Iron therapy for the treatment of iron deficiency in chronic heart failure: intravenous or oral?

Abstract

This article considers the use and modality of iron therapy to treat iron deficiency in patients with heart failure, an aspect of care which has received relatively little attention compared with the wider topic of anaemia management. Iron deficiency affects up to 50% of heart failure patients, and is associated with poor quality of life, impaired exercise tolerance, and mortality independent of haematopoietic effects in this patient population. The European Society of Cardiology Guidelines for heart failure 2012 recommend a diagnostic work-up for iron deficiency in patients with suspected heart failure. Iron absorption from oral iron preparations is generally poor, with slow and often inefficient iron repletion; moreover, up to 60% of patients experience gastrointestinal side effects. These problems may be exacerbated in heart failure due to decreased gastrointestinal absorption and poor compliance due to pill burden. Evidence for clinical benefits using oral iron is lacking. I.v. iron sucrose has consistently been shown to improve exercise capacity, cardiac function, symptom severity, and quality of life. Similar findings were observed recently for i.v. ferric carboxymaltose in patients with systolic heart failure and impaired LVEF in the double-blind, placebo-controlled FAIR-HF and CONFIRM-HF trials. I.v. iron therapy may be better tolerated than oral iron, although confirmation in longer clinical trials is awaited. Routine diagnosis and management of iron deficiency in patients with symptomatic heart failure regardless of anaemia status is advisable, and, based on current evidence, prompt intervention using i.v. iron therapy should now be considered.

The impact of iron deficiency and anaemia on exercise capacity and outcomes in patients with chronic heart failure. Results from the Studies Investigating Co-morbidities Aggravating Heart Failure

“…Various triggers that lead to the activation of T cells and monocytes are directly or indirectly involved in the release of inflammatory cytokines [24]. Nevertheless, results of many published studies of anaemia correction are complicated by various factors including methodological concerns such as open-label designs instead of double-blind studies [25,26,27,28,29]. But according to a number of studies, complete correction of anaemia is not always beneficial and in some cases is associated with adverse effects.…”

Cardiac Cachexia: Perspectives for Prevention and Treatment

“…56 Both anemia and iron deficiency are associated with reduced exercise tolerance. 58 As decreased exercise capacity is related to a reduced skeletal muscle mass, anemia and iron deficiency may be involved in cachexia development. Diagnostic evaluation for reversible causes of anemia and subsequent treatment is appropriate in all patients.…”

Investigation and treatment for iron deficiency in heart failure: the unmet need in Lower and Middle Income Countries

“…The relatively recent availability of iron-carboxymaltose or iron-sucrose parental iron preparations with relatively low toxicity (compared with the older iron-dextran preparation) and the ability to give substantial and therapeutic iron supplementation in one or two doses has led to enormous interest in the therapeutic use of such preparations to a wide spectrum of patients (McDonagh & Macdougall, 2015).…”