IV Iron

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Indication:

  • Severe iron-deficiency anemia (Hb <9 g/dL) especially if there is ongoing bleeding
  • Rate of bleeding too brisk for oral iron
  • Time-sensitive pressures (eg, an urgent surgical procedure; observational studies of the use of IV iron preoperatively for patients with anemia have shown a reduced rate of red cell transfusion being required)
  • Severe anemia of chronic disease and evidence of iron deficiency (eg, ferritin <30 ug/L)
  • Oral iron being poorly tolerated or the failure of an oral trial
  • Poor oral absorption (due to conditions including gastric bypass, celiac disease, and gastritis)

Dose:

IV iron is given as iron sucrose (brand name Venofer) in an infusion of 300 mg in 250 mL of normal saline over two hours. After IV iron, and with ongoing oral supplementation, a patient’s hemoglobin will start to rise in three to seven days. You can expect a 0.1- to 0.2-point rise in the hemoglobin per day; after two to four weeks, the hemoglobin will have risen 2 to 3 g/dL. Ferrous sulfate (300 mg) contains 60 mg of elemental iron, and one tablet can be taken each night on an empty stomach at least two hours after meals with 500 mg of vitamin C to improve absorption. Patients should be counseled to avoid taking iron with calcium or magnesium supplements as they decrease iron absorption.

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IV Iron for Anemia in the ED

Iron Sucrose (Venofer) Ferumoxytol (Feraheme)
Dose (Max) 300mg in 250mL NS 510mg in 17mL (add to 50ml NS)
Infusion Time 2 hrs 15-60 mins
Serious Hypersensitivity 0.6 per million <5 in 1000
Cost $120 $200

Patients with the following risk factors should receive slower infusions (e.g. Feraheme® [ferumoxytol] over 60 minutes or Venofer® [iron sucrose] 300mg over 2 hours)

  • Age > 65 yrs
  • Baseline systolic BP less than 100
  • Severe asthma or eczema
  • Severe respiratory or cardiac disease
  • Treatment with beta-blockers, ACE inhibitors or 3 or more anti-hypertensive medications
  • Nephrology patients

After IV Iron, and with ongoing oral supplementation, a patient’s hemoglobin will start to rise 3-7 days. You can expect a 1-2 point rise in the hemoglobin per day, and after 2-4 weeks the hemoglobin will have risen 20-30g/L. Ferrous sulfate 300mg contains 60mg of elemental iron and 1 tab can be taken each night on an empty stomach at least 2 hours after meals with Vitamin C 500mg. Patients should also avoid taking with calcium or magnesium supplements as these decrease absorption.