Canadian expert consensus: management of hypersensitivity reactions to intravenous iron in adults

Abstract

Background and ObjectivesRare but potentially life‐threatening hypersensitivity reactions can occur during the administration of intravenous iron. To provide guidance to healthcare professionals caring for adults receiving intravenous iron, a panel of 10 Canadian clinical experts developed a practical algorithm for the identification and management of hypersensitivity reactions to intravenous iron.Materials and methodsA systematic search of PubMed to February 2018 was performed. Articles related to hypersensitivity reactions were selected for review. The algorithm was developed during a 1‐day live meeting based on the literature review and clinical expertise where evidence was lacking. The algorithm was then refined through an iterative process involving a web‐based platform and virtual meetings.ResultsThe algorithm provides guidance to healthcare professionals in preparing for and administering IV iron, as well as recognizing and managing hypersensitivity reactions to intravenous iron. Considerations for re‐challenging patients who have experienced prior reactions are provided.ConclusionHealthcare professionals who are involved in the care of patients receiving intravenous iron should be trained to anticipate, recognize and manage hypersensitivity reactions to intravenous iron to optimize patient care.

Clinical data for intravenous iron – debunking the hype around hypersensitivity

“…2) to assist health care personnel in the management of acute infusion reactions. In the management of HSRs experienced with IV iron, key aspects include alleviating patient and health care provider anxiety, using a slow infusion rate, recognizing anaphylaxis and treating it appropriately, and recognizing Fishbane reactions and isolated symptoms 22 . There is no role for premedication with diphenhydramine or steroids; antihistamines should be used only for symptomatic urticaria 22 .…”

“…In the management of HSRs experienced with IV iron, key aspects include alleviating patient and health care provider anxiety, using a slow infusion rate, recognizing anaphylaxis and treating it appropriately, and recognizing Fishbane reactions and isolated symptoms 22 . There is no role for premedication with diphenhydramine or steroids; antihistamines should be used only for symptomatic urticaria 22 . IV iron should be administered only when staff trained to evaluate and manage anaphylactic reactions are immediately available (as well as resuscitation facilities), 25 and it is recommended that administration teams should receive regular training in the management of IV infusions and associated adverse reactions 4 .…”

“…IV iron should be administered only when staff trained to evaluate and manage anaphylactic reactions are immediately available (as well as resuscitation facilities), 25 and it is recommended that administration teams should receive regular training in the management of IV infusions and associated adverse reactions 4 . Patients should be informed that delayed reactions, for example, flulike symptoms, characterized by arthralgia, myalgia, and sometimes fever, can occur from several hours up to a day after administration 22,26 . Delayed reactions are usually mild and self‐limited, and the symptoms can be relieved with simple analgesics 26 .…”

“…Algorithm for the management of immediate infusion reactions. Adapted from: Rampton et al, 4 Lim et al, 22 Macdougall et al, 23 and Simons et al 24 [Color figure can be viewed at wileyonlinelibrary.com]…”

Iron III isomaltose induced hypersensitivity reaction

“…Test dose of iron isomaltose is not recommended 1 4 20. The potential for acute hypersensitivity reaction cause by intravenous iron is rare (<1/250 000 administrations) but due to potential of causing a reaction it should be done in a controlled facility with staff trained to manage promptly,11 21 it should to be treated in timely manner to decrease mortality 21 22…”