INVITATION ARTICLES - I.V. Iron Therapy by Dr. Arulmozhi Ramarajan

Dr. Arulmozhi Ramarajan,

Church of South India Hospital,




Why intravenous iron?

Iron Deficiency Anemia has been in existence for centuries, and oral iron therapy has failed to eradicate this very preventable and treatable malady. Oral iron therapy is certainly very appropriate and first line for most IDA patients, but a good number of patients do not show the desired response because of various reasons. Intravenous iron sucrose appears to have the potential for eradicating IDA because it overcomes the problems of compliance and absorption and has an excellent safety record. It can dramatically reduce maternal morbidity and mortality, promote better neuro-development and cognitive functions in the newborn / infant, and improve the quality of life of women overall.


What should be our target?

  • To achieve a hemoglobin level of not less than 11.0 g/dL;

  • To provide sufficient iron to maintain TSAT (transferrin saturation) ≥ 20% and ferritin ≥ 100 ng/mL;

  • To avoid iron overload: think of non-IDA in non-responders;

  • And, to avoid blood transfusions!


It is important to note that when aggressive iron therapy elicits poor response or no response, one may be dealing with non-IDA. There is a possibility of iatrogenic iron overload in these patients.


What is Intravenous Iron Sucrose?

Intravenous Iron Sucrose is a brown, sterile, aqueous complex of polynuclear iron hydroxide in sucrose containing 20mg elemental iron per ml. The product has no preservatives. Parenteral iron bypasses the gut and circumvents the natural regulatory mechanism to deliver non-protein-bound iron.  Pharmacologic parameters show that the administered iron disappears very rapidly from the serum, insuring a rapid correction of IDA. Since iron disappearance from the serum depends on the need for iron in the iron stores and iron utilizing tissues of the body, serum clearance of iron is expected to be more rapid in iron deficient patients treated with iron sucrose as compared with healthy individuals.


Iron sucrose is dissociated into iron and sucrose by the reticuloendothelial system. Following a single dose of 100mg of iron, iron uptake in bone marrow, liver & spleen is rapid, followed by emergence of iron in circulating RBCs. The sucrose component is eliminated mainly by urinary excretion, some of it gets metabolized.  


What are the common indications for IV Iron therapy?

  • Moderate to severe anemia in pregnancy

  • Intolerance / non-compliance to oral iron therapy.

  • Failure of oral iron therapy (no clinical or hematological improvement after 4 – 6 weeks of treatment and rise in Hb is < 2gms%)

  • IDA in pregnancy, with limited time to treat.

  • Anemic women who refuse / decline blood transfusion (Jehovah’s Witnesses).

  • Those who are donating large amounts of blood for autotransfusion programs

  • Pregnancy in women with chronic renal disease.

  • Postpartum, especially in those who have had significant blood loss at delivery.

  • Those with a disorder of the gastrointestinal tract, such as ulcerative colitis, in which symptoms may be aggravated by oral iron therapy

  • Those with anemia due to chronic blood loss caused by AUB.

  • Pre / post operative correction of iron deficiency in women undergoing surgery.

  • Those with chemotherapy-induced anemia.

  • Hemodialysis associated blood loss and resulting negative iron balance.


How safe is IV iron? What are the side effects?


Intravenous iron sucrose is effective, safe, well tolerated. It is labeled as a Category B drug in pregnancy. The side effects profile is acceptable, with most of the reported side effects being transient, mild, and not requiring any medical intervention. The reported incidence of side effects is less than 0.5%, with a maximum single dose of 200mg IV. Side effects were a major concern with the previously used intravenous irons, including the iron dextran complex. These have been largely eliminated because the iron sucrose preparation is of small molecular weight, and contains no synthetic polymers or preservatives.


Reported side effects to IV iron sucrose include a transient metallic taste, pain at injection site, nausea, lethargy, light headedness and facial flushing. Vasovagal ‘reactions’ are uncommon, and resolve within 30 minutes. Rare sensitivity reactions including anaphylactic shock, requiring medical intervention and discontinuance of drug have been reported. However, these are quite rare, the reported incidence being about 3 – 4 / million / year.

IV iron use within current guidelines is safe.


When NOT to give intravenous iron sucrose:

  • Known sensitivity to the drug

  • Hb >10gms%

  • Serum ferritin >15g/L

  • Hemoglobinopathy or other red cell disorders

  • Gestational age <16weeks


How much IV iron to give?


Dose calculation:

Iron deficit in mg = Pre-pregnancy body wt in kg x Hb deficit in gms / dl x 2.4 + 500 mg for stores.

The total deficit is given in divided doses of 200mg per dose, with a spacing of at least 48 hours between doses.


How to give?


Administration of IV iron sucrose is simple. No test dose required for intravenous iron sucrose. It can be given on an OP basis. Following IV administration the serum iron concentration increases and reaches a peak after 4 hours after administration and decreased to base line after 48 hrs. Positron emission tomography studies have shown that the infused iron is immediately incorporated into the bone marrow. Therefore it is safe to repeat the dose after 48 hours.

Maximum recommended dose per sitting is 200mg. Intravenous iron sucrose may be given undiluted, as an IV push, over a period of 4 – 5 minutes, using a butterfly needle. This method gives enormous benefits including cost and time savings. The same may be diluted in normal saline and given as an IV infusion over 20 minutes. There is no significant difference in the therapeutic benefit / side effect profile between the two methods of administration.


How to assess the efficacy of IV iron sucrose?


Response to therapy is noticed as early as Day 7 of treatment. Patients report a feeling of wellness, and blood test shows reticulocytosis, rise in hemoglobin % and improvement in red cell indices.


What’s the message?

  • IV iron is safe, sure and corrects IDA.

  • Hb of 10gms or less is indication enough to give IV iron

  • Advice on a nutritious iron rich diet is important

  • Deworming & antimalarial treatment need to be given

  • Cost reduction can be achieved by using a butterfly needle & direct undiluted IV iron push over 2 – 5 minutes as per guidelines.

  • Adding proteins, vitamins including folate & minerals to the recipe improves outcome.

  • It is important to check response to therapy.



Although treatment of iron deficiency certainly is not confined to patients with kidney disease, the majority of published evidence on IV iron therapy resides in the nephrology literature.

A Cochrane review on treatments for iron-deficiency anemia during pregnancy stated that despite the high incidence and burden of disease associated with this condition, there is a paucity of good quality studies evaluating clinical maternal and neonatal effects of iron administration in pregnant women with anemia. Daily oral iron therapy improves hematological indices but is associated with gastrointestinal adverse effects. Intramuscular and intravenous iron therapy enhances hematological response, compared with oral iron, but there are concerns regarding possible important adverse effects. The authors noted that large, good quality studies that evaluate clinical outcomes including adverse effects are needed (Reveiz et al, 2007).


Take every opportunity to correct iron deficiency: Adolescents, (why wait to diagnose anemia in pregnancy?) pre-pregnancy, pregnancy, post partum, AUB, those awaiting surgery, those who decline blood transfusion.




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