Key messages

  • Iron infusion practice varies extensively across Victorian hospitals.
  • These resources and guiding principles may assist in developing policies and procedures.

Iron infusion practice varies extensively across Victorian hospitals, with some hospitals using iron carboxymaltose exclusively in the parenteral treatment of iron deficiency anaemia. There are several studies currently being undertaken regarding rapid iron infusion / bolus therapy.

Due to varied practice and little evidence currently available around iron infusion, it is important to seek pharmacy and hospital policy committee approval regarding introduction of policy into your own hospital setting. These resources and guiding principles may assist you in developing policies and procedures.

Intravenous iron preparations

The following products are available in Australia.

Product

Brand

Iron polymaltose

FerrumH®

Ferric carboxymaltose

Ferinject®

Iron sucrose

Venofer®

Patient information

The intravenous iron Infusion patient information leaflet, available on the BloodSafe website, provides practical information and answers some common questions. This leaflet is available in multiple languages.

Guiding principles for iron

This guide is designed to fill a gap in publicly available resources relating to iron infusion management. This gap was identified during consultation with health services regarding the implementation of the National Blood Authority’s Patient Blood Management work plan and, in particular, the management of anaemia.

Considerations for developing policies

When developing or reviewing policies for iron infusion, consideration must be given to the following points:

  • patient consent
  • preparation and storage of infusion once reconstituted per product information
  • anaphylaxis protocol
  • approval for use from relevant committees within your health service
  • awareness and education of relevant staff.

Intravenous iron therapy

While oral iron remains the cornerstone of iron deficiency anaemia (IDA) therapy, some patients require intravenous (IV) iron therapy. Underuse of IV iron may have stemmed in part from concerns about the risk of serious allergic reactions (Pasricha et al. 2011).

Iron polymaltose (Ferrum H® [Aspen Pharmacare], Ferrosig® [Sigma Pharmaceuticals]) Ferric carboxymaltose (Ferinject® [Vifor Phama] and iron sucrose (Venofer® [Aspen Pharmacare]) are the parenteral iron formulations currently available in Australia.

A ‘total-dose’ infusion (where iron stores can be replenished in a single treatment episode) can be administered only with iron polymaltose.

Iron products, costs and dosage


Ferric carboxymaltose

Iron sucrose

Iron polymaltose

Description

Intravenous ferric carboxymaltose is indicated for iron deficiency when oral preparations are ineffective or not tolerated (Australian Prescriber 2011; 34:119-123)

Administered intravenously, it is effective in the treatment of iron-deficiency anaemia, delivering a replenishment dose of up to 1000 mg of iron during a minimum administration time of less-than or equal to 15 minutes (Lyseng-Williamson KA, Keating GM, 2009).

Iron sucrose is funded by the PBS for IDA only in patients with chronic kidney disease who are having erythropoietin- stimulating agent and react systemically to iron polymaltose

Iron polymaltose has been identified as well tolerated with minor infrequent side effects during infusion and some self-limiting side effects that occur up to two days after infusion. Despite this, the risk of a severe anaphylactic reaction is present and must be considered. An average total-dose infusion of iron polymaltose (sufficient to replenish iron stores, commonly 1000 mg to 2500 mg for adults), given at the rates recommended in Australian approved product information, takes around five hours. Surveys of policies at different health services show a broad range of infusion and premedication practices. Published evidence of delivery of total dose iron polymaltose infusions at accelerated rates is limited. Use of iron polymaltose outside of Australia and New Zealand is also limited (Pasricha et al. 2011)

Approximate cost

PBS $37.70 per 1 x 10 mL vial (500 mg total)

($7.54 per 100 mg)

PBS $37.70 per 5 x 5 mL ampoules (500 mg total)

($7.54 per 100 mg)

PBS $37.70 per 5 x 2 mL ampoules (500 mg total)

($7.54 per 100 mg)

Dosage

A single infusion of 1000 mg over 15 minutes

OR

A single IV bolus dose of 200 mg/day NOT more than three times per week

Most adult CKD patients will require a minimum cumulative repletion dose of 1000 mg of elemental iron to achieve a favorable hemoglobin (Hb) response and to replenish iron stores

See Iron polymaltose suggested infusion rates and observation options listed below

Iron polymaltose

The following information applies to iron polymaltose only.

Indications

Treatment of iron deficiency anaemia:

  • when there is demonstrated intolerance, non-compliance or lack of efficacy with oral iron, despite modification of dose, timing and frequency
  • in patients undergoing chronic haemodialysis and who are receiving supplemental erythropoietin therapy.

Key points

  • A written intravenous order by an appropriate medical officer must be obtained.
  • A medical officer need not remain with the patient but should be readily available.
  • Iron infusions should not to be administered out of hours unless urgently required and medical staff are available.
  • The iron infusion must be used within 24 hours of preparation.

Contraindications

Contraindications include: 

  • history of allergic reaction to iron polymaltose
  • anaemia not caused by simple iron deficiency
  • iron overload
  • chronic polyarthritis
  • infectious renal complaints in acute phase
  • uncontrolled hyperparathyroidism
  • decompensated hepatic cirrhosis, infectious hepatitis
  • patients with severe inflammation or infection of the kidney or liver as iron tends to accumulate in inflamed tissues
  • first trimester of pregnancy
  • bronchial asthma.

Precautions

Patients with the following conditions may be at a higher risk of adverse reactions:

  • low iron binding capacity
  • folic acid deficiency
  • history of allergic disorders
  • hepatic insufficiency
  • cardiovascular disease
  • rheumatoid arthritis and other rheumatological inflammatory disease.

Pre-infusion assessment

  • The patient must be educated about possible adverse reactions both immediate and delayed (refer to Adverse reactions).
  • Establish patent IV access.
  • Ensure the resuscitation equipment and emergency drugs are accessible and/or presence of hospital medical emergency/code blue policy.
  • Ensure the patient’s call bell is within reach and instruct them to use it should they become aware of any adverse reaction throughout the infusion.

There is no requirement for routine premedication for patients with no history of adverse reaction to iron infusion; however, if required, premedication should be prescribed according to your health service’s policy and administered at least 30 minutes prior to the commencement of the iron infusion.

Management of infusion

  • An infusion pump must be used to administer iron infusions.
  • Do not add any other medications to infusion or mix in the same line.
  • Follow the hospital guideline for checking the preparation and patient before commencing the infusion.
  • Working oxygen/suction equipment must be available.

Suggested infusion rates and observation options

Option

Iron polymaltose dose in (sodium chloride 0.9%)

Duration of infusion

Initial infusion rate

If initial infusion tolerated increase infusion rate to:

A

500 mg
1000 mg
1500 mg in 250 mL

80 minutes
rapid infusion

40 mL/hour for 15 minutes
Observations every 5 minutes

250 mL/hour
Observations every 15 minutes
Observations include: pulse, temperature, blood pressure and SaO2

B

500 mg
1000 mg
1500 mg in 250 mL

2.5 hours

40 mL/hour for 15 minutes
Observations every 5 minutes

125 mL/hour
Observations every 30 minutes

C

500 mg
1000 mg
1500 mg in 250 mL

5 hours

40 mL/hour for 15 minutes
Observations every 5 minutes

60 mL/hour
Observations every 30 minutes

D

*2000 mg in 500 mL

2.5 hours

40 mL/hour for 15 minutes
Observations every 5 minutes

250 mL/hour
Observations every 30 minutes

E

*2000 mg in 500 mL

5 hours

40 mL/hour for 15 minutes
Observations every 5 minutes

120 mL/hour
Observations every 30 minutes

Table developed from the Western Health Iron Infusion procedure, and the Fremantle Hospital and Health Service Iron polymaltose specialised drug guideline (which is no longer accessible online). 

*Average total-dose infusion of iron polymaltose (sufficient to replenish iron stores, commonly 1000-2500 mg for adults). Facilities providing information to assist with preparation of these guiding principles have policies that allow no more than 2000 mg in a single dose.

If there are concerns at any time during the infusion or an adverse reaction appears likely, stop the infusion and call for medical support.

Adverse reactions

Acute - during infusion

Delayed – 1 to 2 hours post infusion

Delayed – 1 to 2 days post infusion

Uncommon

Very unusual

Very unusual

Sensations of warmth or itching, especially in axilla and groin

Mild erythematous or urticarial rash

Dizziness

Chest pain/occasional arrhythmias

Dyspnoea

Nausea

Headache

Fever, usually hours/days post-infusion

Arthralgia/myalgia

Headache

Mild fever

Joint and muscle aches

These symptoms generally resolve without treatment. They are more common with ‘total dose’ infusions of iron polymaltose.

Note: Patients should be instructed that if they experience chest pain, difficulty breathing, dizziness or neck/mouth swelling, they need to seek urgent medical attention/call an ambulance (000).

References

Diagnosis and management of iron deficiency anaemia: Pasricha, Flecknoe-Brown, Allen, Gibson, McMahon, Olynyk, Roger, Savoia, Tampi, Thomson, Wood and Robinson

Management of iron deficiency in patients admitted to hospital: Ahmed and Gibson

Safety and tolerability of intravenous ferric carboxymaltose in patients with iron deficiency anemia: Bailie, Mason and Valaoras

Efficacy and safety of ferric carboxymaltose in correcting iron-deficiency anemia: Bailie, George R

Delayed adverse reactions to total-dose intravenous iron polymaltose: Haines and Gibson

Acknowledgements

These principles were developed in consultation with and reviewed by:

  • medical experts from several Victorian health services through the Blood Matters Patient Blood Management Steering Group
  • Department of Health Surgical Services, Critical Care and Acute Medical program
  • existing hospital policies (local and interstate)
  • published clinical studies
  • manufacturers product information
  • Peter MacCallum Cancer Centre Pharmacist
  • Victorian Therapeutics Advisory Group.

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