Iron Injection Protocols - Advanced Medical Therapies

Iron Injection Protocols – Advanced Medical Therapies by: Dr. Anderson


As parenteral iron can have anaphylactic type reactions patients must be screened for history of intolerance to injectable iron products. Any patient having a suspicious history should be counselled regarding the increased risks and offered premedication with 25-50 mg IV Benadryl.

Another complicating factor is that parenteral iron compounds have greatly different safety profiles. This is generally less due to the iron component and more due to the solubilizing agent compounded with the iron. Statistically dextran is the most reactive and sucrose and gluconate are the least reactive. (The only major exception being dextran form rapidly infused causing cardiac arrhythmia and arrest). Regardless of form used appropriate emergency medications and equipment to respond to cardiac and other Type-1 reactions must be on hand.

Follow up testing:

While Hemoglobin and Hematocrit will improve more quickly and can be measured 72 hours following an infusion assessment of Ferritin must be made after a 3-4 week wash out (following termination of parenteral iron therapy) for the ferritin to be stable. The ultimate goal initially is ferritin over 100 as the ferritin will drop over time as the iron redistributes to the tissues. The exceptions are the patients who begin to tolerate and absorb oral iron after the ferritin reaches 40-50.

Iron delivery to tissues over time – Considering Hemoglobin-Hematocrit / Ferritin / TIBC / etc:

Hb/Hct are the quickest to change.

Then RBC and TIBC / % Saturation.

Ferritin is quite labile initially.

Picture the Ferritin rising as the temporary storage site, then ferritin giving iron to the transferrin dropping the TIBC. The highly saturated transferrin then delivers the iron to the mitochondrial receptors for use in electron transport, and the marrow for hematopoiesis. Over time if the initial loading dose was sufficient the labs will normalize and stay stable as mentioned below. If not sufficient then the ferritin will continually drop and eventually you will see a low Ferritin and generally a high TIBC with a low % saturation.

Ferritin will rise as mentioned above and slowly redistribute the iron to the transferrin and eventually the tissues. So the initial finding desired is high ferritin, low TIBC and high % Sat. Generally 8-12 weeks later the ferritin should drop slightly, the TIBC should rise some and the % Sat should drop to normal. Ideal stable numbers are ferritin between 50-100, TIBC in the mid-range and % Sat normal. If the ferritin drops below 40 during the follow up process another series of iron infusion should be considered.

Aside from waiting 3-4 weeks to run the first follow up labs, repeat labs including CBC, Ferritin, TIBC, % Sat should be run every 8-12 weeks.

Venofer (iron sucrose)

“Venofer® (iron sucrose injection, USP) is administered as a total cumulative dose of 1000 mg as a 200 mg slow IV injection undiluted over 2 to 5 minutes on 5 different occasions within a 14 day period. There is limited experience with administration of an infusion of 500 mg of Venofer®, diluted in a maximum of 250 mL of 0.9% NaCl, over a period of 3.5-4 hours on day 1 and day 14; hypotension occurred in 2 of 30 patients treated.”

Our general preferred infusion is 100 to 200 mg diluted in 100 -250 mL NS via IV.

In our facility we do not generally push Venofer, although some patients do tolerate it.

Ferrlecit (sodium ferric gluconate)

“Safe administration as an IV push (12.5 mg/min) or by IV infusion over 1 hour (diluted in 100 mL of 0.9% sodium chloride)” Cumulative dosing of 1000 mg prior to re-evaluation of labs.

Our general preferred infusion is 62.5 to 125 mg diluted in 100 -250 mL NS via IV.

In our facility we do not generally push Ferrlecit, although some patients do tolerate it.

Dexferrum, INFeD (Iron Dextran)


While IV protocols do exist for this product our policy is to use it via IM administration only due to anaphylactic and cardiac high grade adverse events.

Our preferred injection is 50-100 mg deep IM / Z-Trak weekly for 12 weeks


© PS Anderson 2018

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