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iron replacement therapy

Also see iron supplement. Complications: - anaphylaxis from IV iron 0.01-0.1% [6] Management: 1) total iron replacement (mg of elemental iron) [1] - blood hemoglobin = 11-13 g/dL: 5000 mg - blood hemoglobin = 9-11 g/dL: 10,000 mg - blood hemoglobin = <9 g/dL: 15,000 mg 2) iron required for replacement a) oral iron: ~10% of oral iron is absorbed - ferrous sulfate 324 mg, 65 mg Fe+2, 75 tablets* - ferrous gluconate 300 mg, 36 mg Fe+2, 140 tablets* - ferrous fumarate 100 mg, 33 mg Fe+2, 150 tablets* - iron polysaccharide 150 mg, 150 mg Fe+2, 33 tablets* b) parenteral iron (iron sucrose) - reserved for patients not candidates for oral therapy - iron dextran (imferon), 50 mg/mL [3] - iron sucrose, 20 mg/mL [3] - four 200-mg infusions of iron sucrose over 2-weeks may reduce fatigue in women with low serum ferritin (< 15 ng/mL) but without anemia - ferric gluconate 12.4 mg/mL (for dialysis patients) - ferumoxytol, 30 mg/mL - ferric carboxymaltose - IV ferric carboxymaltose reduced subsequent hospitalization in patients with acute heart failure (LVEF < 50%) & iron deficiency [5] - rarely anaphylaxis will occur with parenteral iron (0.01-0.1%) [6] - results in fewer transfusions but more infections [2] - safe for patients with cirrhosis 3) iron absorption - QOD dosing may be better than QD, BID or TID dosing* [4] - taking iron in the morning with vitamin C (80 mg, 8 ounces of orange juice) without coffee or other food optimizes iron absorption [7] * compensatory response of hepcidin to dose of iron - absorption of iron is decreased by hepcidin - blocks transport of iron from intestinal epithelial cells to blood - hepcidin levels increased 2.7 fold by a dose of 60 mg Fe as FeSO4 - next day aborption of iron decreased 36% after a dose of 60 mg Fe as FeSO4 - BID dosing of iron increases hepcidin levels more than QD dosing - total dose of iron absorbed was similar whether 2 or 3 doses (60 mg Fe as FeSO4) given within 24 hours (22.6 vs 23.6 mg) * number of tablets of oral iron needed to replace 5000 mg of iron Notes: - packed RBC provide 200-250 mg of iron/unit

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iron supplement

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pharmacologic therapy

References

  1. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  2. Litton E et al Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ 2013;347:f4822 PMID: 23950195 http://www.bmj.com/content/347/bmj.f4822
  3. Medical Knowledge Self Assessment Program (MKSAP) 17, American College of Physicians, Philadelphia 2015
  4. Moretti D et al. Oral iron supplements increase hepcidin and decrease iron absorption from daily or twice-daily doses in iron-depleted young women. Blood 2015 Oct 22; 126:1981 PMID: 26289639
  5. Slomski A Intravenous Iron Therapy Prevents Heart Failure Rehospitalizations. JAMA. 2021;325(4):334. Jan 26 PMID: 33496772 https://jamanetwork.com/journals/jama/fullarticle/2775444
  6. Dave CV et al. Risks for anaphylaxis with intravenous iron formulations: A retrospective cohort study. Ann Intern Med 2022 Mar 29; [e-pub] PMID: 35344378 https://www.acpjournals.org/doi/10.7326/M21-4009
  7. von Siebenthal HK et al. Effect of dietary factors and time of day on iron absorption from oral iron supplements in iron deficient women. Am J Hematol 2023 Sep; 98:1356. PMID: 37357807 https://onlinelibrary.wiley.com/doi/10.1002/ajh.26987 - Powers JM, Auerbach M. When taking iron, a glass of orange juice a day keeps anemia away. Am J Hematol 2023 Sep; 98:1354 PMID: 37403430 https://onlinelibrary.wiley.com/doi/10.1002/ajh.27017
  8. Tabish M, Agarwal S, Gopi S et al Randomized Controlled Trial of Intravenous Ferric Carboxymaltose vs Oral Iron to Treat Iron Deficiency Anemia After Variceal Bleed in Patients With Cirrhosis. Am J Gastroenterol. 2024. May 14. PMID: 38517084 https://journals.lww.com/ajg/abstract/9900/randomized_controlled_trial_of_intravenous_ferric.1084.aspx