IV Iron

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  • Feraheme® (ferumoxytol) and INFeD® (iron dextran) both carry boxed warnings for rare anaphylaxis.
  • Ferric carboxymaltose and ferric derisomaltose allow large single doses, improving convenience.
  • Iron sucrose and ferric gluconate are older, well-studied, and very safe but require multiple infusions.
  • Ferric carboxymaltose commonly causes hypophosphatemia, whereas derisomaltose does not.
  • Ferumoxytol is unique in being MRI-interfering and rapidly infused.

Match the generic with the brand name

Low-molecular-weight iron dextran
Iron sucrose
Ferumoxytol
Infed
Feraheme
Venofer
Correct! Sorry, Incorrect.

Match the generic with the brand name

Ferric carboxymaltose
Ferric gluconate
Ferric derisomaltose
Ferrlecit
Monoferric
Injectafer
Correct! Sorry, Incorrect.

Match the IV iron formulation (Column A) to the key feature (Column B)

Ferumoxytol
Iron sucrose
Iron dextran
2 clinic visits to deliver a full course (510 mg × 2).
The only prep that uses a test dose
Typically 5 clinic visits to deliver ~1 g
Correct! Sorry, Incorrect.

Match the IV iron formulation (Column A) to the key feature (Column B)

Ferric gluconate
Ferric derisomaltose
Ferric carboxymaltose
Single visit total-dose infusion
Hypophosphatemia risk signal.
Often multiple visits (≈8) t
Correct! Sorry, Incorrect.

Your 29 yo female patient with iron deficiency anemia develops sudden flushing and warmth, as well as chest and back pressure within seconds of start of infusion of IV iron dextran. Which of the following is/are true (more than one answer may apply).

a
This represents a Fishbane reaction, a mild infusion reaction related to IV iron
b
It is typically IgE mediated and self-limited
c
The infusion should be stopped; once symptoms resolve, it can often be restarted slowly
d
This reaction predicts future anaphylaxis and the drug should never be given again
e
The reaction is thought to be complement activation–related rather than a true allergy

A 42-year-old woman receiving IV iron sucrose for iron deficiency reports flushing and a feeling of chest tightness within 1 minute of infusion start. Blood pressure and oxygen saturation remain normal. Which statement best describes this reaction?

a
They are IgE-mediated allergic reactions
b
They occur most commonly after completion of infusion
c
They can usually be managed by pausing and then restarting the infusion slowly
d
They are unique to ferumoxytol
e
They invariably progress to hypotension and collapse

True or false: Fishbane reactions are a type of CARPA?

a
True
b
False

The mechanism of a Fishbane reaction is most consistent with:

a
Mast-cell degranulation via IgE antibodies
b
Complement activation and release of anaphylatoxins
c
Endotoxin contamination
d
Bradykinin excess
e
Direct histamine release from iron

Can a patient who had a Fishbane reaction safely receive IV iron again?

a
Yes
Usually safe to re-administer, possibly using a different formulation and slower rate.
b
No

Is premedication with antihistamines or steroids required for someone who has had Fishbane reactions?

a
Yes
b
No
No; these reactions are not histamine- or IgE-mediated

Which of the following is a clear indication for intravenous iron therapy?

a
Mild iron deficiency anemia in a patient tolerating oral iron
b
Iron deficiency anemia with malabsorption due to celiac disease
IV iron is indicated when oral iron is ineffective or cannot be absorbed, such as in celiac disease, inflammatory bowel disease, or post–gastric bypass.
c
Iron deficiency without anemia
d
Ferritin 150 µg/L and TSAT 30%

A patient with chronic kidney disease (CKD) and anemia is on erythropoiesis-stimulating agent (ESA) therapy. Which of the following best describes the role of IV iron?

a
Contraindicated because of infection risk
b
ndicated to optimize ESA response and replete iron stores
In CKD, IV iron enhances hemoglobin response to ESA therapy and corrects functional iron deficiency.
c
Only indicated if ferritin <30 µg/L
d
Equivalent efficacy to oral iron

Which of the following best summarizes general indications for IV iron?

a
First-line for all iron deficiency
b
Failure, intolerance, or contraindication to oral iron
IV iron is reserved for patients who cannot tolerate or fail oral iron, have ongoing blood loss exceeding oral replacement capacity, or need rapid repletion.
c
Only for severe anemia (Hb <7 g/dL)
d
For iron overload syndromes

Match the clinical scenario (Column A) with the appropriate indication (Column B).

Pregnant woman who vomits with every oral iron dose
Patient with Crohn’s disease and iron deficiency anemia not responding to oral iron
Menstrual blood loss causing mild anemia, patient tolerating oral iron
Malabsorption or inflammatory bowel disease
Oral iron adequate—no indication for IV iron
Intolerance or non-adherence to oral iron
Correct! Sorry, Incorrect.

Sort the following clinical scenarios into the correct category:

Post–gastric bypass with malabsorption
Athlete with low ferritin but normal Hb
Preoperative anemia, imminent surgery
Iron deficiency without anemia (unless special circumstances)
Celiac disease with poor absorption
IBD with intolerance to oral iron
Heart failure with iron deficiency
CKD on ESA therapy
Pregnant patient intolerant to oral iron
Mild iron deficiency responding to oral iron
IV Iron Indicated
IV Iron Not Indicated

The Ganzoni formula is used to calculate which of the following?

a
The rate of iron infusion
b
The total body iron deficit (iron replacement dose)
c
The risk of anaphylaxis to IV iron
d
The transferrin saturation (TSAT)

Which of the following best describes the expected hemoglobin (Hb) response after successful IV iron therapy in iron deficiency anemia?

a
Immediate rise within 24 hours
b
~1 g/dL per week for the first 2–3 weeks
c
~1 g/dL per month starting 1–2 weeks after infusion
Reticulocytosis begins in ~5 days, Hb rises by ~1 g/dL every 2–3 weeks, typically peaking at 4–8 weeks.
d
No change until 6 weeks after therapy
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