Iron Infusion Protocol and Laboratory Monitoring

Administration Protocol

• The maximum dose of ferric carboxymaltose is 1000 mg iron per week 1
• Ferric carboxymaltose can be administered as an undiluted slow bolus injection at 100 mg/min (15 minutes for 1000 mg dose) 3
• Iron sucrose can be administered as 200 mg iron over 10 minutes as bolus dosing 4
• The maximum single dose of iron sucrose is 200 mg 4
• Iron dextran can be administered as 500-1000 mg in a single dose diluted in 250 mL normal saline over 1 hour 4

Laboratory Monitoring Schedule

• Iron parameters should be re-evaluated 3 months after intravenous iron infusion, with laboratory testing including CBC, ferritin, and transferrin saturation performed 4-8 weeks after the last dose 1, 2
• The American College of Cardiology recommends checking CBC and iron parameters (ferritin, TSAT) 4-8 weeks after last infusion 2
• The European Society of Cardiology recommends re-evaluating iron status for need of additional repletion 3 months after iron replacement 1, 3, 2

Thresholds for Withholding Iron

• Iron infusion should be stopped or held if TSAT exceeds 50% 6, 2
• Iron infusion should be stopped or held if ferritin exceeds 800-1000 ng/mL 6, 2
• Iron infusion should be stopped or held if there is evidence of iron overload 3
• Iron infusion should be stopped or held if there is active bacteremia 3

Special Considerations

• Resuscitation facilities must be available when administering IV iron preparations, as anaphylaxis may occur, though the risk is <1:250,000 with modern formulations 1
• The American Society of Nephrology recommends monitoring for hypotension during and after each dose, particularly with iron sucrose and ferric gluconate 5
• If no response or Hb decreases after treatment, the European Society of Gastroenterology recommends investigating for occult blood loss 2
• If no response or Hb decreases after treatment, the American Gastroenterological Association recommends considering other causes of anemia 4