Intravenous Iron Therapy in Acutely Ill Patients

Key Considerations

The American College of Physicians and other medical societies probably do not recommend administering iron to reduce red blood cell utilization or morbidity and mortality in critical care patients, due to increased risk of infection, oxidative stress, and inflammation without clear mortality or morbidity benefits 1, 2, 4, 6
IV iron should be used with caution, if at all, in patients with active infection as experimental studies suggest it may be harmful during severe infection 2
Intravenous iron infusion induces oxidative stress and generates pro-inflammatory substances, which could worsen the inflammatory state already present in acutely ill patients 2
Concerns exist regarding IV iron potentially promoting inflammation and bacterial growth in acutely ill patients 3

Studies specifically concerning critically ill patients show that IV iron administration is not associated with lower rates of blood transfusion during hospital stays 1
While IV iron may be associated with slightly higher hemoglobin concentration at discharge, the clinical relevance is very limited (+0.31 g/dL) 1
Due to insufficient power of studies in critical care patients, no significant effects on length of critical care stay or mortality have been observed 1, 4

All forms of IV iron may cause acute adverse events including anaphylactoid reactions, hypotension, shortness of breath, and chills 2, 7
The incidence of life-threatening/serious acute reactions to IV iron dextran has been reported to be 0.65-0.7% 8
Different IV iron formulations have varying safety profiles, with iron dextran (especially high molecular weight) associated with more frequent and severe reactions 2

Iron supplementation is not recommended for cancer patients with active infection due to concerns about promoting inflammation and bacterial growth 3, 9
Concomitant administration of IV iron and cardiotoxic chemotherapy should be avoided 10
IV iron should only be considered in critical care when combined with erythropoiesis-stimulating agents (ESAs) 1, 4, 6

IV iron should only be administered by staff trained to evaluate and manage anaphylactic reactions 10
Patients should be observed for at least 30 minutes following IV iron administration for hypersensitivity reactions 10
Accurate assessment of iron status requires a delay between the last iron infusion and measurement of iron status (24-48 hours for iron sucrose or iron gluconate) 2