How to manage pagophagia with low ferritin and intolerance to oral iron in a non-anemic patient?

From the Guidelines

In patients with pagophagia and low ferritin levels without anemia, yet intolerant to oral iron, intravenous iron supplementation is recommended. This approach is supported by expert reviews, which suggest that intravenous iron should be used if the patient does not tolerate oral iron or if ferritin levels do not improve with a trial of oral iron 1. A dose of 1000 mg of ferric carboxymaltose (e.g., Ferinject) or iron sucrose (e.g., Venofer) administered over 15-60 minutes is suggested, with a repeat dose as needed to achieve a target ferritin level of 50-100 ng/mL.

• Key considerations for intravenous iron supplementation include:
  • Monitoring for adverse reactions, which are often idiosyncratic infusion reactions that can mimic allergic reactions 1
  • Adjusting the infusion rate or using corticosteroids for mild to moderate reactions 1
  • Avoiding diphenhydramine due to potential side effects that can be mistaken for worsening of the reaction 1
• Treatment duration and frequency will depend on individual patient response and ferritin levels, with monitoring recommended at 1-3 months after initiation of therapy to assess efficacy and guide further management.

From the FDA Drug Label

In patients with iron deficiency, red cell uptake of radiolabeled iron ranged from 91% to 99% at 24 days after Injectafer dose Trial 1: A Multi-center, Randomized, Active Controlled Study to Investigate the Efficacy and Safety of Intravenous Ferric Carboxymaltose (FCM) in Patients with Iron Deficiency Anemia (IDA), (NCT00982007) was a randomized, open-label, controlled clinical study in patients with IDA who had an unsatisfactory response to oral iron (Cohort 1) or who were intolerant to oral iron (Cohort 2) during the 14-day oral iron run-in period. Increases from baseline in mean ferritin (264.2 ± 224.2 ng/mL in Cohort 1 and 218.2 ± 211. 4 ng/mL in Cohort 2) were observed at Day 35 in Injectafer-treated patients

Management of Pagophagia with Low Ferritin and Intolerance to Oral Iron in a Non-Anemic Patient:

• Intravenous Iron Therapy: Consider using intravenous ferric carboxymaltose (Injectafer) to manage iron deficiency in patients who are intolerant to oral iron.
• Dosing: The recommended dose is 15 mg/kg body weight up to a maximum single dose of 750 mg of iron on two occasions separated by at least 7 days up to a cumulative dose of 1,500 mg of iron.
• Monitoring: Monitor ferritin levels and adjust treatment as needed.
• Note: While pagophagia is not directly addressed in the label, managing iron deficiency with intravenous iron therapy may help alleviate symptoms associated with pagophagia in patients with low ferritin levels and intolerance to oral iron 2.

From the Research

Managing Pagophagia with Low Ferritin and Intolerance to Oral Iron

To manage pagophagia with low ferritin and intolerance to oral iron in a non-anemic patient, the following options can be considered:

• Intravenous iron therapy: Studies have shown that intravenous iron therapy can be effective in increasing ferritin levels and reducing fatigue in non-anemic patients with low serum ferritin concentration 3, 4.
• Choosing the right intravenous iron formulation: Different intravenous iron formulations, such as iron sucrose and ferric carboxymaltose, have been shown to be effective in increasing ferritin levels and improving symptoms 3, 5, 4.
• Monitoring and adjusting treatment: Regular monitoring of ferritin levels and adjustment of treatment as needed can help ensure that the patient receives the appropriate amount of iron and minimizes the risk of adverse effects 6, 5.

Considerations for Non-Anemic Patients

In non-anemic patients, the goal of treatment is to increase ferritin levels and improve symptoms such as fatigue, rather than to increase hemoglobin levels. Studies have shown that intravenous iron therapy can be effective in achieving these goals 3, 4.

• Fatigue reduction: Intravenous iron therapy has been shown to reduce fatigue in non-anemic patients with low serum ferritin concentration 3, 4.
• Ferritin level increases: Intravenous iron therapy can increase ferritin levels in non-anemic patients, which can help improve symptoms such as pagophagia 3, 4.

Comparison of Oral and Intravenous Iron Therapy

Oral iron therapy may not be effective in patients with intolerance to oral iron, and intravenous iron therapy may be a better option. Studies have compared the effectiveness of oral and intravenous iron therapy in patients with iron deficiency anemia and found that intravenous iron therapy can be more effective in increasing ferritin levels and improving symptoms 5, 7.

• Oral iron limitations: Oral iron therapy has limitations, including poor absorption and gastrointestinal side effects, which can make it less effective in some patients 5, 7.
• Intravenous iron advantages: Intravenous iron therapy can provide a more rapid and reliable increase in ferritin levels, which can help improve symptoms such as pagophagia 5, 7.