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Chauhan A, Lucas S, Garg M. Hypophosphataemia following ferric carboxymaltose and ferric derisomaltose: case closed, but questions remain. Gut 2024; 73:1039. [PMID: 37193585 DOI: 10.1136/gutjnl-2023-330061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Ayushi Chauhan
- Department of Gastroenterology, Northern Health, Melbourne, Victoria, Australia
| | - Sarah Lucas
- Department of Gastroenterology, Northern Health, Melbourne, Victoria, Australia
| | - Mayur Garg
- Department of Gastroenterology, Northern Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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2
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Grino M, Rigaux M, Lagarde AV, Robert V, Papailhau C, Vincentelli MB. [Hypophosphatemia after injectable iron treatments in adults: Comparison between ferric carboxymaltose and iron sucrose]. ANNALES PHARMACEUTIQUES FRANÇAISES 2023; 81:790-800. [PMID: 36963655 DOI: 10.1016/j.pharma.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 03/26/2023]
Abstract
Hypophosphatemia is a recognized side effect of treatment of iron deficiency anemias with injectable iron. We analyzed 35 clinical trials that used ferric carboxymaltose (FCM) or iron sucrose (IS). Hypophosphatemia prevalence ranged from 0 to 91.7%. FCM-induced a significant (P<0.001) greater hypophosphatemia prevalence and phosphatemia decrease than IS (52.0% [95% CI: 42.2-61.8%] vs. 7.7% [95% CI: -2.8 to 18.2%] and -1.12mmol/L [95% CI: -1.36 to -0.89mmol/L] vs. -0.13mmol/L [95% CI: -0.59 to 0.32mmol/L]). FCM-induced hypophosphatemia was dose-dependent. The nadir of hypophosphatemia was reached in almost all studies after 7 and 14days. Hypophosphatemia persisted at the end of the study in 53.8% of the reported studies that used FCM and lasted up to 6months. FCM-induced an increase in intact circulating fibroblast growth factor 23 and in renal phosphorus excretion while serum 1-25 dihydroxyvitamin D was decreased. Risk factors for hypophosphatemia after FCM therapy were low basal circulating phosphate or ferritin, low body weight, high glomerular filtration rate, serum parathyroid hormone or hemoglobin and age, whereas renal insufficiency was associated with a lower risk. In conclusion, hypophosphatemia is common after treatment with injectable iron, FCM being associated with a higher risk than IS and with disorders of phosphocalcium metabolism. Monitoring of blood phosphate and 1-25 dihydroxyvitamin D could be considered during FCM therapy.
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Affiliation(s)
- Michel Grino
- Département de recherche clinique, Centre gérontologique départemental de Marseille, 176, avenue de Montolivet, 13012 Marseille, France.
| | - Marine Rigaux
- Pharmacie à usage intérieur, Centre gérontologique départemental de Marseille, 176, avenue de Montolivet, 13012 Marseille, France
| | - Anne-Violette Lagarde
- Pharmacie à usage intérieur, Centre gérontologique départemental de Marseille, 176, avenue de Montolivet, 13012 Marseille, France
| | - Vincent Robert
- Pharmacie à usage intérieur, Centre gérontologique départemental de Marseille, 176, avenue de Montolivet, 13012 Marseille, France
| | - Charlotte Papailhau
- Pharmacie à usage intérieur, Centre gérontologique départemental de Marseille, 176, avenue de Montolivet, 13012 Marseille, France
| | - Marie-Bénédicte Vincentelli
- Pharmacie à usage intérieur, Centre gérontologique départemental de Marseille, 176, avenue de Montolivet, 13012 Marseille, France
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3
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Jara Vidal M, Ruiz de Assín Valverde A, Aznar Rodríguez S. Severe hypophospathemia secondary to intravenous iron. Med Clin (Barc) 2023:S0025-7753(23)00166-5. [PMID: 37211481 DOI: 10.1016/j.medcli.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/12/2023] [Accepted: 03/15/2023] [Indexed: 05/23/2023]
Affiliation(s)
- Marina Jara Vidal
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Albacete, España.
| | | | - Silvia Aznar Rodríguez
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Albacete, España
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Vilaca T, Velmurugan N, Smith C, Abrahamsen B, Eastell R. Osteomalacia as a Complication of Intravenous Iron Infusion: A Systematic Review of Case Reports. J Bone Miner Res 2022; 37:1188-1199. [PMID: 35426179 PMCID: PMC9322686 DOI: 10.1002/jbmr.4558] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/18/2022] [Accepted: 04/08/2022] [Indexed: 12/05/2022]
Abstract
Randomized control trials (RCTs) have shown that certain intravenous iron preparations can induce high levels of fibroblast growth factor 23 (FGF-23) and persistent hypophosphatemia. Repeated iron infusions may lead to prolonged hypophosphatemia and osteomalacia events not captured by RCTs. Several previous case reports have described skeletal adverse effects after repeated iron infusions. To characterize these effects, we conducted a systematic review of case reports. MEDLINE, Embase, Web of Science, and Cochrane databases were searched in March 2021. We selected case reports of patients ≥16 years old. Study quality was assessed using the tool from Murad and colleagues. We report the results in a narrative summary. We identified 28 case reports, reporting 30 cases. Ages ranged from 28 to 80 years (median 50 years). Most patients (n = 18) received ferric carboxymaltose (FCM), whereas 8 received saccharated ferric oxide (SFO) and 3 received iron polymaltose (IPM). All but 2 cases had more than five infusions (range 2 to 198, median 17). The lowest phosphate levels ranged from 0.16 to 0.77 mmol/L (median 0.36 mmol/L). Intact FGF-23 (iFGF-23) was high when measured. Serum 25OH vitamin D was low in 10 of 21 cases measured and 1,25(OH)2 vitamin D in 12 of 18. Alkaline phosphatase was high in 18 of 22 cases. Bone or muscle pain was reported in 28 of the 30 cases. Twenty patients had pseudofractures, 9 had fractures, and 6 patients had both. All 15 available bone scans showed focal isotope uptake. Case reports tend to report severe cases, so potential reporting bias should be considered. Osteomalacia is a potential complication of repeated iron infusion, especially in patients with gastrointestinal disorders receiving prolonged therapy. Pain and fractures or pseudofractures are common clinical findings, associated with low phosphate, high iFGF-23, high alkaline phosphatase, and abnormal isotope bone scan. Discontinuing or switching the iron formulation was an effective intervention in most cases. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Tatiane Vilaca
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Christopher Smith
- Open Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bo Abrahamsen
- Department of Medicine, Holbaek Hospital, Holbaek, Denmark.,Open Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Denmark and NDORMS, University of Oxford, Oxford, UK
| | - Richard Eastell
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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Blumenstein I, Shanbhag S, Langguth P, Kalra PA, Zoller H, Lim W. Newer formulations of intravenous iron: a review of their chemistry and key safety aspects - hypersensitivity, hypophosphatemia, and cardiovascular safety. Expert Opin Drug Saf 2021; 20:757-769. [PMID: 33993818 DOI: 10.1080/14740338.2021.1912010] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The newest intravenous (IV) iron products show an improved safety profile over predecessors, allowing for the rapid administration of relatively high doses. Ferric derisomaltose (FDI; also known as iron isomaltoside), ferric carboxymaltose (FCM), and ferumoxytol (FER), are successful treatments for iron deficiency (Europe; FDI and FCM) and iron deficiency anemia (US; FDI, FCM, and FER).Areas covered: This review focusses on the chemistry and structure of FDI, FCM, and FER, and on three key aspects of IV iron safety: (1) hypersensitivity; (2) hypophosphatemia and sequelae; (3) cardiovascular safety.Expert opinion: Although the safety of modern IV iron has improved, immediate infusion reactions and the development of hypophosphatemia must be appreciated and recognized by those who prescribe and administer IV iron. Immediate infusion reactions can occur with any IV iron and are usually mild; severe reactions - particularly anaphylaxis - are extremely rare. The recognition and appropriate management of infusion reactions is an important consideration to the successful administration of IV iron. Severe, persistent, hypophosphatemia is a specific side effect of FCM. No cardiovascular safety signal has been identified for IV iron. Ongoing trials in heart failure will provide additional long-term efficacy and safety data.
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Affiliation(s)
- Irina Blumenstein
- Medical Department 1, Department of Gastroenterology, Hepatology, and Clinical Nutrition, University Clinic Frankfurt, Frankfurt, Germany
| | - Satish Shanbhag
- Department of Hematology/Medical Oncology, Cancer Specialists of North Florida, Fleming Island, FL, USA.,Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Peter Langguth
- Institute of Pharmacy and Biochemistry, Department of Biopharmaceutics and Pharmaceutical Technology, Johannes Gutenberg University, Mainz, Germany
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Heinz Zoller
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
| | - Wendy Lim
- Department of Medicine, Division of Hematology and Thromboembolism, St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
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Kassianides X, Bhandari S. Hypophosphataemia, fibroblast growth factor 23 and third-generation intravenous iron compounds: a narrative review. Drugs Context 2021; 10:dic-2020-11-3. [PMID: 33519940 PMCID: PMC7819638 DOI: 10.7573/dic.2020-11-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/08/2020] [Indexed: 02/06/2023] Open
Abstract
Third-generation intravenous (i.v.) iron preparations are safe and efficacious and are increasingly used in the treatment of iron-deficiency anaemia. Hypophosphataemia is emerging as an established side-effect following the administration of certain compounds. Symptoms of hypophosphataemia can be masked by their similarity to those of iron-deficiency anaemia and both acute and chronic hypophosphataemia can be detrimental. Hypophosphataemia appears to be linked to imbalances in the metabolism of the phosphatonin fibroblast growth factor 23. In this narrative review, we discuss the possible pathophysiology behind this phenomenon, the studies comparing third-generation i.v. iron compounds, and the potential implications of the changes in fibroblast growth factor 23 and hypophosphataemia. We also present an algorithm of how to approach such patients requiring i.v. iron in anticipation of hypophosphataemia and how the impact related to it can be minimized.
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Affiliation(s)
- Xenophon Kassianides
- Department of Academic Renal Research, Hull University Teaching Hospitals NHS Trust, 2nd Floor Alderson House, Hull Royal Infirmary, Anlaby Road, Kingston upon Hull, UK
| | - Sunil Bhandari
- Department of Academic Renal Research, Hull University Teaching Hospitals NHS Trust, 2nd Floor Alderson House, Hull Royal Infirmary, Anlaby Road, Kingston upon Hull, UK
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Pasricha SR, Tye-Din J, Muckenthaler MU, Swinkels DW. Iron deficiency. Lancet 2021; 397:233-248. [PMID: 33285139 DOI: 10.1016/s0140-6736(20)32594-0] [Citation(s) in RCA: 349] [Impact Index Per Article: 116.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/06/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023]
Abstract
Iron deficiency is one of the leading contributors to the global burden of disease, and particularly affects children, premenopausal women, and people in low-income and middle-income countries. Anaemia is one of many consequences of iron deficiency, and clinical and functional impairments can occur in the absence of anaemia. Iron deprivation from erythroblasts and other tissues occurs when total body stores of iron are low or when inflammation causes withholding of iron from the plasma, particularly through the action of hepcidin, the main regulator of systemic iron homoeostasis. Oral iron therapy is the first line of treatment in most cases. Hepcidin upregulation by oral iron supplementation limits the absorption efficiency of high-dose oral iron supplementation, and of oral iron during inflammation. Modern parenteral iron formulations have substantially altered iron treatment and enable rapid, safe total-dose iron replacement. An underlying cause should be sought in all patients presenting with iron deficiency: screening for coeliac disease should be considered routinely, and endoscopic investigation to exclude bleeding gastrointestinal lesions is warranted in men and postmenopausal women presenting with iron deficiency anaemia. Iron supplementation programmes in low-income countries comprise part of the solution to meeting WHO Global Nutrition Targets.
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Affiliation(s)
- Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.
| | - Jason Tye-Din
- Immunology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Martina U Muckenthaler
- Department of Pediatric Oncology, Hematology, and Immunology and Molecular Medicine Partnership Unit, University of Heidelberg, Heidelberg, Germany; Molecular Medicine Partnership Unit, European Molecular Biology Laboratory, Heidelberg, Germany; Translational Lung Research Center, German Center for Lung Research, Heidelberg, Germany; German Centre for Cardiovascular Research, Partner Site Heidelberg, Mannheim, Germany
| | - Dorine W Swinkels
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
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Spagnuolo R, Abenavoli L, Larussa T, Iannelli C, Pellicano R, Fagoonee S, Doldo P, Luzza F. Safety profile of intravenous iron in inflammatory bowel disease: an up-to-date overview. Minerva Gastroenterol (Torino) 2020; 68:111-118. [PMID: 33267572 DOI: 10.23736/s2724-5985.20.02819-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Up to 30-70% of patients may experience mild and moderate side effects during iron therapy and this is often associated with a poor adherence to therapy. Anemia is frequent in patients with active inflammatory bowel disease (IBD), due to both iron deficiency and chronic inflammation, therefore iron supplementation is frequently needed. Considering that gastrointestinal disorders are the most common side effects with oral iron, in IBD patients intravenous administration must be preferred. Although intravenous iron supplementation remains the most effective therapy of IBD-associated iron deficiency anemia, the perception of risk related to intravenous administration by clinicians could limit this successful strategy. In this narrative review we provided an up to date on the safety of the different iron formulations for intravenous administration, by reporting the most recent studies in IBD patients.
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Affiliation(s)
- Rocco Spagnuolo
- Department of Clinical and Experimental Medicine, "Magna Graecia" University, Catanzaro, Italy
| | - Ludovico Abenavoli
- Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy -
| | - Tiziana Larussa
- Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Chiara Iannelli
- Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Rinaldo Pellicano
- Unit of Gastroenterology, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Sharmila Fagoonee
- Institute of Biostructure and Bioimaging, National Research Council, Molecular Biotechnology Center, Turin, Italy
| | - Patrizia Doldo
- Department of Clinical and Experimental Medicine, "Magna Graecia" University, Catanzaro, Italy
| | - Francesco Luzza
- Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy
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Garg M, Chand S, Weenink P, Yunqiu Wu K, Cheng RKY. Letter: assessing iron deficiency in patients with IBD-a step in the right direction, but uncertainty remains. Aliment Pharmacol Ther 2020; 52:413-415. [PMID: 32592245 DOI: 10.1111/apt.15833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Mayur Garg
- Department of Gastroenterology, Northern Hospital, Melbourne, Vic, Australia.,Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Vic, Australia.,Department of Medicine, University of Melbourne, Melbourne, Vic, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Vic, Australia.,Department of Gastroenterology, Eastern Health, Box Hill, Vic, Australia
| | - Sheital Chand
- Department of Gastroenterology, Eastern Health, Box Hill, Vic, Australia
| | - Petrus Weenink
- Eastern Health Clinical School, Monash University, Melbourne, Vic, Australia
| | - Karen Yunqiu Wu
- Eastern Health Clinical School, Monash University, Melbourne, Vic, Australia
| | - Richard K Y Cheng
- Department of Gastroenterology, Redcliffe Hospital, Redcliffe, Qld, Australia
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