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Van Doren L, Steinheiser M, Boykin K, Taylor KJ, Menendez M, Auerbach M. Expert consensus guidelines: Intravenous iron uses, formulations, administration, and management of reactions. Am J Hematol 2024; 99:1338-1348. [PMID: 38282557 DOI: 10.1002/ajh.27220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 01/01/2024] [Accepted: 01/08/2024] [Indexed: 01/30/2024]
Abstract
Intravenous iron has become an essential component for the treatment of iron deficiency and iron deficiency anemia. Individuals administering Intravenous iron should have knowledge in intravenous iron administration, including a pre-infusion assessment to evaluate infusion reaction risks, pre- and post-infusion monitoring, identification of and management of infusion reactions, accurate documentation of these reactions, laboratory monitoring and recognition and management of treatment-emergent hypophosphatemia. This comprehensive consensus provides step-by-step guidance and tools for practitioners to promote safe delivery of intravenous iron, recognition, and management of infusion reactions and treatment-emergent hypophosphatemia.
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Affiliation(s)
- Layla Van Doren
- Section of Hematology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Kristen Boykin
- Florida Cancer Specialists and Research Institute, Florida, USA
| | | | - Monica Menendez
- FEM Iron Infusion Centers by Heme Onc Call, Miami, Florida, USA
| | - Michael Auerbach
- Department of Medicine, Georgetown University School of Medicine, Washington, District of Columbia, USA
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Clark P. Iron Deficiency Related to Obesity. JOURNAL OF INFUSION NURSING 2024; 47:163-174. [PMID: 38744241 DOI: 10.1097/nan.0000000000000546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
There is a direct correlation between being overweight and iron deficiency. Physiological changes occur in obese adipose cells that contribute to the development of iron deficiency (ID) and iron deficiency anemia (IDA). These changes disrupt the normal iron metabolic checks and balances. Furthermore, bariatric surgery can lead to long-term ID and IDA. Oral iron supplementation may not be effective for many of these patients. Intravenous iron infusions can significantly increase the quality of life for individuals experiencing this condition but are also associated with potentially serious complications. Adequate knowledge about intravenous (IV) iron administration can greatly increase the safety of this beneficial therapy. This review article explains the relationship between obesity, ID/IDA, bariatric surgery and the safe administration of IV iron.
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Affiliation(s)
- Pamela Clark
- Author Affiliations: Houston Methodist Sugar Land Hospital, Outpatient IV Therapy Clinic, Sugar Land, Texas (Clark)
- Pamela Clark, RN, BSN, CRNI, has been a registered nurse for 47 years, practicing exclusively in infusion nursing for 40 of those years. She has worked in multiple practice settings, including home health, skilled nursing facilities, free-standing infusion centers, physician office-based infusion centers, and hospital-based infusion centers. Pamela has presented at Infusion Nurses Society conferences on various topics related to infusion nursing and is president of the Greater Houston Area Chapter of the Infusion Nurses Society
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Almodares AAS, Elder GJ, Abrahamsen B. Sustained hypophosphatemia after denosumab in a patient on hemodialysis. Bone 2024; 181:117045. [PMID: 38341165 DOI: 10.1016/j.bone.2024.117045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/19/2023] [Accepted: 02/06/2024] [Indexed: 02/12/2024]
Abstract
An 81-year-old Caucasian man who had commenced thrice weekly hemodialysis (HD) three months earlier, presented with a hip fracture, two vertebral fractures and a bone mineral density T-score of -3.6. He had received weekly iron sucrose infusions for 6 weeks and alphacalcidol on dialysis days. Although he suffered from coeliac disease and cirrhosis, he was fully ambulatory and well-nourished. He was normocalcaemic with a marginally low plasma phosphate and the PTH was 11.8 pmol/L (<2-times the upper range of the assay). In view of his severe osteoporosis, it was decided to treat him with denosumab (dmab). Laboratory assessment 2 weeks post dmab showed severe hypophosphatemia and hypocalcemia; phosphate 0.11 mmol/L and ionized calcium 0.83 mmol/L, and he was admitted for intravenous phosphate infusion. Three months later he remained on a phosphate supplement. The case illustrates that, in addition to the risks of hypocalcemia in patients with kidney failure and high bone turnover, kidney failure patients without evidence of high bone turnover, can also be at risk of hypocalcemia and severe hypophosphatemia requiring acute hospitalization and phosphate infusion. The potential role of compromised phosphate absorption versus increased deposition will be discussed. We recommend a cautious approach to dmab therapy in patients on dialysis, with evaluation of bone turnover and serum phosphate levels prior to initiation of treatment.
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Affiliation(s)
- Ahmed A S Almodares
- Department of Medicine 1 - Endocrinology- Nephrology and Cardiology, Holbæk Hospital, Holbæk, Denmark
| | - Grahame J Elder
- Skeletal Biology Program, Garvan Institute of Medical Research, Australia; Department of Renal Medicine, Westmead Hospital, Sydney, Australia
| | - Bo Abrahamsen
- Department of Medicine 1 - Endocrinology- Nephrology and Cardiology, Holbæk Hospital, Holbæk, Denmark.; Open Patient Data Exploratory Network (OPEN), University of Southern Denmark, Odense, Denmark.
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Manokaran K, Spaan J, Cataldo G, Lyons C, Mitchell PD, Sare T, Zimmerman LA, Rufo PA. Inpatient management of iron deficiency anemia in pediatric patients with inflammatory bowel disease: A single center experience. World J Clin Pediatr 2024; 13:89318. [PMID: 38596440 PMCID: PMC11000066 DOI: 10.5409/wjcp.v13.i1.89318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/07/2024] [Accepted: 01/22/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Screening for iron deficiency anemia (IDA) is important in managing pediatric patients with inflammatory bowel disease (IBD). Concerns related to adverse reactions may contribute to a reluctance to prescribe intravenous (IV) iron to treat IDA in this population. AIM To track the efficacy and safety of IV iron therapy in treating IDA in pediatric IBD patients admitted to our center. METHODS A longitudinal observational cohort study was performed on 236 consecutive pediatric patients admitted to our tertiary IBD care center between September 2017 and December 2019. 92 patients met study criteria for IDA, of which 57 received IV iron, 17 received oral iron, and 18 were discharged prior to receiving iron therapy. RESULTS Patients treated with IV iron during their hospitalization experienced a significant increase of 1.9 (± 0.2) g/dL in mean (± SE) hemoglobin (Hb) concentration by the first ambulatory follow-up, compared to patients who received oral iron 0.8 (± 0.3) g/dL or no iron 0.8 (± 0.3) g/dL (P = 0.03). One out of 57 (1.8%) patients that received IV iron therapy experienced an adverse reaction. CONCLUSION Our findings demonstrate that treatment with IV iron therapy is safe and efficacious in improving Hb and iron levels in pediatric patients with IDA and active IBD.
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Affiliation(s)
- Krishanth Manokaran
- Center for Inflammatory Bowel Disease, Boston Children's Hospital, Boston, MA 02115, United States
| | - Jonathan Spaan
- Center for Inflammatory Bowel Disease, Boston Children's Hospital, Boston, MA 02115, United States
| | - Giulio Cataldo
- Center for Inflammatory Bowel Disease, Boston Children's Hospital, Boston, MA 02115, United States
| | - Christopher Lyons
- Center for Inflammatory Bowel Disease, Boston Children's Hospital, Boston, MA 02115, United States
| | - Paul D Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA 02115, United States
| | - Tatyana Sare
- Center for Inflammatory Bowel Disease, Boston Children's Hospital, Boston, MA 02115, United States
| | - Lori A Zimmerman
- Center for Inflammatory Bowel Disease, Boston Children's Hospital, Boston, MA 02115, United States
| | - Paul A Rufo
- Center for Inflammatory Bowel Disease, Boston Children's Hospital, Boston, MA 02115, United States
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Jin J, Ran Z, Noseda E, Roubert B, Marty M, Mezzacasa A, Göring UM. A randomized, controlled, open label non-inferiority trial of intravenous ferric carboxymaltose versus iron sucrose in patients with iron deficiency anemia in China. Front Med 2024; 18:98-108. [PMID: 37897561 DOI: 10.1007/s11684-023-1001-2] [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: 08/16/2022] [Accepted: 04/01/2023] [Indexed: 10/30/2023]
Abstract
Iron deficiency (ID) and ID anemia (IDA) pose significant public health concerns in China. Although iron sucrose (IS) treatment is well-established in the country, ferric carboxymaltose (FCM) offers the advantage of higher doses and fewer infusions. This open label, randomized, controlled, non-inferiority trial was conducted at multiple sites in China to compare the outcomes of FCM (maximum of 2 doses, 500 or 1000 mg iron) and IS (up to 11 infusions, 200 mg iron) treatments in subjects with IDA. The primary endpoint was the achievement of hemoglobin (Hb) response (an increase of ⩾2 g/dL from baseline) within 8 weeks, whereas secondary endpoints included changes in Hb, transferrin saturation, and serum ferritin levels. Among the 371 randomized subjects, a similar percentage of subjects treated with FCM and IS achieved Hb-response (FCM 99.4%, IS 98.3%), thereby confirming the non-inferiority of FCM compared with IS (difference 1.12 (-2.15, 4.71; 95% confidence interval (CI))). Furthermore, a significantly higher proportion of FCM-treated subjects achieved early Hb-response at Week 2 (FCM 85.2%, IS 73.2%; difference 12.1 (3.31, 20.65; 95% CI)). Additionally, the increase in TSAT and serum ferritin levels from baseline was significantly greater at all time points for FCM-treated subjects. The safety profiles of FCM and IS were comparable, with the exception of transient hypophosphatemia and pyrexia, which are consistent with FCM's known safety profile. In conclusion, FCM proves to be an efficacious treatment for IDA, providing faster Hb-response and correction of ID with fewer administrations than IS.
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Affiliation(s)
- Jie Jin
- The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, 310058, China
| | - Zhihua Ran
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
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Iqbal TH, Kennedy N, Dhar A, Ahmed W, Pollock RF. Cost-utility analysis of ferric derisomaltose versus ferric carboxymaltose in patients with inflammatory bowel disease and iron deficiency anemia in England. J Med Econ 2024; 27:392-403. [PMID: 38391240 DOI: 10.1080/13696998.2024.2313932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
AIMS Anemia is the most common extraintestinal complication of inflammatory bowel disease (IBD), with approximately half of cases caused by iron deficiency (ID). Intravenous iron is the preferred ID anemia (IDA) treatment where oral iron is contraindicated, ineffective or not tolerated, or where ID correction is urgent. The objective was to evaluate the cost-utility of ferric derisomaltose (FDI) versus ferric carboxymaltose (FCM) in patients with IBD and IDA in England, in whom IV iron treatment is preferred. MATERIALS AND METHODS A patient-level simulation model was developed, capturing quality of life (QoL) differences based on SF-36v2 data from the PHOSPHARE-IBD randomized controlled trial, monitoring and incidence of post-infusion hypophosphatemia, and number of iron infusions required. Analyses were conducted over a five-year time horizon from the Department of Health and Social Care (DHSC) perspective, with healthcare provider and societal perspectives adopted in separate analyses. Future costs and effects were discounted at 3.5% per annum and one-way and probabilistic sensitivity analyses were performed. RESULTS FDI increased quality-adjusted life expectancy by 0.075 QALYs versus FCM from 2.57 QALYs to 2.65 QALYs per patient. Patients receiving FDI required 1.63 fewer iron infusions over the five-year time horizon, driving infusion-related cost savings of GBP 496 per patient (GBP 2,188 versus GBP 1,692) from the DHSC perspective. Costs of monitoring and treating hypophosphatemia after FCM were GBP 226, yielding total savings of GBP 722 per patient (GBP 2,414 versus GBP 1,692) over the five-year time horizon. FDI also led to reduced costs versus FCM in the societal and provider analyses and was therefore the dominant intervention across all three perspectives. LIMITATIONS The analysis did not capture patient adherence, hypophosphatemic osteomalacia, or fractures. CONCLUSIONS Results showed that FDI improved patient QoL and reduced direct healthcare expenditure versus FCM in patients with IBD and IDA in England.
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Affiliation(s)
| | | | - Anjan Dhar
- Department of Gastroenterology, County Durham & Darlington NHS Foundation Trust, Durham, UK
- School of Health and Life Sciences, Teesside University, Teesside, UK
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Van Doren L, Auerbach M. IV iron formulations and use in adults. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:622-629. [PMID: 38066930 PMCID: PMC10727060 DOI: 10.1182/hematology.2023000495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Intravenous iron has become a major component of the therapeutic armamentarium for iron deficiency and iron deficiency anemia. The earliest formulations were associated with unacceptable toxicity. Newer formulations, with complex carbohydrate cores that bind elemental iron more tightly, allow the administration of full therapeutic doses in 15 to 60 minutes. Nonetheless, a folklore of danger, fueled by earlier formulations no longer available, continues to foment caution. Complement-mediated minor infusion reactions, referred to as complement activation-related pseudo-allergy, resolve without therapy. Inappropriate intervention with vasopressors and H1 blockers converts these minor reactions into hemodynamically significant adverse events. Four new formulations, low-molecular-weight iron dextran, ferumoxytol, ferric carboxymaltose, and ferric derisomaltose, all approved for the treatment of iron deficiency in a host of conditions, are now widely used with an excellent safety profile. Herein, the administration, safety, indications, and management of infusion reactions are discussed. Treatment-emergent hypophosphatemia, a newly recognized side effect for some formulations, is also reviewed. Based on the preponderance of published evidence, intravenous iron should be moved up-front for the treatment of iron deficiency and iron deficiency anemia in those conditions in which oral iron is suboptimal.
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Affiliation(s)
- Layla Van Doren
- Division of Hematology, Yale School of Medicine, New Haven, CT
| | - Michael Auerbach
- Division of Hematology, Georgetown School of Medicine, Baltimore, MD
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Corsello A, Trovato CM, Dipasquale V, Bolasco G, Labriola F, Gottrand F, Verduci E, Diamanti A, Romano C. Refeeding Syndrome in Pediatric Age, An Unknown Disease: A Narrative Review. J Pediatr Gastroenterol Nutr 2023; 77:e75-e83. [PMID: 37705405 PMCID: PMC10642700 DOI: 10.1097/mpg.0000000000003945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/29/2023] [Indexed: 09/15/2023]
Abstract
Refeeding syndrome (RS) is characterized by electrolyte imbalances that can occur in malnourished and abruptly refed patients. Typical features of RS are hypophosphatemia, hypokalemia, hypomagnesemia, and thiamine deficiency. It is a potentially life-threatening condition that can affect both adults and children, although there is scarce evidence in the pediatric literature. The sudden increase in food intake causes a shift in the body's metabolism and electrolyte balance, leading to symptoms such as weakness, seizures, and even heart failure. A proper management with progressive increase in nutrients is essential to prevent the onset of this condition and ensure the best possible outcomes. Moreover, an estimated incidence of up to 7.4% has been observed in pediatric intensive care unit patients receiving nutritional support, alone or as an adjunct. To prevent RS, it is important to carefully monitor feeding resumption, particularly in severely malnourished individuals. A proper strategy should start with small amounts of low-calorie fluids and gradually increasing the calorie content and amount of food over several days. Close monitoring of electrolyte levels is critical and prophylactic use of dietary supplements such as thiamine may be required to correct any imbalances that may occur. In this narrative review, we aim to provide a comprehensive understanding of RS in pediatric clinical practice and provide a possible management algorithm.
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Affiliation(s)
- Antonio Corsello
- From the Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
- Department of Health Science, University of Milan, Milan, Italy
| | - Chiara Maria Trovato
- Hepatology Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Valeria Dipasquale
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood “G. Barresi,” University of Messina, Messina, Italy
| | - Giulia Bolasco
- Hepatology Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Flavio Labriola
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Frédéric Gottrand
- the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, CHU Lille, University of Lille, Lille, France
| | - Elvira Verduci
- From the Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
- Department of Health Science, University of Milan, Milan, Italy
| | - Antonella Diamanti
- Hepatology Gastroenterology and Nutrition Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Claudio Romano
- From the Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood “G. Barresi,” University of Messina, Messina, Italy
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Seng NWP, Barco JB, Wong MHL, Lim KX, Peh WM, Ng CT, Cushway T, Foo FJ, Koh FHX. Hypophosphatemia related to intravenous iron therapy with ferric carboxymaltose: A case series. Transfus Med 2023; 33:503-508. [PMID: 37263781 DOI: 10.1111/tme.12980] [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: 08/13/2022] [Revised: 01/28/2023] [Accepted: 04/13/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES This case series would like to highlight hypophosphatemia related to ferric carboxymaltose and its adverse clinical consequences. BACKGROUND Intravenous iron supplementation is a good alternative to oral iron replacement in iron deficiency anaemia due to its ability to correct iron deficit with minimal infusions without incurring the gastrointestinal side effects of oral iron replacement. Ferric carboxymaltose is one common formula for intravenous iron supplementation. However, an increasingly recognised adverse side-effect of intravenous ferric carboxymaltose is hypophosphatemia. There has been increasing reports and studies highlighting hypophosphatemia related to intra-venous iron therapy. Though initially thought to be transient and asymptomatic, recent studies have shown that persistent hypophosphatemia in iron therapy can result in debilitating disease including myopathy, fractures and osteomalacia. METHODS A retrospective analysis of all patients who had ferric carboxymaltose was performed. RESULTS We highlight 3 cases where hyposphatemia affected the clinical outcomes. CONCLUSION With the increased use of IV iron it is important to be aware of the high potential for hypophosphatemia secondary to ferric carboxymaltose.
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Affiliation(s)
- Nigel Wei-Peng Seng
- Ministry of Health Holdings, Singapore, Singapore
- Sengkang General Hospital, Singapore, Singapore
| | | | | | | | | | | | - Tim Cushway
- The Iron Suites Medical Centre, Singapore, Singapore
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Arora I, Kaprove A, Perrone R, Ceglia L. An Unusually Prolonged Case of FGF23-mediated Hypophosphatemia Secondary to Ferric Carboxymaltose Use. JCEM CASE REPORTS 2023; 1:luad117. [PMID: 37908221 PMCID: PMC10612470 DOI: 10.1210/jcemcr/luad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Indexed: 11/02/2023]
Abstract
Ferric carboxymaltose (FCM)-induced hypophosphatemia is seen in up to 75% of patients receiving this therapy for iron deficiency anemia. Hypophosphatemia has been attributed to increased circulating levels of fibroblast growth factor-23 (FGF23), the transcription of which is upregulated in an iron-deficient state. However, hypophosphatemia typically resolves within 12 weeks of FCM administration. Here, we present a case of unusually prolonged hypophosphatemia that developed after treatment with FCM in a 39-year-old female with autosomal dominant polycystic kidney disease (ADPKD) but normal renal function. Workup was significant for low tubular reabsorption of phosphate and inappropriately normal FGF23. Genetic disorders of hypophosphatemia and a FGF23-secreting tumor were ruled out. Treatment with calcitriol was required for nearly 3.5 years. The prolonged hypophosphatemia was attributed to underlying ADPKD because these patients demonstrate inappropriately elevated FGF23 levels for the degree of severity of reduced glomerular filtration rate. However, the stimulus driving FGF23 secretion in these patients is incompletely understood. Elevated FGF23 in the kidney suppresses renal tubular phosphate reabsorption and 1α-hydroxylase activity ultimately leading to hypophosphatemia. We conclude that our patient was at a high risk of developing hypophosphatemia because of underlying ADPKD, and FCM was the likely precipitant to identify this underlying process.
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Affiliation(s)
- Ipsa Arora
- Division of Endocrinology, Tufts Medical Center, Boston, MA 02111, USA
| | - Alison Kaprove
- Division of Nephrology, Tufts Medical Center, Boston, MA 02111, USA
| | - Ronald Perrone
- Division of Nephrology, Tufts Medical Center, Boston, MA 02111, USA
| | - Lisa Ceglia
- Division of Endocrinology, Tufts Medical Center, Boston, MA 02111, USA
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Chu Z, Cushway T, Wong M, Lim KX, Peh WM, Ng CT, Lim WY, Ong SGK, Tey TT, Foo FJ, Koh FH. Incidence and predictors of hypophosphataemia after ferric carboxymaltose use-A 3-year experience from a single institution in Singapore. Br J Haematol 2023; 202:1199-1204. [PMID: 37455143 DOI: 10.1111/bjh.18979] [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: 04/17/2023] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
Ferric carboxymaltose (FCM) administration helps reduce transfusion requirements in the perioperative situation, which improves patient outcomes and reduces healthcare costs. However, there is increasing evidence of hypophosphataemia after FCM use. We aim to determine the incidence of hypophosphataemia after FCM administration and elucidate potential biochemical factors associated with the development of subsequent hypophosphataemia. A retrospective review of anonymised data of all FCM administrations in a single institution was conducted from August 2018 to August 2021. Each unique FCM dose administered was examined to assess its effect on Hb and serum phosphate levels within the subsequent 28 days from each FCM administration. Phosphate levels were repeatedly measured within the 28-day interval and the lowest phosphate level within that period was determined. Patients' serum phosphate levels within 28 days of FCM administration were compared against normal serum phosphate levels within 2 weeks before FCM administration. The odds ratios of various pre-FCM serum markers were calculated to elucidate potential biochemical predictors of post-FCM hypophosphataemia. In 3 years, a total of 1296 doses of FCM were administered to 1069 patients. The mean improvement in Hb was 2.45 g/dL (SD = 1.94) within 28 days of FCM administration, with the mean time taken to peak Hb levels being 6.3 days (SD = 8.63), which is earlier than expected, but was observed in this study and hence reported. The incidence of hypophosphataemia <0.8 mmol/L was 22.7% (n = 186), and <0.4 mmol/L was 1.6% (n = 9). This figure is lower than the numbers reported in previously published meta-analyses given that routine checks of serum phosphate levels were not conducted initially and hence could possibly be higher. The odds of developing hypophosphataemia (<0.8 mmol/L) were 27.7 (CI: 17.3-44.2, p < 0.0001) if baseline serum phosphate was less than 1 mmol/L. The odds of developing hypophosphataemia (<0.8 mmol/L) were 1.3 (CI: 1.08-1.59, p < 0.01) if the change in Hb levels observed after FCM administration were more than 4 g/dL. Hypophosphataemia after FCM administration is significant and FCM should be used by clinicians with caution.
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Affiliation(s)
- Zachary Chu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tim Cushway
- The Integrative Medical Centre by The Iron Suites, Singapore, Singapore
| | - Marc Wong
- Department of Internal Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Kai-Xiong Lim
- Department of Internal Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Wee-Ming Peh
- Department of Internal Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Choong-Tatt Ng
- Department of Internal Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Wan-Yen Lim
- Department of Anaesthesiology, Sengkang General Hospital, Singapore, Singapore
| | - Sharon G K Ong
- Department of Anaesthesiology, Sengkang General Hospital, Singapore, Singapore
| | - Tze-Tong Tey
- Department of Gastroenterology, Sengkang General Hospital, Singapore, Singapore
| | - Fung-Joon Foo
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Frederick H Koh
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
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Samões B, Silva B, Martins A, Oliveira D, Rajão Martins F, Fonseca D, Costa L, Bernardes M. Hypophosphatemic osteomalacia induced by intravenous iron therapy: a case report. Joint Bone Spine 2023; 90:105586. [PMID: 37127260 DOI: 10.1016/j.jbspin.2023.105586] [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: 02/04/2023] [Revised: 03/05/2023] [Accepted: 04/18/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Osteomalacia is an uncommon, overlooked and debilitating metabolic bone disease with numerous aetiologies. Herein, we report an atypical cause of osteomalacia - intravenous iron therapy. METHODS Description of a case report of hypophophatemic osteomalacia induced by ferric carboxymaltose infusions. RESULTS A 70-year-old male with Rendu-Osler-Weber syndrome requiring repeated infusions of ferric carboxymaltose was admitted for disabling lower limb pain associated with persistent hypophosphatemia (1.6mg/dL) and increased urinary fractional excretion of phosphate (43%, UP04=118.3mg/dL), serum fibroblast growth factor 23 (324UA/mL), intact parathyroid hormone (110pg/mL) and bone alkaline phosphatase (40.1mcg/L). X-ray and CT of the feet showed severe diffuse bone demineralization. Feet MRI displayed a subchondral fracture of the cuneiform-navicular joints. Spine X-ray revealed dorsolumbar vertebral flattening. Somatostatin receptor PET scan excluded an occult tumor. Bone biopsy with histomorphometry confirmed the presence of osteomalacia. After excluding other causes, a diagnosis of hypophosphatemic osteomalacia induced by frequent ferric carboxymaltose infusions was made. The iron formulation was replaced by saccharated ferric oxide infusions and progressive titration of calcitriol up to 1.5mg/day and oral disodium phosphate up to 5740mg/day was started. After 6 months, there was a clear clinical and analytical improvement. CONCLUSION Osteomalacia may be a consequence of prolonged hypophosphatemia induced by recurrent ferric infusions, which is an uncommon and neglected bone adverse event of this therapy. Phosphate levels and bone symptoms should be monitored during repetitive iron infusions, maintaining a high level of suspicion for osteomalacia as it is important to identify and treat it in a timely manner, minimizing its severe morbidity.
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Affiliation(s)
- Beatriz Samões
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal.
| | - Bruna Silva
- Rheumatology Department, Centro Hospitalar Universitário do S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Ana Martins
- Rheumatology Department, Centro Hospitalar Universitário do S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Daniela Oliveira
- Rheumatology Department, Centro Hospitalar Universitário do S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, R. Dr. Plácido da Costa, 4200-450 Porto, Portugal
| | - Frederico Rajão Martins
- Rheumatology Department, Centro Hospitalar Universitário do Algarve, R. Leão Penedo, 8000-386 Faro, Portugal
| | - Diogo Fonseca
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, R. Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal
| | - Lúcia Costa
- Rheumatology Department, Centro Hospitalar Universitário do S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Miguel Bernardes
- Rheumatology Department, Centro Hospitalar Universitário do S. João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
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13
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Berg EP, Mohammed A, Shipp ZJ, Tenegra JC. Colorectal Cancer Screening and Iron Deficiency Anemia. Prim Care 2023; 50:481-491. [PMID: 37516515 DOI: 10.1016/j.pop.2023.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
In the United States, colorectal cancer has the fourth highest amount of annual new cancer cases per year between 2014 and 2018. In this article, the authors review the data and guidelines supporting effective direct visualization and stool-based testing methods of colon cancer screening along with work-up and management of Iron Deficiency Anemia.
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Affiliation(s)
- Ethan P Berg
- SIU Decatur Family Medicine Residency, 102 West Kenwood Avenue, Ste 100, Decatur, IL 62526, USA; Department of Family & Community Medicine, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Asiya Mohammed
- Department of Family & Community Medicine, Southern Illinois University School of Medicine, Springfield, IL, USA; SIU Springfield Family Medicine Residency, 520 N. 4th Street, Springfield, IL 62702, USA
| | - Zachary J Shipp
- SIU Decatur Family Medicine Residency, 102 West Kenwood Avenue, Ste 100, Decatur, IL 62526, USA; Department of Family & Community Medicine, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Johnny C Tenegra
- SIU Decatur Family Medicine Residency, 102 West Kenwood Avenue, Ste 100, Decatur, IL 62526, USA; Department of Family & Community Medicine, Southern Illinois University School of Medicine, Springfield, IL, USA; Department of Family & Community Medicine, Southern Illinois University School of Medicine Decatur Family Medicine Residency, Decatur, IL, USA.
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14
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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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15
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Struppe A, Schanda JE, Baierl A, Watzl P, Muschitz C. Impact of Intravenous Iron Substitution on Serum Phosphate Levels and Bone Turnover Markers-An Open-Label Pilot Study. Nutrients 2023; 15:2693. [PMID: 37375595 DOI: 10.3390/nu15122693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
The association between intravenous iron substitution therapy and hypophosphatemia was previously reported in patients with iron deficiency anemia. However, the extent of hypophosphatemia is thought to depend on the type of iron supplementation. We hypothesized that the intravenous application of ferric carboxymaltose and iron sucrose leads to a different longitudinal adaptation in serum phosphate levels. In this open-label pilot study, a total of 20 patients with inflammatory bowel diseases or iron deficiency anemia were randomly assigned to one of two study groups (group 1: ferric carboxymaltose, n = 10; group 2: iron sucrose, n = 10). Serum values were controlled before iron substitution therapy, as well as 2, 4, and 12 weeks after the last drug administration. The primary objective of the study was the longitudinal evaluation of serum phosphate levels after iron substitution therapy with ferric carboxymaltose and iron sucrose. The secondary objective was the longitudinal investigation of calcium, 25-hydroxyvitamin D (25(OH)D), intact parathyroid hormone, procollagen type 1 amino-terminal propeptide (P1NP), beta-CrossLaps (CTX), hemoglobin (Hb), iron, ferritin, and transferrin saturation levels. Two weeks after drug administration, phosphate levels were significantly lower (p < 0.001) in group 1 and ferritin levels were significantly higher (p < 0.001) in group 1. Phosphate levels (0.8-1.45 mmol/L) were below the therapeutic threshold and ferritin levels (10-200 ng/mL for women and 30-300 ng/mL for men) were above the therapeutic threshold in group 1. P1NP (15-59 µg/L) and CTX (<0.57 ng/mL) levels were above the therapeutic threshold in group 2. Four weeks after drug administration, significant differences were still observed between both study groups for phosphate (p = 0.043) and ferritin (p = 0.0009). All serum values except for Hb were within the therapeutic thresholds. Twelve weeks after drug administration, no differences were observed in all serum values between both study groups. Hb values were within the therapeutic threshold in both study groups. Serum 25(OH)D levels did not differ between both study groups throughout the whole study period and remained within the therapeutic threshold.
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Affiliation(s)
- Alexandra Struppe
- St. Vincent Hospital Vienna, II Medical Department-Gastroenterology, Hepatology, Metabolic, and Inflammation Medicine, Academic Teaching Hospital of the Medical University of Vienna, 1060 Vienna, Austria
| | - Jakob E Schanda
- AUVA Trauma Center Vienna-Meidling, Department for Trauma Surgery, 1120 Vienna, Austria
- Ludwig Boltzmann Institute for Traumatology, 1200 Vienna, Austria
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria
| | - Andreas Baierl
- Insitute for Statistics and Operations Research, University of Vienna, 1090 Vienna, Austria
| | - Paul Watzl
- St. Vincent Hospital Vienna, II Medical Department-Gastroenterology, Hepatology, Metabolic, and Inflammation Medicine, Academic Teaching Hospital of the Medical University of Vienna, 1060 Vienna, Austria
| | - Christian Muschitz
- St. Vincent Hospital Vienna, II Medical Department-Gastroenterology, Hepatology, Metabolic, and Inflammation Medicine, Academic Teaching Hospital of the Medical University of Vienna, 1060 Vienna, Austria
- HealthPi Medical Center, 1010 Vienna, Austria
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16
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Kassianides X, Bhandari S. Methodology and Baseline Data of a Comparative Exploratory Double-Blinded Randomized Study of Intravenous Iron on Fibroblast Growth Factor 23 and Phosphate in Chronic Kidney Disease. Kidney Blood Press Res 2023; 48:151-164. [PMID: 37015198 DOI: 10.1159/000528313] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/14/2022] [Indexed: 04/06/2023] Open
Abstract
Modern intravenous iron compounds (e.g., ferric carboxymaltose [FCM] and ferric derisomaltose [FDI]) are utilized in the treatment of iron deficiency anemia in non-dialysis-dependent chronic kidney disease (ND-CKD). Product-specific alterations in the metabolism of fibroblast growth factor 23 (FGF-23) leading to hypophosphatemia have been described for certain intravenous iron compounds, such as FCM, with potential effects on bone and cardiovascular health and quality of life. No prior head-to-head comparison between FCM and FDI exists in ND-CKD. This single-center exploratory double-blind randomized controlled trial primarily aimed to investigate the differential impact of FCM and FDI on FGF-23 and phosphate in patients with iron deficiency +/- anemia and ND-CKD (stages 3a-5 - serum ferritin <200 μg/L or serum ferritin 200-299 μg/L and transferrin saturation <20%). Patients were randomized (1:1) to receive either FCM or FDI over two infusions (1 month apart). Follow-up was 3 months. Measurements of serum intact FGF-23, phosphate, vitamin D metabolites, parathyroid hormone, other bone metabolism, cardiovascular, and quality of life markers were monitored. 168 patients were prescreened. Thirty-five patients were screened; 26 patients were randomized. The mean (standard deviation) age was 67.9 (12.4) years and 17 participants were male. Most participants had stage 4 CKD (median [interquartile range] estimated glomerular filtration rate [eGFR]: 18.0 [11.3] mL/min/1.73 m2). A higher than normal median (interquartile range) level of intact FGF-23 (212.1 [116.4] pg/mL) was noted. Serum phosphate was within normal range, while parathyroid hormone was higher and 1,25 (OH)2 vitamin D lower than the normal range. The "Iron and Phosphaturia - ExplorIRON-CKD" trial will provide important information regarding the differential effect of intravenous iron products in terms of FGF-23, phosphate, and other markers of bone and cardiovascular metabolism, alongside patient-reported outcome measures in patients with ND-CKD.
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Affiliation(s)
- Xenophon Kassianides
- Academic Renal Research Department, Hull University Teaching Hospitals NHS Trust and Hull York Medical School, Kingston upon Hull, UK
| | - Sunil Bhandari
- Academic Renal Research Department, Hull University Teaching Hospitals NHS Trust and Hull York Medical School, Kingston upon Hull, UK
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17
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Rosano GMC, Kalantar‐Zadeh K, Jankowska EA. Hypophosphataemia risk associated with ferric carboxymaltose in heart failure: A pooled analysis of clinical trials. ESC Heart Fail 2023; 10:1294-1304. [PMID: 36722321 PMCID: PMC10053364 DOI: 10.1002/ehf2.14286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/30/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023] Open
Abstract
AIMS Iron deficiency is a common finding among patients with heart failure (HF) and is associated with adverse outcomes, including decreased quality of life, increased risk of hospitalization, and decreased survival. Intravenous ferric carboxymaltose (FCM) has been shown to improve outcomes among patients with HF and concomitant iron deficiency, but FCM is associated with an increased risk of hypophosphataemia. We aimed to better characterize this risk among HF populations. METHODS AND RESULTS This pooled analysis examined data from 41 studies of adults with iron deficiency across disease states and therapeutic areas. Among the 7931 patients treated with FCM available for analysis, 14% made up the HF subgroup. Additional subgroups included women's health (36%), non-dialysis-dependent chronic kidney disease (NDD-CKD; 27%), haemodialysis-dependent chronic kidney disease (HD-CKD; 1%), gastrointestinal (10%), neurology (3%), and other (10%). The incidence of post-baseline moderate or severe hypophosphataemia (i.e. serum phosphate [PO4 3- ] level <2.0 mg/dL) varied across the therapeutic areas, with the lowest incidences observed in the HD-CKD (0%), HF (8.1%), and NDD-CKD (12.8%) subgroups. The prevalence of moderate or severe hypophosphataemia among the women's health, other, gastrointestinal, and neurology subgroups was 30.1%, 40.6%, 51.0%, and 55.6%, respectively. In the HF subgroup, one patient (<0.1%) had a serum PO4 3- of <1.0 mg/dL recorded, compared with 4.8% and 4.0% of the subjects in the neurology and gastrointestinal groups, respectively. With the exception of the HD-CKD subgroup, mean serum PO4 3- levels decreased through weeks 2 to 4, and then returned toward baseline and plateaued by week 8. The strongest predictor of hypophosphataemia was preserved kidney function (estimated glomerular filtration rate: >60 mL/min/1.73 m2 vs. <30 mL/min/1.73 m2 ; odds ratio: 12.2). Among patients in the HF subgroup, the incidence of treatment-emergent adverse events potentially related to hypophosphataemia (e.g. cardiac failure, ventricular tachyarrhythmias, fatigue, muscle weakness, bone pain, neurological symptoms, and muscle pain) was lower among FCM-treated patients than among those receiving placebo, and lower among patients with a post-baseline PO4 3- <2 mg/dL vs. those not meeting such criteria. CONCLUSIONS The risk of laboratory-assessed hypophosphataemia in HF patients treated with FCM was lower than that seen in patients in other therapeutic areas treated with FCM, and clinical events associated with hypophosphataemia are uncommon with FCM therapy in this population. Appropriate monitoring, particularly soon after administration in the unlikely event of repeated dosing in HF patients, will allow for further refinement of management strategies. [Correction added on 24 February 2023, after first online publication: In the preceding sentence, "…administration, will allow…" has been corrected to "…administration in the unlikely event of repeated dosing in HF patients, will allow…" in this version.].
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Affiliation(s)
| | - Kamyar Kalantar‐Zadeh
- Division of Nephrology and Hypertension and Kidney TransplantationUniversity of CaliforniaIrvineCaliforniaUSA
| | - Ewa A. Jankowska
- Institute of Heart DiseasesWrocław Medical UniversityWrocławPoland
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18
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Zoller H, Wolf M, Blumenstein I, Primas C, Lindgren S, Thomsen LL, Reinisch W, Iqbal T. Hypophosphataemia following ferric derisomaltose and ferric carboxymaltose in patients with iron deficiency anaemia due to inflammatory bowel disease (PHOSPHARE-IBD): a randomised clinical trial. Gut 2023; 72:644-653. [PMID: 36343979 PMCID: PMC10086283 DOI: 10.1136/gutjnl-2022-327897] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/20/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVE Intravenous iron-a common treatment for anaemia and iron deficiency due to inflammatory bowel disease (IBD)-can cause hypophosphataemia. This trial compared the incidence of hypophosphataemia after treatment with ferric carboxymaltose (FCM) or ferric derisomaltose (FDI). DESIGN This randomised, double-blind, clinical trial was conducted at 20 outpatient hospital clinics in Europe (Austria, Denmark, Germany, Sweden, UK). Adults with IBD and iron deficiency anaemia (IDA) were randomised 1:1 to receive FCM or FDI at baseline and at Day 35 using identical haemoglobin- and weight-based dosing regimens. The primary outcome was the incidence of hypophosphataemia (serum phosphate <2.0 mg/dL) at any time from baseline to Day 35 in the safety analysis set (all patients who received ≥1 dose of study drug). Markers of mineral and bone homeostasis, and patient-reported fatigue scores, were measured. RESULTS A total of 156 patients were screened; 97 (49 FDI, 48 FCM) were included and treated. Incident hypophosphataemia occurred in 8.3% (4/48) FDI-treated patients and in 51.0% (25/49) FCM-treated patients (adjusted risk difference: -42.8% (95% CI -57.1% to -24.6%) p<0.0001). Both iron formulations corrected IDA. Patient-reported fatigue scores improved in both groups, but more slowly and to a lesser extent with FCM than FDI; slower improvement in fatigue was associated with greater decrease in phosphate concentration. CONCLUSION Despite comparably effective treatment of IDA, FCM caused a significantly higher rate of hypophosphataemia than FDI. Further studies are needed to address the longer-term clinical consequences of hypophosphataemia and to investigate mechanisms underpinning the differential effects of FCM and FDI on patient-reported fatigue.
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Affiliation(s)
- Heinz Zoller
- Department of Medicine I and Christian Doppler Laboratory on Iron and Phosphate Biology, Medical University of Innsbruck, Innsbruck, Austria
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Irina Blumenstein
- Medical Clinic I, Department of Gastroenterology, Hepatology, and Clinical Nutrition, University Clinic Frankfurt, Frankfurt, Germany
| | - Christian Primas
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Stefan Lindgren
- Department of Gastroenterology and Hepatology, Skåne University Hospital Malmö, Lund University, Lund, Sweden
| | - Lars L Thomsen
- Department of Clinical and Non-Clinical Research, Pharmacosmos A/S, Holbæk, Denmark
| | - Walter Reinisch
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Tariq Iqbal
- Department of Gastroenterology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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19
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McEwan P, Ponikowski P, Shiri T, Rosano GMC, Coats AJS, Dorigotti F, Ramirez de Arellano A, Jankowska EA. Clinical and economic impact of ferric carboxymaltose treatment for iron deficiency in patients stabilized following acute heart failure: a multinational study. J Med Econ 2023; 26:51-60. [PMID: 36476095 DOI: 10.1080/13696998.2022.2155375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To estimate clinical events and evaluate the financial implications of introducing ferric carboxymaltose (FCM) to treat iron deficiency (ID) at discharge in patients hospitalized for acute heart failure (AHF) with left ventricular ejection fraction (LVEF) <50% in the UK, Switzerland and Italy. METHODS A decision analytic cost-offset model was developed to evaluate the costs associated with introducing FCM for all eligible patients in three countries compared to a world without FCM, over a five-year time horizon. Data from AFFIRM-AHF clinical trial were used to model clinical outcomes, using an established cohort state-transition Markov model. Country-specific prevalence estimates were derived using data from real-world studies to extrapolate number of events and consequent cost totals to the population at risk on a national scale. RESULTS The cost-offset modeling demonstrated that FCM is projected to be a cost-saving intervention in all three country settings over a five-year time horizon. Savings were driven primarily by reduced hospitalizations and avoided cardiovascular deaths, with net cost savings of -£14,008,238, -CHF25,456,455 and -€105,295,146 incurred to the UK, Switzerland and Italy, respectively. LIMITATIONS Although AFFIRM-AHF was a multinational trial, efficacy data per country was not sufficiently large to enable country-specific analysis, therefore overall clinical parameters have been assumed to apply to all countries. CONCLUSIONS This study provides further evidence of the potential cost savings achievable by treating ID with FCM at discharge in patients hospitalized for AHF with LVEF <50%. The value of FCM treatment within the healthcare systems of the UK, Switzerland and Italy was demonstrated even within a limited time frame of one year, with consistent cost savings indicated over a longer term.
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Affiliation(s)
- Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | | | - Giuseppe M C Rosano
- Cardiovascular and Cell Sciences Research Institute, St George's University, London, UK
| | | | | | | | - Ewa A Jankowska
- Institute of Heart Diseases, University Hospital, Wrocław, Poland
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20
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Lupu M, Tudor D, Filip A. Iron metabolism and cardiovascular disease: Basic to translational purviews and therapeutical approach. Rev Port Cardiol 2022; 41:1037-1046. [PMID: 36228833 DOI: 10.1016/j.repc.2021.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/09/2021] [Accepted: 09/13/2021] [Indexed: 11/15/2022] Open
Abstract
Iron interactions with the cardiovascular system were proposed about half a century ago, yet a clear-cut understanding of this micronutrient and its intricacies with acute and chronic events is still lacking. In chronic heart failure, patients with decreased iron stores appear to benefit from intravenous administration of metallic formulations, whereas acute diseases (e.g., myocardial infarction, stroke) are barely studied in randomized controlled trials in humans. However, proof-of-concept studies have indicated that the dual redox characteristics of iron could be involved in atherosclerosis, necrosis, and ferroptosis. To this end, we sought to review the currently available body of literature pertaining to these temporal profiles of heart diseases, as well as the pathophysiologic mechanism by which iron enacts, underlining key points related to treatment options.
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Affiliation(s)
- Mihai Lupu
- Iuliu Hatieganu University of Medicine and Pharmacy, Department of Physiology, Cluj-Napoca, Romania.
| | - Diana Tudor
- Iuliu Hatieganu University of Medicine and Pharmacy, Department of Physiology, Cluj-Napoca, Romania
| | - Adriana Filip
- Iuliu Hatieganu University of Medicine and Pharmacy, Department of Physiology, Cluj-Napoca, Romania
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21
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Benson AE, Shatzel JJ, Ryan KS, Hedges MA, Martens K, Aslan JE, Lo JO. The incidence, complications, and treatment of iron deficiency in pregnancy. Eur J Haematol 2022; 109:633-642. [PMID: 36153674 PMCID: PMC9669178 DOI: 10.1111/ejh.13870] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/30/2022]
Abstract
Iron deficiency and/or iron deficiency anemia (IDA) complicate nearly 50% of pregnancies globally, negatively impacting both maternal and fetal outcomes. Iron deficiency can cause a range of symptoms that range from aggravating to debilitating including fatigue, poor quality of life, pagophagia, and restless leg syndrome. Iron deficiency and IDA are also associated with maternal complications including preterm labor, increased rates of cesarean delivery, postpartum hemorrhage, and maternal death. Fetal complications include increased rates of low birth weight and small for gestational age newborns. Prenatal maternal anemia has also been associated with autism spectrum disorders in the neonate, although causation is not established. Deficiency in the newborn is associated with compromised memory, processing, and bonding, with some of these deficits persisting into adulthood. Despite the prevalence and consequences associated with iron deficiency in pregnancy, data show that it is routinely undertreated. Due to the physiologic changes of pregnancy, all pregnant individuals should receive oral iron supplementation. However, the bioavailability of oral iron is poor and it is often ineffective at preventing and treating iron deficiency. Likewise, it frequently causes gastrointestinal symptoms that can worsen the quality of life in pregnancy. Intravenous iron formulations administered in a single or multiple dose series are now available. There is increasing data suggesting that newer intravenous formulations are safe and effective in the second and third trimesters and should be strongly considered in pregnant individuals without optimal response to oral iron repletion.
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Affiliation(s)
- Ashley E Benson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon, USA
| | - Kim S Ryan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Madeline A Hedges
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Kylee Martens
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Joseph E Aslan
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Jamie O Lo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
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22
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Aksan A, Zepp F, Anand S, Stein J. Intravenous ferric carboxymaltose for the management of iron deficiency and iron deficiency anaemia in children and adolescents: a review. Eur J Pediatr 2022; 181:3781-3793. [PMID: 36056175 PMCID: PMC9439269 DOI: 10.1007/s00431-022-04582-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/24/2022] [Accepted: 07/29/2022] [Indexed: 11/25/2022]
Abstract
Iron deficiency is the primary cause of anaemia worldwide and is particularly common among children and adolescents. Intravenous (IV) iron therapy is recommended for paediatric patients with certain comorbidities or if oral iron treatment has been unsuccessful. IV ferric carboxymaltose (FCM) has recently been approved by the US Food and Drug Administration for use in children aged > 1 year. This narrative review provides an overview of the available publications on the efficacy and safety of IV FCM in children and adolescents. A literature search using PubMed and Embase yielded 153 publications; 33 contained clinical data or reports on clinical experience relating to IV FCM in subjects < 18 years of age and were included in the review. No prospective, randomised controlled studies on the topic were found. Most publications were retrospective studies or case reports and included patients with various underlying conditions or patients with inflammatory bowel disease. Efficacy data were included in 27/33 publications and improvements in anaemia, and/or iron status parameters were reported in 26 of them. Safety data were included in 25/33 publications and were in line with the adverse events described in the prescribing information. CONCLUSION The available publications indicate that IV FCM, a nanomedicine with a unique and distinctive therapeutic profile, is an effective and generally well-tolerated treatment for iron deficiency or iron deficiency anaemia in children and adolescents. Despite the wealth of retrospective evidence, prospective, randomised controlled trials in the paediatric setting are still necessary. WHAT IS KNOWN • Iron deficiency and iron deficiency anaemia are usually managed using oral iron therapy, but intravenous iron therapy is recommended for certain paediatric patients. • Intravenous ferric carboxymaltose (FCM) has recently been approved in the US for use in children aged > 1 year. WHAT IS NEW • Despite evidence that FCM is effective and generally well tolerated in children and adolescents, so far, only retrospective studies, non-randomised uncontrolled prospective studies, or case reports have been published in full. • There is a strong need for prospective, randomised controlled trials on FCM in the paediatric setting.
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Affiliation(s)
- Aysegül Aksan
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt, Germany
- Institute of Nutritional Science, Justus-Liebig University, Giessen, Germany
| | - Fred Zepp
- University Medical Center of the Johannes-Gutenberg University, Mainz, Germany
| | | | - Jürgen Stein
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt, Germany.
- Department of Gastroenterology and Clinical Nutrition, DGD Clinics Sachsenhausen, Frankfurt, Germany.
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23
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Severe Hypophosphatemia Occurring After Repeated Exposure to a Parenteral Iron Formulation. Case Rep Endocrinol 2022; 2022:1011401. [PMID: 36248222 PMCID: PMC9568323 DOI: 10.1155/2022/1011401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
Hypophosphatemia is a less known complication of parenteral iron use, particularly after the use of certain iron formulations. We report the case of a young male with inflammatory bowel disease and iron deficiency anemia, who developed severe symptomatic hypophosphatemia after his third exposure to iron carboxymaltose with no evidence of the same occurring upon prior exposures to the compound. Investigations revealed serum phosphorous levels of 0.7 mg/dl, corrected serum calcium of 8-9.5 mg/dl, alkaline phosphatase of 50 U/L (38-126), 25 hydroxy vitamin D level of 40.2 ng/ml, and intact PTH elevated to 207 pg/ml. Urine studies indicated renal phosphate wasting. Presentation was not in keeping with refeeding syndrome. Intact fibroblast growth factor 23 level, measured after the initiation of treatment was within the normal range at 179 RU/mL (44-215). 1,25 dihydroxy vitamin D level, also measured after the initiation of treatment, was normal at 26.3 pg/ml (19.9-79.3). The patient was treated with calcitriol and aggressive oral and intravenous phosphorous repletion. Symptoms then resolved and the patient was discharged on an oral regimen. This phenomenon is postulated to occur due to an increase in the level and activity of FGF23 and decreased cleavage of the same, due to anemia as well as use of specific iron formulations. This is the first instance, in our literature review, of this complication known to occur, not after initial exposure to an implicated iron formulation but occurring on subsequent exposure.
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24
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Boots JMM, Quax RAM. High-Dose Intravenous Iron with Either Ferric Carboxymaltose or Ferric Derisomaltose: A Benefit-Risk Assessment. Drug Saf 2022; 45:1019-1036. [PMID: 36068430 PMCID: PMC9492608 DOI: 10.1007/s40264-022-01216-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/22/2022]
Abstract
The intravenous iron formulations ferric carboxymaltose (FCM) and ferric derisomaltose (FDI) offer the possibility of administering a large amount of iron in one infusion. This results in faster correction of anemia and the formulations being better tolerated than oral iron formulations. This triad of logistic advantages, improved patient convenience, and fast correction of anemia explains the fact that intravenous iron formulations nowadays are frequently prescribed worldwide in the treatment of iron deficiency anemia. However, these formulations may result in hypophosphatemia by inducing a strong increase in active fibroblast growth factor-23 (FGF-23), a hormone that stimulates renal phosphate excretion. This effect is much more pronounced with FCM than with FDI, and therefore the risk of developing hypophosphatemia is remarkably higher with FCM than with FDI. Repeated use of FCM may result in severe osteomalacia, which is characterized by bone pain, Looser zones (pseudofractures), and low-trauma fractures. Intravenous iron preparations are also associated with other adverse effects, of which hypersensitivity reactions are the most important and are usually the result of a non-allergic complement activation on nanoparticles of free labile iron-Complement Activation-Related Pseudo-Allergy (CARPA). The risk on these hypersensitivity reactions can be reduced by choosing a slow infusion rate. Severe hypersensitivity reactions were reported in < 1% of prospective trials and the incidence seems comparable between the two formulations. A practical guideline has been developed based on baseline serum phosphate concentrations and predisposing risk factors, derived from published cases and risk factor analyses from trials, in order to establish the safe use of these formulations.
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Affiliation(s)
- Johannes M M Boots
- Department of Internal Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands.
| | - Rogier A M Quax
- Department of Internal Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands
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25
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Biruete A, Metzger CE, Chen NX, Swallow EA, Vrabec C, Clinkenbeard EL, Stacy AJ, Srinivasan S, O'Neill K, Avin KG, Allen MR, Moe SM. Effects of ferric citrate and intravenous iron sucrose on markers of mineral, bone, and iron homeostasis in a rat model of CKD-MBD. Nephrol Dial Transplant 2022; 37:1857-1867. [PMID: 35482713 PMCID: PMC9494145 DOI: 10.1093/ndt/gfac162] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Anemia and chronic kidney disease-mineral and bone disorder (CKD-MBD) are common and begin early in CKD. Limited studies have concurrently compared the effects of ferric citrate (FC) versus intravenous (IV) iron on CKD-MBD and iron homeostasis in moderate CKD. METHODS We tested the effects of 10 weeks of 2% FC versus IV iron sucrose in rats with moderate CKD (Cy/+ male rat) and untreated normal (NL) littermates. Outcomes included a comprehensive assessment of CKD-MBD, iron homeostasis and oxidative stress. RESULTS CKD rats had azotemia, elevated phosphorus, parathyroid hormone and fibroblast growth factor-23 (FGF23). Compared with untreated CKD rats, treatment with FC led to lower plasma phosphorus, intact FGF23 and a trend (P = 0.07) toward lower C-terminal FGF23. FC and IV iron equally reduced aorta and heart calcifications to levels similar to NL animals. Compared with NL animals, CKD animals had higher bone turnover, lower trabecular volume and no difference in mineralization; these were unaffected by either iron treatment. Rats treated with IV iron had cortical and bone mechanical properties similar to NL animals. FC increased the transferrin saturation rate compared with untreated CKD and NL rats. Neither iron treatment increased oxidative stress above that of untreated CKD. CONCLUSIONS Oral FC improved phosphorus homeostasis, some iron-related parameters and the production and cleavage of FGF23. The intermittent effect of low-dose IV iron sucrose on cardiovascular calcification and bone should be further explored in moderate-advanced CKD.
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Affiliation(s)
- Annabel Biruete
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Nutrition and Dietetics, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - Corinne E Metzger
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Neal X Chen
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elizabeth A Swallow
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Curtis Vrabec
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
- College of Osteopathic Medicine, Marian University, Indianapolis, IN, USA
| | - Erica L Clinkenbeard
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexander J Stacy
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shruthi Srinivasan
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kalisha O'Neill
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Keith G Avin
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Physical Therapy, Indiana University School of Health and Human Sciences, Indiana University, Indianapolis, IN, USA
| | - Matthew R Allen
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
- Roudebush Veterans Affairs Medical Center, Indianapolis, IN, IN, USA
| | - Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
- Roudebush Veterans Affairs Medical Center, Indianapolis, IN, IN, USA
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26
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Bergamaschi G, Caprioli F, Lenti MV, Elli L, Radaelli F, Rondonotti E, Mengoli C, Miceli E, Ricci C, Ardizzone S, Vecchi M, Di Sabatino A. Pathophysiology and therapeutic management of anemia in gastrointestinal disorders. Expert Rev Gastroenterol Hepatol 2022; 16:625-637. [PMID: 35696485 DOI: 10.1080/17474124.2022.2089114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Anemia is a common complication of gastrointestinal (GI) disorders, with a prevalence up to 60% in celiac disease (CeD) and inflammatory bowel disease (IBD). Iron deficiency anemia (IDA) is the most prevalent form of anemia in these conditions, but chronic inflammation and vitamin B12 deficiency represent other common contributing mechanisms, especially in IBD. AREAS COVERED We discuss the pathogenesis of anemia in various medical GI disorders, the sometime problematic distinction between IDA, anemia of inflammation (AI) and the association of the two, and therapeutic and preventive measures that can be useful for the management of anemia in GI disorders. Unfortunately, with the exception of IDA and AI in IBD, large RCT concerning the treatment of anemia in GI disorders are lacking. EXPERT OPINION Anemia management strategies in GI disorders are outlined, with a focus on the main prevention, diagnostic, and therapeutic measures. Specific problems and situations such as the role of gluten-free diet for IDA treatment in CeD, the choice between oral and parenteral supplementation of iron or vitamin B12 in carential anemias, the use of endoscopic procedures to stop bleeding in intestinal angiodysplasia and preventive/treatment strategies for NSAID-associated GI bleeding are discussed.
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Affiliation(s)
- Gaetano Bergamaschi
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Flavio Caprioli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Luca Elli
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | | | | | - Caterina Mengoli
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Emanuela Miceli
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Chiara Ricci
- Gastroenterology Unit, Spedali Civili di Brescia and Department of Clinical and Experimental Sciences, University of Brescia, Brescia Italy
| | - Sandro Ardizzone
- Sacco, University of MilanGastroenterology and Digestive Endoscopy Unit, Department of Biochemical and Clinical Sciences L , Milano, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
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27
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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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28
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Auerbach M, Achebe MM, Thomsen LL, Derman RJ. Efficacy and safety of ferric derisomaltose (FDI) compared with iron sucrose (IS) in patients with iron deficiency anemia after bariatric surgery. Obes Surg 2022; 32:810-818. [PMID: 35000068 PMCID: PMC8866325 DOI: 10.1007/s11695-021-05858-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 11/30/2022]
Abstract
Purpose Iron deficiency is common following bariatric surgery, and treatment with intravenous iron is often required. This post hoc analysis of data from two randomized, open-label, multicenter trials evaluated the efficacy and safety of ferric derisomaltose (FDI; formerly iron isomaltoside 1000) versus iron sucrose (IS) over 4 weeks in adults with iron deficiency anemia (IDA) resulting from prior bariatric surgery. Materials and methods Data were pooled for participants who received FDI or IS in the PROVIDE or FERWON-IDA trials for the treatment of IDA post bariatric surgery. Efficacy outcomes included changes in hemoglobin (Hb) and iron parameters; safety outcomes included the incidence of adverse drug reactions (ADRs), serious or severe hypersensitivity reactions (HSRs), and hypophosphatemia. Results The analysis included 159 patients. Mean (standard deviation) cumulative iron doses were 1199 (± 347) mg for FDI and 937 (± 209) mg for IS. Compared with IS, FDI resulted in a faster and more pronounced Hb response, and a higher proportion of responders (Hb level increase ≥ 2 g/dL from baseline) at all time points. The incidence of ADRs was similar with FDI and IS (15.1% and 18.2%, respectively), with no serious ADRs or serious or severe HSRs reported. The incidence of hypophosphatemia was low and similar in both treatment groups, with no cases of severe hypophosphatemia observed. Conclusions In patients with IDA resulting from bariatric surgery, FDI produced a faster and more pronounced Hb response than IS. Both FDI and IS were well tolerated. Graphical abstract ![]()
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Affiliation(s)
- Michael Auerbach
- Department of Medicine, Georgetown University School of Medicine, Washington, DC, USA.
| | - Maureen M Achebe
- Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Lars L Thomsen
- Department of Clinical and Non-Clinical Research, Pharmacosmos A/S, Holbæk, Denmark
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29
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Aljuraibah F, Bacchetta J, Brandi ML, Florenzano P, Javaid MK, Mäkitie O, Raimann A, Rodriguez M, Siggelkow H, Tiosano D, Vervloet M, Wagner CA. An Expert Perspective on Phosphate Dysregulation With a Focus on Chronic Hypophosphatemia. J Bone Miner Res 2022; 37:12-20. [PMID: 34870347 PMCID: PMC9306528 DOI: 10.1002/jbmr.4486] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/18/2021] [Accepted: 11/27/2021] [Indexed: 12/11/2022]
Abstract
Because of their rarity, diseases characterized by chronic hypophosphatemia can be underrecognized and suboptimally managed, resulting in poor clinical outcomes. Moreover, serum phosphate may not be measured routinely in primary care practice. Authors participated in several working sessions to advance the understanding of phosphate homeostasis and the causes, consequences, and clinical implications of chronic hypophosphatemia. Phosphate levels are regulated from birth to adulthood. Dysregulation of phosphate homeostasis can result in hypophosphatemia, which becomes chronic if phosphate levels cannot be normalized. Chronic hypophosphatemia may be underrecognized as serum phosphate measurement is not always part of routine analysis in the primary care setting and results might be misinterpreted, for instance, due to age-specific differences not being accounted for and circadian variations. Clinical consequences of chronic hypophosphatemia involve disordered endocrine regulation, affect multiple organ systems, and vary depending on patient age and the underlying disorder. Signs and symptoms of chronic hypophosphatemic diseases that manifest during childhood or adolescence persist into adulthood if the disease is inadequately managed, resulting in an accumulation of clinical deficits and a progressive, debilitating impact on quality of life. Early identification and diagnosis of patients with chronic hypophosphatemia is crucial, and clinical management should be started as soon as possible to maximize the likelihood of improving health outcomes. Furthermore, in the absence of a universally accepted description for "chronic hypophosphatemia," a definition is proposed here that aims to raise awareness of these diseases, facilitate diagnosis, and guide optimal phosphate management strategies by improving monitoring and assessment of patient response to treatment. © 2021 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)
- Fahad Aljuraibah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | | | | | | | - Outimaija Mäkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | | | | | - Marc Vervloet
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Carsten A Wagner
- University of Zurich, Zurich.,Swiss National Center of Competence in Research NCCR Kidney.CH, Zurich
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30
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Schaefer B, Tobiasch M, Wagner S, Glodny B, Tilg H, Wolf M, Zoller H. Hypophosphatemia after intravenous iron therapy: Comprehensive review of clinical findings and recommendations for management. Bone 2022; 154:116202. [PMID: 34534708 DOI: 10.1016/j.bone.2021.116202] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/06/2021] [Accepted: 09/10/2021] [Indexed: 12/19/2022]
Abstract
Contemporary intravenous iron formulations allow administration of high doses of elemental iron and enable correction of total iron deficit in one or two infusions. An important but underappreciated complication of certain formulations is hypophosphatemia caused by increased secretion of the phosphaturic hormone, fibroblast growth factor 23 (FGF23). The pathophysiology of FGF23-induced hypophosphatemia due to certain intravenous iron formulations has been recently investigated in prospective clinical trials. To reach the correct diagnosis, clinicians must recognize the typical clinical manifestations of intravenous iron-induced hypophosphatemia and identify a specific pattern of biochemical changes (hyperphosphaturic hypophosphatemia triggered by high FGF23 that causes low 1,25 (OH)2 vitamin D, hypocalcemia and secondary hyperparathyroidism). Physicians and patients should be aware of hypophosphatemia as a common complication of intravenous iron therapy and monitor serum phosphate concentrations in patients receiving repeated doses of specific intravenous iron formulations. Symptoms of hypophosphatemia are associated with severity and duration. Persistent hypophosphatemia can occur with iron therapy and can cause debilitating diseases including myopathy, osteomalacia and fractures. This review summarizes the current understanding of the iron-phosphate axis as well as complications of intravenous iron-induced hypophosphatemia.
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Affiliation(s)
- Benedikt Schaefer
- Medical University of Innsbruck, Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Innsbruck, Austria; Christian Doppler Laboratory on Iron and Phosphate Biology, Austria
| | - Moritz Tobiasch
- University Teaching Hospital of Hall in Tirol, Department of Medicine, Hall, Austria
| | - Sonja Wagner
- Medical University of Innsbruck, Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Innsbruck, Austria; Christian Doppler Laboratory on Iron and Phosphate Biology, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Herbert Tilg
- Medical University of Innsbruck, Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Innsbruck, Austria
| | - Myles Wolf
- Department of Medicine, Division of Nephrology, Duke University, Durham, NC, United States of America
| | - Heinz Zoller
- Medical University of Innsbruck, Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Innsbruck, Austria; Christian Doppler Laboratory on Iron and Phosphate Biology, Austria.
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31
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Richards T, Breymann C, Brookes MJ, Lindgren S, Macdougall IC, McMahon LP, Munro MG, Nemeth E, Rosano GMC, Schiefke I, Weiss G. Questions and answers on iron deficiency treatment selection and the use of intravenous iron in routine clinical practice. Ann Med 2021; 53:274-285. [PMID: 33426933 PMCID: PMC7877947 DOI: 10.1080/07853890.2020.1867323] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023] Open
Abstract
Iron deficiency is a common cause of morbidity and can arise as a consequence or complication from many diseases. The use of intravenous iron has increased significantly in the last decade, but concerns remain about indications and administration. Modern intravenous iron preparations can facilitate rapid iron repletion in one or two doses, both for absolute iron deficiency and, in the presence of inflammation, functional iron deficiency, where oral iron therapy is ineffective or has not worked. A multidisciplinary team of experts experienced in iron deficiency undertook a consensus review to support healthcare professionals with practical advice on managing iron deficiency in gastrointestinal, renal and cardiac disease, as well as; pregnancy, heavy menstrual bleeding, and surgery. We explain how intravenous iron may work where oral iron has not. We provide context on how and when intravenous iron should be administered, and informed opinion on potential benefits balanced with potential side-effects. We propose how intravenous iron side-effects can be anticipated in terms of what they may be and when they may occur. The aim of this consensus is to provide a practical basis for educating and preparing staff and patients on when and how iron infusions can be administered safely and efficiently. Key messages Iron deficiency treatment selection is driven by several factors, including the presence of inflammation, the time available for iron replenishment, and the anticipated risk of side-effects or intolerance. Intravenous iron preparations are indicated for the treatment of iron deficiency when oral preparations are ineffective or cannot be used, and therefore have applicability in a wide range of clinical contexts, including chronic inflammatory conditions, perioperative settings, and disorders associated with chronic blood loss. Adverse events occurring with intravenous iron can be anticipated according to when they typically occur, which provides a basis for educating and preparing staff and patients on how iron infusions can be administered safely and efficiently.
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Affiliation(s)
- Toby Richards
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Christian Breymann
- Obstetric Research-Feto Maternal Haematology Unit, University Hospital Zurich, Zurich, Switzerland
| | - Matthew J. Brookes
- Gastroenterology Unit, Royal Wolverhampton NHS Trust, Wolverhampton, UK
- Research Institute in Healthcare Science (RIHS), University of Wolverhampton, Wolverhampton, UK
| | - Stefan Lindgren
- Department of Gastroenterology and Hepatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | | | - Lawrence P. McMahon
- Departments of Renal Medicine and Obstetric Medicine, Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Malcolm G. Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Obstetrics and Gynecology, Kaiser-Permanente, Los Angeles Medical Center, Los Angeles, CA, USA
| | - Elizabeta Nemeth
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | - Ingolf Schiefke
- Department of Gastroenterology, Hepatology, Diabetology and Endocrinology, Klinikum St. Georg, Leipzig, Germany
| | - Günter Weiss
- Department of Internal Medicine II, Medical University Innsbruck, Innsbruck, Austria
- Christian Doppler Laboratory for Iron Metabolism and Anemia Research, University of Innsbruck, Innsbruck, Austria
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32
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Abu-Zaid A, Magzoub D, Aldehami MA, Behiry AA, Bhagavathula AS, Hajji R. The Effect of Iron Supplementation on FGF23 in Chronic Kidney Disease Patients: a Systematic Review and Time-Response Meta-Analysis. Biol Trace Elem Res 2021; 199:4516-4524. [PMID: 33462793 DOI: 10.1007/s12011-021-02598-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/13/2021] [Indexed: 12/22/2022]
Abstract
Fibroblast growth factor 23 (FGF23) gene is found to be responsible for autosomal dominant hypophosphatemic rickets, and is highly expressed in chronic kidney disease (CKD) and end-stage renal disease patients with iron deficiency anemia (IDA). We evaluated the efficacy of different iron treatments on FGF23 levels in dialysis-dependent and non-dialysis-dependent CKD patients with IDA. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing different types of iron treatment versus placebo in CKD patients up to May 2020. We investigated the efficacy of iron treatment on the levels of FGF23 and C-terminal FGF23 (cFGF23) in CKD patients. We estimated weighted mean differences (WMDs) and 95% confidence intervals (CIs) using the random-effects model. Nine studies with 11 arms were included in the meta-analysis. Overall, iron treatment showed a significant reduction in FGF23 levels compared to control group (WMD: - 60.56 pg/ml, 95% CI: - 92.17, - 28.95). Compared to placebo, subgroup analysis showed that oral iron therapy (WMD: - 6.98 pg/ml, 95% CI: - 10.66, - 3.31) was more effective than intravenous (IV) iron therapy (WMD: 4.90 pg/ml, 95% CI: - 12.03, 21.83) on FGF23 levels. There was no significant change in cFGF23 levels between iron treatment and control group (WMD: - 64.72 Ru/ml, 95% CI: - 147.69, 18.25). Subgroup analysis showed that oral iron therapy resulted in a significant reduction in cFGF23 levels compared to control group (WMD: - 150.48 RU/ml, 95% CI: - 151.31, - 149.65). In conclusion, iron treatment was associated with a significant decrease in FGF23 levels in CKD patients.
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Affiliation(s)
- Ahmed Abu-Zaid
- College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN, 38163, USA.
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Duha Magzoub
- School of Public Health, The University of Memphis, Memphis, TN, USA
| | | | | | - Akshaya Srikanth Bhagavathula
- Department of Internal Medicine, College of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates
| | - Raouf Hajji
- Medicine Faculty of Sousse, University of Sousse, 4000, Sousse, Tunisia
- Internal Medicine Department, Sidi Bouzid Hospital, 9100, Sidi Bouzid, Tunisia
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33
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Adhikari S, Mamlouk O, Rondon-Berrios H, Workeneh BT. Hypophosphatemia in cancer patients. Clin Kidney J 2021; 14:2304-2315. [PMID: 34754427 PMCID: PMC8572986 DOI: 10.1093/ckj/sfab078] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Indexed: 12/19/2022] Open
Abstract
Dysregulation of phosphorus homeostasis resulting in hypophosphatemia is common in cancer patients and can result in serious complications and impact outcomes. Several factors, including critical illness, nutritional status, cancer type and therapy, influence the development of hypophosphatemia. Hypophosphatemia can develop as a result of phosphaturic mesenchymal tumors or as a paraneoplastic phenomenon. The clinical presentation for hypophosphatemia varies depending on the duration and severity of the hypophosphatemia and affects several organ systems. Among other serious effects, hypophosphatemia can impair tissue oxygenation and can cause hemolysis, leukocyte and platelet dysfunction, encephalopathy, seizures, arrhythmias, cardiomyopathy, rhabdomyolysis and coma. Multiple studies have demonstrated that hypophosphatemia is an adverse prognostic marker in inpatients with increased in-hospital stay, mortality and postoperative complications. The phosphate level is homeostatically regulated and maintained in a narrow range by three main hormones: parathyroid hormone, fibroblast growth factor 23 and 1,25-dihydroxyvitaminD3. Together, these hormones regulate how the intestine, kidneys and bones traffic phosphorus. Several hematological malignancies and cancer therapies are associated with proximal tubular dysfunction (Fanconi syndrome), resulting in phosphaturia. Caution should be taken with parenteral administration of phosphate salts, because secondary complications can develop, principally due to hypocalcemia. The general approach to hypophosphatemia should target the underlying cause. Early recognition and prevention are essential and the approach to hypophosphatemia in the cancer patient, because of the nuances and complexity, should be multidisciplinary.
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Affiliation(s)
- Shreedhar Adhikari
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Omar Mamlouk
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Helbert Rondon-Berrios
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Biruh T Workeneh
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Bazeley JW, Wish JB. Recent and Emerging Therapies for Iron Deficiency in Anemia of CKD: A Review. Am J Kidney Dis 2021; 79:868-876. [PMID: 34758368 DOI: 10.1053/j.ajkd.2021.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/03/2021] [Indexed: 12/29/2022]
Abstract
Iron deficiency commonly contributes to the anemia affecting individuals with chronic kidney disease. Diagnostic criteria for iron deficiency in chronic kidney disease are explained. Mechanisms of functional and absolute iron deficiency and general treatment Principles as delineated in the Kidney Disease: Improving Global Outcomes guidelines are reviewed. Repletion of absolute iron deficits has progressed over time with the addition of better tolerated, more effective oral agents including ferric citrate, ferric maltol, and sucrosomial iron. Structural characteristics and trial data enabling regulatory approval of these novel oral agents are examined. Newer intravenous iron therapies including ferric carboxymaltose and ferric derisomaltose allow for fewer infusions and decreased risk of serious hypersensitivity reactions. Concerns about adverse events including cardiovascular events and infections are discussed. The potential risk of 6H syndrome due to these intravenous agents, including hypophosphatemia, osteomalacia, and pathologic fractures is emphasized. The proposed pathophysiology of 6H syndrome and hypophosphatemia is described. Ferric pyrophosphate citrate enables administration of iron for repletion through dialysate. Relative merits, costs, and risks of various iron agents such as hypersensitivity and 6H syndrome/hypophosphatemia are summarized.
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Affiliation(s)
- Jonathan W Bazeley
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jay B Wish
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA.
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Brandi ML, Clunie GPR, Houillier P, Jan de Beur SM, Minisola S, Oheim R, Seefried L. Challenges in the management of tumor-induced osteomalacia (TIO). Bone 2021; 152:116064. [PMID: 34147708 DOI: 10.1016/j.bone.2021.116064] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 12/16/2022]
Abstract
Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is a rare acquired paraneoplastic disease, which is challenging to diagnose and treat. TIO is characterized by hypophosphatemia resulting from excess levels of tumor-secreted fibroblast growth factor 23 (FGF23), one of the key physiological regulators of phosphate metabolism. Elevated FGF23 results in renal phosphate wasting and compromised vitamin D activation, ultimately resulting in osteomalacia. Patients typically present with progressive and non-specific symptoms, including bone pain, multiple pathological fractures, and progressive muscle weakness. Diagnosis is often delayed or missed due to the non-specific nature of complaints and lack of disease awareness. Additionally, the disease-causing tumour is often difficult to detect and localize because they are often small, lack localizing symptoms and signs, and dwell in widely variable anatomical locations. Measuring serum/urine phosphate should be an inherent diagnostic component when assessing otherwise unexplained osteomalacia, fractures and weakness. In cases of hypophosphatemia with inappropriate (sustained) phosphaturia and inappropriately normal or frankly low 1,25-dihydroxy vitamin D, differentiation of the potential causes of renal phosphate wasting should include measurement of FGF23, and TIO should be considered. While patients experience severe disability without treatment, complete excision of the tumour is typically curative and results in a dramatic reversal of symptoms. Two additional key current unmet needs in optimizing TIO management are: (1 and 2) the considerable delay in diagnosis and consequent delay between the onset of symptoms and surgical resection; and (2) alternative management. These may be addressed by raising awareness of TIO, and taking into consideration the accessibility and variability of different healthcare infrastructures. By recognizing the challenges associated with the diagnosis and treatment of TIO and by applying a stepwise approach with clear clinical practice guidelines, patient care and outcomes will be improved in the future.
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Affiliation(s)
- Maria Luisa Brandi
- FirmoLab, FIRMO Foundation, Stabilimento Chimici Farmaceutico Militare di Firenze, Via Reginaldo Giuliani 201, 50141 Florence, Italy.
| | - Gavin P R Clunie
- Cambridge University Hospitals, Box 204, Hills Road, Cambridge CB2 0QQ, UK.
| | - Pascal Houillier
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Hopital Européen Georges Pompidou, 20 Rue Leblanc, 75015 Paris, France.
| | - Suzanne M Jan de Beur
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA.
| | | | - Ralf Oheim
- University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529 Hamburg, Germany.
| | - Lothar Seefried
- Julius-Maximilians University, Brettreichstr. 11, 97074 Würzburg, Germany.
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36
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Ghelichi-Ghojogh M, Fararouei M, Seif M, Shahryari B, Pakfetrat M. Impact of social and clinical factors on the diagnostic delay of chronic kidney disease: an evaluation study. Int Urol Nephrol 2021; 54:1603-1612. [PMID: 34713367 DOI: 10.1007/s11255-021-03037-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to investigate the impact of social and clinical factors on the diagnostic delay of chronic kidney disease (CKD) among Iranian patients. MATERIALS AND METHODS Our study was conducted on 350 CKD patients who were referred to Faghihi and Motahari clinics (the two largest kidney diseases referral centers in Shiraz the capital of Fars province). Data were collected via an interviewer-administered questionnaire. A multiple linear regression model was used to measure the effect of factors affecting the delay of CKD diagnosis. RESULTS The medians and Interquartile ranges (IQR) of all delays, patient delay, and doctor delay were 6.5 (0-12.2), 5.1 (0-11.2), and 0.9 (0-3.1) months, respectively. The results showed that women were diagnosed 1.61 months earlier than men (p < 0.05). The duration of all delays in patients residing in the rural areas was 1.28 months longer than patients residing in the urban areas (p < 0.05). Also, patients with perceived good economic status were diagnosed 1.30 months earlier than patients who reported having very poor economic status (p < 0.05). CONCLUSIONS The delay is in part due to the neglect and misinterpretation of symptoms by both patients and physicians. It is necessary to improve the awareness of CKD among general public and medical professionals.
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Affiliation(s)
| | - Mohammad Fararouei
- HIV/AIDS Research Center, School of Health, Shiraz University of Medical Sciences, P.O. Box: 71645-111, Shiraz, Iran.
| | - Mozhgan Seif
- Department of Epidemiology, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Maryam Pakfetrat
- Shiraz Nephro-Urology Research Center, Department of Internal Medicine, Emergency Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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McGrath KH, Khoo PWR. Hypophosphataemia Following Ferric Carboxymaltose Infusion. J Paediatr Child Health 2021; 57:1546. [PMID: 34291512 DOI: 10.1111/jpc.15662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/01/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Kathleen H McGrath
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Patricia W R Khoo
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
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Rosner MH, DeMauro Renaghan A. Disorders of Divalent Ions (Magnesium, Calcium, and Phosphorous) in Patients With Cancer. Adv Chronic Kidney Dis 2021; 28:447-459.e1. [PMID: 35190111 DOI: 10.1053/j.ackd.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022]
Abstract
Disorders of the divalent ions (magnesium, calcium, and phosphorous) are frequently encountered in patients with cancer. Of these, hypomagnesemia, hypocalcemia, hypercalcemia, and hypophosphatemia are seen most commonly. These electrolyte disturbances may be related to the underlying malignancy or due to side effects of anticancer therapy. When caused by a paraneoplastic process, these abnormalities may portend a poor prognosis. Importantly, the development of severe electrolyte derangements may be associated with symptoms that negatively impact quality of life, preclude the administration of critical chemotherapeutic agents, or lead to life-threatening complications that require hospitalization and emergent treatment. In accordance, prompt recognition and treatment of these disorders is key to improving outcomes in patients living with cancer. This review will discuss selected derangements of the divalent ions seen in this population, with a focus on paraneoplastic and therapy-associated etiologies.
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Glaspy JA, Wolf M, Strauss WE. Intravenous Iron-Induced Hypophosphatemia: An Emerging Syndrome. Adv Ther 2021; 38:3531-3549. [PMID: 34053011 PMCID: PMC8279965 DOI: 10.1007/s12325-021-01770-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/30/2021] [Indexed: 12/14/2022]
Abstract
Some, but not all, intravenous iron formulations have been recognized to induce renal phosphate wasting syndrome. Most commonly this has been reported following treatment of iron deficiency anemia (IDA) with ferric carboxymaltose (FCM). A search of PubMed identified relevant randomized controlled trials (RCTs), and case studies evaluating hypophosphatemia (HPP) resulting from intravenous iron treatment. While more recent larger comparative RCTs have confirmed that the majority of patients receiving FCM, especially those with normal renal function, may experience severe HPP, complete documentation is hampered by inconsistent reporting of serum phosphate in such trials. Similarly, while case series and RCTs have documented the persistence of HPP for several weeks or even months, the lack of studies lasting beyond 5–6 weeks has constrained full understanding of the duration of effect. Clinical trials have established that the mechanism involves the bone/metabolic axis with the elevation of intact fibroblast growth factor 23 playing the central role. Reports continue to accumulate of the clinical consequences of severe HPP which are, most commonly, bone abnormalities following repetitive dosing. Case reports and studies, however, have also shown that symptomatic hypophosphatemia can occur after a single FCM dose. The frequency of such events remains unknown, in part due to lack of awareness of hypophosphatemia coupled with the fact that the most common acute symptoms of HPP (fatigue and weakness) are the same for IDA and for many of the chronic diseases that cause IDA. Changes to US and European prescribing information for FCM should raise awareness of the potential for HPP and need to monitor patients at risk for it.
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Affiliation(s)
- John A Glaspy
- Division of Hematology-Oncology, Department of Medicine, UCLA School of Medicine, Los Angeles, CA, 90095, USA.
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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40
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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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41
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ISIKTAS SAYILAR E. Kronik böbrek hastalarında ferrik karboksimaltoz tedavisinin serum fosfor düzeyine etkisi. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.794501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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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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43
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Kassianides X, Bodington R, Bhandari S. An evaluation of ferric derisomaltose as a treatment for anemia. Expert Rev Hematol 2020; 14:7-29. [PMID: 33317356 DOI: 10.1080/17474086.2021.1858406] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Originally approved in Europe in 2009, ferric derisomaltose is the most recently authorized intravenous iron compound in the United States of America (2020). Ferric derisomaltose given as a rapid high-dose infusion can allow complete iron repletion in a single dose and it is now widely used in the treatment of iron deficiency. Areas covered: The chemistry, pharmacodynamics and pharmacokinetics of ferric derisomaltose are reviewed. Results from phase II, III and IV trials regarding efficacy and safety are presented. Mechanisms behind minor infusion reactions, hypersensitivity and hypophosphatemia are discussed. The economic impact of ferric derisomaltose use is presented. Data pertaining to the use of ferric derisomaltose in iron deficiency anemia, chronic kidney disease, inflammatory bowel disease, chronic heart failure, perioperative care and other patient groups are comprehensively covered. Expert opinion: Ferric derisomaltose is an effective intravenous iron formulation with a good safety profile, providing rapid, cost-effective iron repletion. Ferric derisomaltose releases low quantities of labile iron relative to older compounds. Anaphylaxis is extremely rare, and 'Fishbane' reactions are uncommon. Hypophosphatemia following ferric derisomaltose administration is infrequent in comparison to other intravenous irons such as ferric carboxymaltose. The scope of ferric derisomaltose use is growing with increasing research in these areas.
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Affiliation(s)
- Xenophon Kassianides
- Academic Renal Department, Hull University Teaching Hospitals NHS Trust and Hull York Medical School , Hull, UK
| | - Richard Bodington
- Academic Renal Department, Hull University Teaching Hospitals NHS Trust and Hull York Medical School , Hull, UK
| | - Sunil Bhandari
- Academic Renal Department, Hull University Teaching Hospitals NHS Trust and Hull York Medical School , Hull, UK
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44
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Delgado JF, Oliva J, González-Franco Á, Cepeda JM, García-García JÁ, González-Domínguez A, Garcia-Casanovas A, Jiménez Merino S, Comín-Colet J. Budget impact of ferric carboxymaltose treatment in patients with chronic heart failure and iron deficiency in Spain. J Med Econ 2020; 23:1418-1424. [PMID: 33073660 DOI: 10.1080/13696998.2020.1838872] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The treatment of iron deficiency (ID) with ferric carboxymaltose (FCM) improves the functional class and quality of life of chronic heart failure (CHF) patients with reduced left ventricular ejection fraction (LVEF), and reduces the rate of hospitalization due to worsening CHF. This study aims to evaluate the budget impact for the Spanish National Health System (SNHS) of treating ID in reduced LVEF CHF with FCM compared to non-iron treatment. METHODS We simulated a hypothetical cohort of 1000 CHF patients with ID and reduced LVEF based on the Spanish population characteristics. A decision-analytic model was also built using the data from the largest FCM clinical trial (CONFIRM-HF) that lasted for a year. We considered the use of healthcare resources from a national prospective study. A deterministic sensitivity analysis was carried out varying the corresponding baseline data by ±25%. RESULTS The cost of treating the simulated population with FCM was €2,570,914, while that of the non-iron treatment was €3,105,711, which corresponds to a cost saving of €534,797 per 1,000 patients in one year. Cost savings were mainly due to a decrease in the number of hospitalizations. All sensitivity analysis showed cost savings for the SNHS. CONCLUSIONS FCM results in an annual cost saving of €534.80 per patient, and would thus be expected to reduce the economic burden of CHF in Spain.
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Affiliation(s)
- Juan F Delgado
- Cardiology Service, Hospital Universitario 12 de Octubre, Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Faculty of Medicine, Complutense University, Madrid, Spain
| | - Juan Oliva
- Department of Economic Analysis, University of Castilla-La Mancha, Toledo, Spain
| | - Álvaro González-Franco
- Department of Internal Medicine, Hospital Universitario Central de Asturias, Asturias, Spain
- Heart Failure and Atrial Fibrillation Group, Spanish Society of Internal Medicine (SEMI)
| | - Jose María Cepeda
- Department of Internal Medicine, Hospital Vega Baja de Orihuela, Alicante, Spain
| | | | | | | | | | - Josep Comín-Colet
- Community Heart Failure Program, Department of Cardiology, Hospital Universitario de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
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45
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Kassianides X, Hazara AM, Bhandari S. Improving the safety of intravenous iron treatments for patients with chronic kidney disease. Expert Opin Drug Saf 2020; 20:23-35. [PMID: 33203251 DOI: 10.1080/14740338.2021.1853098] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Iron-deficiency anemia in chronic kidney disease (CKD) is common and has prognostic, financial, and quality of life implications. Intravenous (IV) iron is a key intervention for optimal management, however, ongoing safety concerns exist. Area covered: The potential side effects associated with IV iron use are addressed as we review the most recent studies. Hypersensitivity reactions and true anaphylaxis are indeed rare with a greater understanding of the nature of labile iron and 'Fishbane' reactions. Hypophosphatemia appears commoner with certain IV iron preparations, however its significance in CKD requires exploration. The long-standing questions regarding oxidative stress and the potential susceptibility to infections and worsening cardiovascular morbidity are discussed. Iron overload secondary to repeat IV iron infusions is plausible, however, a number of guidelines limit and strictly guide prescription. Expert opinion: The past decade has improved our understanding of IV iron administration safety in patients with CKD. Third generation IV iron compounds have minimized hypersensitivity reactions while allowing high doses to be administered safely and rapidly in non-dialysis-dependent CKD patients. However, differences in safety profiles such as hypophosphatemia require further study and therapy should be tailored to the individual. Clinicians should feel confident in using IV iron therapy.
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Affiliation(s)
- Xenophon Kassianides
- Academic Renal Medicine, Hull University Teaching Hospitals NHS Trust , Kingston upon Hull, UK
| | - Adil Mohammad Hazara
- Academic Renal Medicine, Hull University Teaching Hospitals NHS Trust , Kingston upon Hull, UK
| | - Sunil Bhandari
- Academic Renal Medicine, Hull University Teaching Hospitals NHS Trust , Kingston upon Hull, UK
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46
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Rund D. Intravenous iron: do we adequately understand the short- and long-term risks in clinical practice? Br J Haematol 2020; 193:466-480. [PMID: 33216989 DOI: 10.1111/bjh.17202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/28/2020] [Indexed: 12/31/2022]
Abstract
Intravenous (IV) iron as a therapeutic agent is often administered but not always fully understood. The benefits of IV iron are well proven in many fields, particularly in nephrology. IV iron is beneficial not only for true iron deficiency but also for iron-restricted anaemia (functional iron deficiency). Yet, the literature on intravenous iron has many inconsistencies regarding its adverse effects. Over the last several years, newer forms of iron have been developed, leading to the more regular use of iron and in larger doses. This review will summarize some of the older and newer literature regarding the differences among iron products, including the mechanisms and frequency of their adverse events (AEs). The pathway and frequency of an underrecognized adverse event (hypophosphataemia) will be discussed. Recent insights on infection risk and iron handling by macrophages are examined. Potential but presently unproven risks of iron overload due to IV iron are discussed. The impact of these on the risk:benefit ratio and dosing of intravenous iron are considered in different clinical settings, including pregnancy and cancer. IV iron is an essential component of the therapy of anaemia and understanding these issues will enable more informed treatment decisions and knowledgeable use of these drugs.
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Affiliation(s)
- Deborah Rund
- Hebrew University-Hadassah Medical Organization, Ein Kerem, Jerusalem, Israel
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47
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A Pooled Analysis of Serum Phosphate Measurements and Potential Hypophosphataemia Events in 45 Interventional Trials with Ferric Carboxymaltose. J Clin Med 2020; 9:jcm9113587. [PMID: 33172157 PMCID: PMC7694774 DOI: 10.3390/jcm9113587] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/20/2022] Open
Abstract
Ferric carboxymaltose (FCM) has been shown to achieve rapid replenishment of iron stores and correction of anaemia in various populations with iron deficiency. A decrease in serum phosphate (PO43−) levels, which in most cases is asymptomatic, has been reported with IV iron preparations. Hypophosphataemia (HP) is a known adverse drug reaction with FCM. This post hoc pooled analysis investigates the frequency, duration, risk factors, and clinical signs of HP as reported in interventional clinical trials with FCM. Pooled data from subjects enrolled across 45 clinical trials in different therapy areas were included. A three-step adjudication process was utilised to identify adverse events of HP. Stratified analyses by therapy group and stepwise logistic regression analysis were used to identify predictors of HP. This pooled analysis confirms that FCM is associated with increased rates of serum PO43− lowering, but mean serum PO43− values were seen to recover at Week 4 and further recover at Week 8. Among all subjects receiving FCM therapy (n = 6879), 41.4% (n = 2847) reached a PO43− nadir value <2.5 mg/dL at any point on study and 0.7% (n = 49) reached a nadir <1 mg/dL. Although gastroenterology and women’s health subjects were identified to be at higher risk, occurrence of severe HP (<1 mg/dL [0.3 mmol/L]) following FCM administration was not observed to be common among subjects in these studies. Furthermore, there was no correlation between laboratory serum PO43− values and the occurrence of reported adverse events related to low PO43− levels.
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Ozsahin H, Schaeppi M, Bernimoulin M, Allard M, Guidard C, van den Ouweland F. Intravenous ferric carboxymaltose for iron deficiency anemia or iron deficiency without anemia after poor response to oral iron treatment: Benefits and risks in a cohort of 144 children and adolescents. Pediatr Blood Cancer 2020; 67:e28614. [PMID: 32729200 DOI: 10.1002/pbc.28614] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/21/2020] [Accepted: 07/10/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of this single-center observational study was to determine the clinical and hematologic responses to intravenous ferric carboxymaltose (FCM) in a cohort of pediatric patients with poor response to oral iron therapy. The occurrence of adverse events was systematically recorded for up to 96 hours after infusion. STUDY DESIGN A retrospective cohort of 144 consecutive patients aged 18 months to < 18 years with iron deficiency anemia (IDA) or iron deficiency (ID) without anemia was investigated. All patients had failed oral iron therapy. The assessments before and after FCM treatment followed a predefined protocol. RESULTS One hundred of 117 (85 %) of patients with complete data achieved the target ferritin level ≥ 30 µg/L after a single FCM dose. Of 77 patients with IDA and complete data, 38 (49%) showed a complete hematological response within 6-12 weeks; a complete or partial response was achieved by 83%. Clinical symptoms improved in 85% of all patients. In 92% of patients (n = 133 /144), FCM infusion was uneventful. During the 96-hour follow-up, five patients reported potentially related symptoms. No serious adverse events occurred. CONCLUSION The study confirms the safety and efficacy of FCM in children (aged 18 months and older) and adolescents unresponsive to oral therapy, in real-world experience. Single-dose FCM treatment was followed by clinical improvement with advantages of safety, compliance, and lower cost compared with previous generation parenteral iron preparations that had to be administered in fractionated sessions.
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Affiliation(s)
- Hulya Ozsahin
- Centre de Pédiatrie, Clinique des Grangettes, Chêne-Bougeries, Switzerland
| | - Michela Schaeppi
- Centre de Pédiatrie, Clinique des Grangettes, Chêne-Bougeries, Switzerland
| | - Michael Bernimoulin
- Department of Oncology and Hematology, Hôpital de La Tour, Meyrin, Switzerland.,Dianalabs Medical Laboratory, Geneva, Switzerland
| | - Magali Allard
- Centre de Pédiatrie, Clinique des Grangettes, Chêne-Bougeries, Switzerland
| | - Clémence Guidard
- Centre de Pédiatrie, Clinique des Grangettes, Chêne-Bougeries, Switzerland
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Wong P, White M, Tozzi F, Warner SG, Woo Y, Singh G, Fong Y, Melstrom L. Implications of Postpancreatectomy Hypophosphatemia. Am Surg 2020; 87:61-67. [PMID: 32924538 DOI: 10.1177/0003134820949517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Electrolyte abnormalities are commonly found after major abdominal surgery for malignancy. We hypothesized that the severity of hypophosphatemia developed in pancreatectomy patients would be associated with the incidence of complications postoperatively. METHODS A retrospective analysis of an institutional database was conducted for all pancreatic resections (2009-2017). Patient charts were reviewed for demographics, clinicopathologic factors, and perioperative outcomes. RESULTS In a cohort of 283 pancreatectomy patients, 107 (37.8%) and 134 (47.3%) developed mild (2.0-2.5 mg/dL) and moderate/severe hypophosphatemia (<2.0 mg/dL), respectively. Nadir serum phosphate levels were shown to occur on postoperative day (POD) 2 for patients without complications and POD3 for patients who had at least 1 complication. Patients who developed severe hypophosphatemia were significantly more likely to suffer fistula-related complications (P = .0401). CONCLUSIONS Assessing the severity and timing of postpancreatectomy hypophosphatemia presents an opportunity for early detection of impending fistula-related complications.
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Affiliation(s)
- Paul Wong
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Michael White
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Federico Tozzi
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA.,14742Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Susanne G Warner
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Yanhgee Woo
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Gagandeep Singh
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Yuman Fong
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh Melstrom
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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Callejas-Moraga EL, Casado E, Gomez-Nuñez M, Caresia-Aroztegui AP. Severe osteomalacia with multiple insufficiency fractures secondary to intravenous iron therapy in a patient with Rendu-Osler-Weber syndrome. Bone Rep 2020; 13:100712. [PMID: 32923530 PMCID: PMC7475229 DOI: 10.1016/j.bonr.2020.100712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/08/2020] [Accepted: 08/19/2020] [Indexed: 12/19/2022] Open
Abstract
Summary This case report describes a 65-year-old man with a Rendu-Osler-Weber syndrome with secondary chronic anaemia, who received multiple intravenous (IV) iron infusions and sustained diffuse bone pain secondary to multiple insufficiency fractures. Laboratory study confirmed fibroblast growth factor 23 (FGF-23)-mediated hypophosphatemia as the main cause of a severe osteomalacia induced by ferric carboxymaltose (FCM). After 3 months or oral phosphate replacement and switching to iron sucrose, serum phosphate levels were normalized and patient improved clinically. Introduction Some drugs can induce asymptomatic hypophosphatemia, which if sustained, can lead to a severe osteomalacia with multiple skeletal fractures. This complication has also been described with IV iron therapy. Methods This case report describes a patient with Rendu-Osler-Weber syndrome with chronic iron deficiency anaemia, recurrently treated with FCM, who developed a severe osteomalacia with multiple skeletal fractures. Results Laboratory study showed hypophosphatemia, with high ALP and high FGF-23. Images studies confirmed bone mass loss and multiple insufficiency fractures. A Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT) did not show hidden tumor, so a diagnosis of FCM-induced hypophosphatemic osteomalacia was performed. Phosphate replacement improved clinical symptoms of the patient. Conclusion Intravenous iron therapy, mainly FCM form, can cause hypophosphatemia, and in some cases induce a severe osteomalacia with multiple fractures, so it seems advisable to monitor serum phosphate levels in high risk patients, as those who receive repeated dose. Intravenous iron therapy can cause hypophosphatemia and in some cases osteomalacia. Ferric carboxymaltose can raise fibroblast growth factor 23, a phosphaturic hormone. Osteomalacia should be considered if a patient treated with iron therapy develops pain. It's advisable to monitor serum phosphate in patients who receive iron therapy. In case of persistent hypophosphatemia, switch to another iron therapy is suggested.
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Affiliation(s)
- Eduardo Luis Callejas-Moraga
- Department of Internal Medicine, University Hospital Parc Taulí, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
| | - Enrique Casado
- Department of Rheumatology, University Hospital Parc Taulí, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
| | - Marta Gomez-Nuñez
- Department of Hematology, University Hospital Parc Taulí, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
| | - Ana Paula Caresia-Aroztegui
- Department of Nuclear Medicine, University Hospital Parc Taulí, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
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