Efficacy and safety of high‐dose intravenous iron as the first‐choice therapy in outpatients with severe iron deficiency anemia

Abstract

BACKGROUNDAsymptomatic severe iron deficiency anemia is a common finding in subjects admitted to the outpatient anemia clinic. Although the condition can be easily be reversed with intravenous iron (IVI) therapy and several guidelines have suggested a restrictive threshold for using transfusion in hemodynamically stable patients, transfusion is often the rule in clinical practice. This study describes clinical practice results of IVI therapy without transfusion.STUDY DESIGN AND METHODSIn this multicenter retrospective observational study, data of severely anemic outpatients treated only with high‐dose IVI with ferric carboxymaltose were collected. Inclusion criteria were hemoglobin (Hb) level of less than 7.0 g/dL and ferritin level of less than 30 ng/mL or mean corpuscular volume of less than 75 fL.RESULTSOverall, 303 patients referred to the anemia clinic mainly from primary health care centers (46.2%) or the emergency department (28.7%) met the inclusion criteria. Median (interquartile range [IQR]) age was 47 (37‐62) years and 84.5% were female. The median (IQR) Hb concentration at first visit was 6.5 (6.1‐6.8) g/dL, 64 patients (21.1%) presented with a Hb level of less than 6.0 g/dL at diagnosis, and 11 of them (3.6%) had extreme anemia (Hb ≤ 5 g/dL). Gynecologic and gastroenteric bleeding were the main cause. After a mean IV administration of 1500 mg of iron, the Hb increased by a median of 5.7 g/dL. Thirteen patients experienced only mild side effects.CONCLUSIONSIn chronic very severe sideropenic anemias, third‐generation IVI is effective and safe for quick correction and avoidance of red blood cell transfusion. These results suggest that more specific guidelines for this clinical setting are warranted.

Organizational Strategies for the Management of Intravenous Iron Therapy in Non-Hospitalized Settings: A Safe Opportunity to Implement Patient Blood Management in Italy

“…Though necessitating careful execution with a full understanding of the potential undesired effects [ 43 , 44 ], intravenous iron infusion is an excellent strategy for improving patient quality of life and reducing recourse to allogeneic transfusions. There are numerous articles [ 45 , 46 , 47 , 48 ] in support of the efficacy and safety of treating anemia with intravenous iron infusion. The document issued by Emilia Romagna opens the way for the extensive use of iron infusion in the field.…”

Indications and hemoglobin thresholds for red blood cell transfusion and iron replacement in adults with gastrointestinal bleeding: An algorithm proposed by gastroenterologists and patient blood management experts

“…RBC transfusion should be considered for patients with hemoglobin levels < 5 g/dL and for those with hemoglobin levels < 6 g/dL in the presence of risk factors such as cardiopulmonary failure, ischemic heart disease, cardiac arrhythmia, and COPD. These hemoglobin thresholds are supported by studies showing how in patients with severe chronic anemia (hemoglobin < 6 g/dL), and even extreme anemia (hemoglobin ≤ 5 g/dL) due to digestive or gynecological blood loss, third-generation intravenous iron is effective and safe for the rapid correction of anemia (28,72). This policy helps to avoid unnecessary blood transfusions.…”

“…Hemoglobin thresholds for transfusion in the case of chronic anemia associated with occult GI bleeding (Figure 4) differ from those used in the setting of acute bleeding (Figure 2) (72,73,81). RBC transfusion should be considered for patients with hemoglobin levels < 5 g/dL and for those with hemoglobin levels < 6 g/dL in the presence of risk factors such as cardiopulmonary failure, ischemic heart disease, cardiac arrhythmia, and COPD.…”

“…In the absence of risk factors and warning signs or organ dysfunction, a hemoglobin level of < 7 g/dL is often used as the cutoff for transfusion when a restrictive approach is being used ( 16 , 17 , 20 , 73 , 74 ). This threshold is not mandatory and the final decision whether to transfuse should be made on an individual basis.…”

“…In patients with iron deficiency/iron deficiency anemia due to chronic GI bleeding, treatment with intravenous iron can be a very good alternative to RBC transfusion, thereby reducing or avoiding the need for transfusions ( 73 ). However, transfusion should be used in these patients when pharmacologic treatment of anemia has failed or in cases of severe anemia.…”