How does a physician write an order for intravenous (IV) iron replacement therapy?

From the Guidelines

A doctor writes an iron infusion order by specifying the type of iron preparation, dosage, administration rate, and monitoring parameters, with the most recent guidelines suggesting the use of formulations that can replace iron deficits with 1 or 2 infusions, such as ferric carboxymaltose or iron sucrose, as stated in the 2024 study by the American Gastroenterological Association 1.

Key Components of an Iron Infusion Order

• Type of iron preparation: iron sucrose (Venofer), ferric carboxymaltose (Injectafer), or iron dextran (INFeD)
• Dosage: calculated based on the patient's weight and hemoglobin deficit, with typical doses ranging from 200mg to 1000mg
• Administration rate: infusion over 15-60 minutes, with slower rates associated with lower infusion reactions 1
• Monitoring parameters: vital sign monitoring, observation for adverse reactions, and parameters for stopping the infusion if necessary

Administration Guidelines

• Initiate iron infusion at a slow rate, with observation during the first 10 minutes for immediate infusion reactions 1
• Assess risk of reaction, with high-risk patients requiring closer monitoring and potential pre-medication
• Educate patients on management of delayed reactions, such as flu-like symptoms, arthralgias, and myalgias, with NSAIDs

Indications for Iron Infusion

• Oral iron is ineffective, poorly tolerated, or not likely to be absorbed due to certain medical conditions, as stated in the 2024 study by the American Gastroenterological Association 1
• Rapid correction of iron deficiency is needed, with IV iron bypassing limited intestinal absorption and more effectively replenishing iron stores
• Conditions such as active inflammatory bowel disease, impaired absorption, or excessive iron loss may require IV iron supplementation, as noted in the 2024 study by the Clinical Gastroenterology and Hepatology journal 1

From the FDA Drug Label

The recommended adult dosage is 10 mL (125 mg of elemental iron) diluted in 100 mL of 0.9% sodium chloride administered by intravenous infusion over 1 hour per dialysis session or undiluted as a slow intravenous injection (at a rate of up to 12.5 mg/min) per dialysis session. The recommended pediatric dosage is 0.12 mL/kg (1. 5 mg/kg of elemental iron) diluted in 25 mL 0.9% sodium chloride and administered by intravenous infusion over 1 hour per dialysis session.

To write an order for an iron infusion, a doctor should specify the following:

• Dosage: 10 mL (125 mg of elemental iron) for adults or 0.12 mL/kg (1.5 mg/kg of elemental iron) for pediatric patients
• Dilution: 100 mL of 0.9% sodium chloride for adults or 25 mL 0.9% sodium chloride for pediatric patients
• Administration: intravenous infusion over 1 hour per dialysis session or slow intravenous injection (at a rate of up to 12.5 mg/min) per dialysis session
• Frequency: per dialysis session, with a cumulative dose of 1000 mg of elemental iron administered over 8 dialysis sessions for repletion treatment 2 2

From the Research

Iron Infusion Orders

To write an order for an iron infusion, a doctor typically follows these steps:

• Determine the patient's iron deficiency status and medical history to decide on the appropriate iron formulation and dosage 3, 4
• Choose an intravenous iron preparation, such as iron sucrose, ferric gluconate, or ferric carboxymaltose, based on the patient's specific needs and medical condition 3, 4, 5
• Calculate the total dose of iron required, which may be up to 1000 mg, and decide on the administration schedule, which can be a single dose or multiple doses 3, 5, 6
• Specify the rate of administration, which can range from 1.5 to 2.5 hours, depending on the iron preparation and patient's condition 6, 7
• Monitor the patient's vital signs and laboratory parameters, such as hemoglobin, ferritin, and transferrin saturation, before, during, and after the iron infusion 3, 4, 5

Key Considerations

When writing an order for an iron infusion, the doctor should consider the following:

• The patient's renal function and ability to tolerate the iron infusion 6, 7
• The presence of any allergies or sensitivities to the iron preparation 5
• The potential for adverse reactions, such as anaphylaxis or hypotension, and have emergency procedures in place 3, 4, 5
• The need for concurrent administration of other medications, such as erythropoiesis-stimulating agents, and adjust the iron infusion order accordingly 4, 7