Lay Summary: As IV iron preparation have become safer, they are increasingly being used. However, the oral route is still best, when possible.
Anemia is a common complication of kidney disease. Although erythropoietin deficiency is the most important cause of anemia in patients with kidney disease, iron deficiency is common and can complicate treatment by causing a relative resistance to epoetin alfa therapy. I.V. iron is widely used in hemodialysis patients but less so in patients with non-dialysis-dependent chronic kidney disease (NDDCKD). Although oral iron can be used in the latter patients, its use is limited by adverse effects, poor compliance, and the long time period required to replete iron stores.
There are three commercially available i.v. iron products, iron dextran, iron sucrose, and iron ferric gluconate, or Ferrlecit. The use of iron dextran has decreased because of the risk of anaphylaxis. Iron sucrose recently received Food and Drug Administration (FDA)-approved labeling for the treatment of iron deficiency anemia in NDDCKD patients, making it the first of the non-dextran iron supplements to receive such approval. Before this approval, both iron sucrose and iron ferric gluconate were indicated only for the treatment of iron deficiency in dialysis patients. Ferrlecit is FDA approved for treating iron deficiency anemia in patients undergoing hemodialysis who are also receiving epoetin therapy.
Indications for the use of intravenous iron include chronic uncorrectable bleeding, intestinal malabsorption, intolerance to oral iron, nonadherence, or a hemoglobin level less than 6 g per dL (60 g per L) with signs of poor perfusion in patients who would otherwise receive transfusion (e.g., those who have religious objections).41 Until recently, iron dextran (Dexferrum) has been the only parenteral iron preparation available in the United States. The advantage of iron dextran over Ferrlecit is the ability to administer large doses (200 to 500 mg) at one time. One major drawback of iron dextran is the risk of anaphylactic reactions that can be fatal. There also is a delayed reaction, which consists of myalgias, headache, and arthralgias, that can occur 24 to 48 hours after infusion. Nonsteroidal anti-inflammatory drugs will usually relieve these symptoms, but they may be prolonged in patients with chronic inflammatory joint disease.
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Ioannou GN, Spector J, Scott K, Rockey DC. Prospective evaluation of a clinical guideline for the diagnosis and management of iron deficiency anemia. Am J Med 2002;113:281-7.
