What is the recommended dose and administration schedule of intravenous iron sucrose for adults with iron‑deficiency anemia (including chronic kidney disease, inflammatory bowel disease, heavy menstrual loss, pregnancy, and dialysis patients) and for pediatric patients?

Iron Sucrose Dosing for Iron Deficiency Anemia

For adult patients with iron deficiency anemia, administer iron sucrose 200 mg intravenously over 10 minutes (or 2-minute push), given 2-3 times weekly until a total cumulative dose of 1000-1200 mg is reached during the induction phase. 1, 2

Standard Adult Dosing Protocol

Induction Phase

• Administer 200 mg per infusion as an IV push over 10 minutes without dilution 2
• Give doses 2-3 times weekly until total cumulative dose of 1000-1200 mg is achieved 1
• Alternative regimen: 100-300 mg weekly for total dose of 1-1.2 g 1
• No test dose is required (unlike iron dextran which mandates a 25 mg test dose) 1, 2
• Maximum single dose is typically 200 mg per infusion 1

Total Dose Calculation Based on Clinical Parameters

• Patients with hemoglobin 10-12 g/dL (women) or 10-13 g/dL (men) and ≥70 kg body weight: 1500 mg total dose 1
• Patients with hemoglobin 7-10 g/dL and ≥70 kg body weight: 2000 mg total dose 1

Maintenance Therapy

• For dialysis patients: 2 mg/kg once or twice per month 1
• For hemodialysis patients: 100 mg per dialysis session, typically 3 times weekly 2

Special Population Dosing

Chronic Kidney Disease (Hemodialysis Patients)

• Administer 100 mg undiluted as IV push over 5 minutes for 10 consecutive hemodialysis sessions (total 1000 mg) 3, 4
• Can be given directly into the hemodialysis line 2
• Alternative: 100-200 mg administered 2-3 times weekly 2
• Maintenance: 100 mg weekly after achieving iron repletion 5

Pediatric Patients

Weight-based dosing for children with chronic kidney disease: 2

• <10 kg: 25 mg per dose
• 10-20 kg: 50 mg per dose
• >20 kg: 100 mg per dose

For general pediatric IDA (ages 1.2-14 years):

• Individual doses: 100-200 mg (median 200 mg) 6
• Total doses: 200-1200 mg (median 400 mg) 6
• Administer on alternate days up to 3 times per week 6
• Number of infusions: 2-6 (median 3) 6
• Iron sucrose is FDA-approved for children from 2 years of age in the USA 1

Inflammatory Bowel Disease

• Single doses up to 7 mg/kg (not exceeding 500 mg) have been studied, administered over 3.5 hours 2
• Intravenous iron should be first-line treatment in patients with clinically active IBD, previous intolerance to oral iron, or hemoglobin below 10 g/dL 1

Pregnancy and Postpartum

• Standard adult dosing applies (second and third trimester only) 7
• 200 mg per infusion, 2-3 times weekly until total dose achieved 1

Administration Technique

Rapid Push Method (Most Practical)

• 200 mg can be administered as a 2-minute IV push in CKD patients 8
• This method was safe in 2,297 injections across 657 patients 8
• Saves considerable time and cost compared to traditional infusion 8
• Most common side effect: transient metallic taste in 17.9% of injections (mild, not distressing) 8

Standard Method

• 200 mg IV push over 10 minutes without dilution 2
• Alternatively, dilute in normal saline and infuse over 30 minutes minimum 1

Monitoring Parameters

Before Treatment

• Confirm iron deficiency: transferrin saturation (TSAT) <20% and ferritin <100 ng/mL 1
• In inflammatory conditions, use ferritin <100 ng/mL threshold (higher cutoff due to acute phase reactant effect) 1

During Treatment

• Monitor hemoglobin at baseline and periodically during treatment 2
• Expected response: hemoglobin increase of at least 2 g/dL within 4 weeks 1
• First hemoglobin increase evident after 3 doses of iron sucrose 4

After Treatment

• Wait at least 7 days after 200 mg doses before checking iron parameters for accurate assessment 2
• Do not evaluate iron parameters within first 4 weeks after administration (circulating iron interferes with assay results) 1
• Follow-up monitoring at 3-month intervals for first year after hemoglobin normalization 2
• Check iron parameters (ferritin, TSAT) at least every 3 months in patients receiving IV iron 2

Target Parameters

• TSAT ≥20% and serum ferritin ≥100 ng/mL 3, 1
• Hemoglobin 11-12 g/dL 3
• Avoid iron overload: maintain TSAT <50% and ferritin <800 ng/mL 3, 1
• Preferably keep ferritin ≤500 μg/L to avoid toxicity 2

Safety Profile and Adverse Events

Anaphylaxis Risk

• Exceedingly rare: <1:200,000 administrations 1, 2
• Significantly safer than iron dextran (which has boxed FDA warning) 9
• No test dose required 1, 2

Common Side Effects

• Transient metallic taste (17.9% of injections, mild) 8
• Arthralgia and hypotension 2
• Injection site reactions 2
• Pain during or after injection 8

Serious Adverse Events

• In 2,297 injections, only 7 acute anaphylactoid reactions occurred (0.3%) 8
• All resolved completely within 30 minutes with no sequelae or hospitalization 8
• No serious or life-threatening drug-related adverse events in 8,583 doses across 665 hemodialysis patients 5

Contraindications

• Active infection or bacteremia is an absolute contraindication 2
• History of anaphylaxis to iron sucrose 9

Clinical Pearls and Pitfalls

When to Use IV Iron Sucrose

• First-line in clinically active IBD, previous oral iron intolerance, hemoglobin <10 g/dL, or need for erythropoiesis-stimulating agents 1
• Oral iron may be used in mild anemia with clinically inactive disease and no previous oral iron intolerance 1

Avoiding Common Errors

• Do not check iron parameters too early after dosing (wait 7 days minimum after 200 mg doses, 4 weeks after completing course) 1, 2
• Do not withhold iron in chronically bleeding patients (e.g., IBD) due to overload concerns (risk intrinsically low) 1
• Ensure resuscitation facilities are available during administration despite low risk 2
• Administration should be performed by healthcare professionals trained in managing infusion reactions 2

Optimizing Erythropoiesis

• In hemodialysis patients with TSAT ≥20% and ferritin ≥100 ng/mL but hemoglobin <11 g/dL or requiring high erythropoietin doses, give 1000 mg IV iron over 8-10 weeks and observe response 3
• If hemoglobin increases or erythropoietin requirement decreases, repeat 1000 mg course to achieve target hemoglobin 11-12 g/dL 3
• Patients unlikely to respond further if TSAT increases to 50% or ferritin increases to 800 ng/mL 3