for signs of hypersensitivity (rash, itching, dizziness, dyspnea, hypotension). 2
Hypophosphatemia is a recognized adverse effect, particularly with repeat courses; check serum phosphate levels before repeat treatment in at-risk patients or if repeat dosing occurs within 3 months. 1, 2
Alternative IV Iron Formulations
Iron dextran, ferric gluconate, and iron sucrose are older formulations that typically require multiple infusions (>2 doses) and are less preferred due to inconvenience. 5, 6
Iron dextran carries a higher historical risk of anaphylaxis compared to newer non-dextran formulations, though modern low-molecular-weight iron dextran is safer than older high-molecular-weight preparations. 5, 4
Monitoring Response to IV Iron
Expect hemoglobin to rise by approximately 1 g/dL within 1–2 weeks of IV iron administration. 3, 7
Continue monitoring hemoglobin every 4 weeks until normalization, then check every 6 months during the first year to detect recurrence. 3
Repeat IV iron courses are safe if iron-deficiency anemia recurs, but always check serum phosphate before retreatment. 2
Common Pitfalls to Avoid
Do not delay IV iron in favor of prolonged oral iron trials when malabsorption or intolerance is evident; early oral non-responders have only a 21% chance of later response with continued oral iron versus 65% with IV iron. 3
Do not assume all IV iron reactions are anaphylaxis; most are infusion reactions that do not contraindicate future IV iron use with appropriate premedication and slower infusion rates. 1
Do not use total-dose infusion of older iron dextran formulations due to higher adverse reaction rates (up to 25% in some series); modern high-dose single-vial formulations like ferric carboxymaltose are safer. 8, 4
Avoid red blood cell transfusion as first-line therapy for iron-deficiency anemia when IV iron can achieve similar hemoglobin correction within 1–2 weeks without transfusion risks. 3, 4