1
|
Neogi SB, Devasenapathy N, Singh R, Bhushan H, Shah D, Divakar H, Zodpey S, Malik S, Nanda S, Mittal P, Batra A, Chauhan MB, Yadav S, Dongre H, Saluja S, Malhotra V, Gupta A, Sangwan R, Radhika AG, Singh A, Bhaskaran S, Kotru M, Sikka M, Agarwal S, Francis P, Mwinga K, Baswal D. Safety and effectiveness of intravenous iron sucrose versus standard oral iron therapy in pregnant women with moderate-to-severe anaemia in India: a multicentre, open-label, phase 3, randomised, controlled trial. LANCET GLOBAL HEALTH 2020; 7:e1706-e1716. [PMID: 31708151 DOI: 10.1016/s2214-109x(19)30427-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/27/2019] [Accepted: 09/17/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Intravenous iron sucrose is a promising therapy for increasing haemoglobin concentration; however, its effect on clinical outcomes in pregnancy is not yet established. We aimed to assess the safety and clinical effectiveness of intravenous iron sucrose (intervention) versus standard oral iron (control) therapy in the treatment of women with moderate-to-severe iron deficiency anaemia in pregnancy. METHODS We did a multicentre, open-label, phase 3, randomised, controlled trial at four government medical colleges in India. Pregnant women, aged 18 years or older, at 20-28 weeks of gestation with a haemoglobin concentration of 5-8 g/dL, or at 29-32 weeks of gestation with a haemoglobin concentration of 5-9 g/dL, were randomly assigned (1:1) to receive intravenous iron sucrose (dose was calculated using a formula based on bodyweight and haemoglobin deficit) or standard oral iron therapy (100 mg elemental iron twice daily). Logistic regression was used to compare the primary maternal composite outcome consisting of potentially life-threatening conditions during peripartum and postpartum periods (postpartum haemorrhage, the need for blood transfusion during and after delivery, puerperal sepsis, shock, prolonged hospital stay [>3 days following vaginal delivery and >7 days after lower segment caesarean section], and intensive care unit admission or referral to higher centres) adjusted for site and severity of anaemia. The primary outcome was analysed in a modified intention-to-treat population, which excluded participants who refused to participate after randomisation, those who were lost to follow-up, and those whose outcome data were missing. Safety was assessed in both modified intention-to-treat and as-treated populations. The data safety monitoring board recommended stopping the trial after the first interim analysis because of futility (conditional power 1·14% under the null effects, 3·0% under the continued effects, and 44·83% under hypothesised effects). This trial is registered with the Clinical Trial Registry of India, CTRI/2012/05/002626. FINDINGS Between Jan 31, 2014, and July 31, 2017, 2018 women were enrolled, and 999 were randomly assigned to the intravenous iron sucrose group and 1019 to the standard therapy group. The primary maternal composite outcome was reported in 89 (9%) of 958 patients in the intravenous iron sucrose group and in 95 (10%) of 976 patients in the standard therapy group (adjusted odds ratio 0·95, 95% CI 0·70-1·29). 16 (2%) of 958 women in the intravenous iron sucrose group and 13 (1%) of 976 women in the standard therapy group had serious maternal adverse events. Serious fetal and neonatal adverse events were reported by 39 (4%) of 961 women in the intravenous iron sucrose group and 45 (5%) of 982 women in the standard therapy group. At 6 weeks post-randomisation, minor side-effects were reported by 117 (16%) of 737 women in the intravenous iron sucrose group versus 155 (21%) of 721 women in the standard therapy group. None of the serious adverse events was found to be related to the trial procedures or the interventions as per the causality assessment made by the trial investigators, ethics committees, and regulatory body. INTERPRETATION The study was stopped due to futility. There is insufficient evidence to show the effectiveness of intravenous iron sucrose in reducing clinical outcomes compared with standard oral iron therapy in pregnant women with moderate-to-severe anaemia. FUNDING WHO, India.
Collapse
Affiliation(s)
- Sutapa B Neogi
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, India.
| | | | - Ranjana Singh
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, India
| | | | - Duru Shah
- Breach Candy Hospital, Mumbai, India; Indian College of Obstetricians and Gynaecologists, Federation of Obstetrics and Gynaecology Society of India, Mumbai, India
| | | | - Sanjay Zodpey
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, India
| | - Sunita Malik
- Department of Obstetrics and Gynaecology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Smiti Nanda
- Department of Obstetrics and Gynaecology, Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, India
| | - Pratima Mittal
- Department of Obstetrics and Gynaecology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Achla Batra
- Department of Obstetrics and Gynaecology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Meenakshi B Chauhan
- Department of Obstetrics and Gynaecology, Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, India
| | - Sunita Yadav
- Department of Obstetrics and Gynaecology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Harsha Dongre
- Department of Obstetrics and Gynaecology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sumita Saluja
- Department of Hematology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Vani Malhotra
- Department of Obstetrics and Gynaecology, Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, India
| | - Anjali Gupta
- Department of Obstetrics and Gynaecology, Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, India
| | - Roopa Sangwan
- Department of Obstetrics and Gynaecology, Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, India
| | - A G Radhika
- Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India
| | - Alpana Singh
- Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India
| | - Sruti Bhaskaran
- Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India
| | - Mrinalini Kotru
- Department of Pathology, Guru Teg Bahadur Hospital, New Delhi, India
| | - Meera Sikka
- Department of Pathology, Guru Teg Bahadur Hospital, New Delhi, India
| | - Sonika Agarwal
- Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India
| | | | | | - Dinesh Baswal
- Ministry of Health and Family Welfare, Government of India, New Delhi, India
| |
Collapse
|
2
|
Qassim A, Mol BW, Grivell RM, Grzeskowiak LE. Safety and efficacy of intravenous iron polymaltose, iron sucrose and ferric carboxymaltose in pregnancy: A systematic review. Aust N Z J Obstet Gynaecol 2017; 58:22-39. [PMID: 28921558 DOI: 10.1111/ajo.12695] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 08/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intravenous (IV) iron in pregnancy is useful where oral iron is not tolerated or a rapid replenishment of iron is required. AIMS To review the literature on the efficacy and safety of different IV iron preparations in the management of antenatal iron-deficiency anaemia (IDA). MATERIALS AND METHODS We searched MEDLINE, Embase and Scopus from inception to June 2016. Eligible studies were randomised controlled trials (RCTs) and observational studies, involving administration of IV iron (ferric carboxymaltose (FCM), iron polymaltose (IPM) or iron sucrose (IS)), regardless of comparator, to manage antenatal IDA. Two independent reviewers selected studies, extracted data and assessed quality. RESULTS A total of 47 studies were eligible (21 RCTs and 26 observational studies), investigating IS (n = 2635; 41 studies), FCM (n = 276; four studies) and IPM (n = 164; three studies). All IV preparations resulted in significant improvements in haematological parameters, with a median increase of 21.8 g/L at 3-4 weeks and 30.1 g/L by delivery, but there was no evidence of any associated improvements in clinical outcomes. A greater median increase in Hb was observed with a high (25 g/L; range: 20-39.6 g/L) compared with low dose (20 g/L; range: 6.2-50.3 g/L). The median prevalence of adverse drug reactions for IPM (2.2%; range: 0-4.5%) was lower than FCM (5.0%; range: 0-20%) and IS (6.7%; range: 0-19.5%). CONCLUSION While IV iron in pregnancy improves haematological parameters, there is an absence of evidence for improvements in important maternal or perinatal outcomes. No single preparation of IV iron appeared to be superior, with the current IV iron preparation of choice largely determined by cost and convenience around administration.
Collapse
Affiliation(s)
- Alaa Qassim
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA, Australia
| | - Ben W Mol
- The Robinson Research Institute, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Rosalie M Grivell
- The Robinson Research Institute, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia.,Department of Obstetrics and Gynaecology, Flinders Medical Centre, Bedford Park, SA, Australia.,Department of Obstetrics and Gynaecology, School of Medicine, Flinders University, Bedford Park, SA, Australia
| | - Luke E Grzeskowiak
- The Robinson Research Institute, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia.,SA Pharmacy, SA Health, Flinders Medical Centre, Bedford Park, SA, Australia
| |
Collapse
|