How should deferoxamine be administered intravenously for acute iron overdose?

Deferoxamine IV Administration for Acute Iron Overdose

For acute iron overdose, administer deferoxamine intravenously ONLY in patients with cardiovascular collapse or shock, using a continuous infusion at a rate not exceeding 15 mg/kg/hr for the first 1000 mg, followed by subsequent doses at no more than 125 mg/hr, with a maximum total dose of 6000 mg in 24 hours. 1

Route Selection Algorithm

Intravenous administration is reserved exclusively for patients in cardiovascular collapse or shock 1. For all other patients, including those with severe toxicity but stable hemodynamics, intramuscular administration is the preferred route 1.

Critical Decision Point:

• Cardiovascular collapse/shock present → IV route mandatory 1
• Stable hemodynamics (even with severe toxicity) → IM route preferred 1

IV Dosing Protocol

Initial Dose Administration

• Start with 1000 mg IV at a rate NOT exceeding 15 mg/kg/hr 1
• This initial infusion rate limit is critical to prevent hypotension, which can occur with rapid IV bolus administration 2

Subsequent Dosing

• Administer 500 mg over 4 hours for two additional doses 1
• Further doses of 500 mg may be given every 4-12 hours based on clinical response 1
• After the initial 1000 mg dose, all subsequent IV dosing MUST NOT exceed 125 mg/hr 1

Maximum Daily Dose

• Total dose must not exceed 6000 mg in 24 hours 1

Preparation and Reconstitution

For IV Administration:

• Reconstitute with sterile water for injection: 1
  • 500 mg vial: Add 5 mL sterile water (final concentration 95 mg/mL)
  • 2 gram vial: Add 20 mL sterile water (final concentration 95 mg/mL)
• Add reconstituted solution to physiologic saline (0.9% or 0.45% sodium chloride), glucose in water, or Ringer's lactate 1
• Use immediately after reconstitution (within 3 hours) 1
• If prepared under validated aseptic conditions, may store at room temperature for maximum 24 hours 1

Transition Strategy

As soon as the patient's cardiovascular status stabilizes, discontinue IV administration and switch to intramuscular route 1. This transition is essential because:

• IV administration carries higher risk of pulmonary toxicity with prolonged use 3
• IM route is safer for extended chelation therapy 1

Monitoring During IV Therapy

Essential Parameters:

• Blood pressure continuously during infusion (risk of hypotension with rapid administration) 2
• Serum iron concentrations serially (expect significant decrease within 8-9 hours of therapy) 4
• Urine color for "vin rosé" appearance (indicates ferrioxamine excretion) 4
• Clinical signs of iron toxicity improvement (mental status, hemodynamic stability, metabolic acidosis) 4, 5

Critical Safety Considerations

Infusion Rate Warnings:

The two-tiered rate restriction is non-negotiable: 1

1. First 1000 mg: ≤15 mg/kg/hr maximum
2. All subsequent doses: ≤125 mg/hr maximum

Exceeding these rates significantly increases risk of: 2, 3

• Acute hypotension
• Cardiovascular collapse
• Acute respiratory distress syndrome (ARDS)

Duration Limitations:

• Prolonged IV infusion (>24-48 hours) increases pulmonary toxicity risk 3
• ARDS has been reported with excessively high IV doses 6
• Transition to IM route as soon as hemodynamically stable 1

Common Pitfalls to Avoid

Dosing Errors:

• Never administer as rapid IV bolus (causes hypotension) 2
• Never exceed 6000 mg/24 hours (increases toxicity without additional benefit) 1
• Never continue IV route when patient stabilizes (unnecessary pulmonary risk) 1, 3

Route Selection Errors:

• Never use IV route in hemodynamically stable patients (IM is safer and equally effective) 1
• Never delay chelation waiting for IV access in stable patients (give IM immediately) 1

Monitoring Failures:

• Never assume clinical improvement means adequate chelation (continue until urine clears and serum iron normalizes) 4
• Never discontinue prematurely based on single serum iron level (requires sustained normalization) 4

Special Considerations

Severe Overdose Management:

In cases with extremely elevated serum iron (>2000 mcg/dL) and life-threatening toxicity, consider adjunctive hemodialysis in addition to deferoxamine to rapidly decrease serum iron concentrations 5. However, deferoxamine remains the primary antidote 5.

Infection Risk:

Monitor for Yersinia and Klebsiella infections during therapy, as deferoxamine increases susceptibility to these organisms 6, 2.