Intravenous iron sucrose: establishing a safe dose

It is now recognized that the majority of patients on epoetin therapy require intravenous (IV) iron supplementation to maximize the response to treatment. Of the IV iron preparations available, iron sucrose has proved its efficacy and safety; however, there are no guidelines or systematic studies examining the optimum safe dosage regimen for this compound. The aim of the present study was to investigate prospectively a variety of dosing regimens for IV iron sucrose in patients with renal failure to develop treatment strategies for this preparation. A total of 335 iron infusions was administered to 249 patients in this study, which was conducted in four phases. In phase I, 89 patients were administered a dose of 200 mg as an IV infusion over 2 hours. No adverse events were seen. A 500-mg dose by 2-hour infusion was then assessed, but was abandoned after 8 of 22 patients developed reactions characterized by dizziness, hypotension, and nausea. The dose was then reduced to 300 mg by 2-hour infusion for the next 189 patients, and again, no adverse reactions were witnessed. Finally, a 400-mg dose by 2-hour infusion was examined in 35 patients, but 2 patients experienced such symptoms as hypotension, nausea, and lower back pain. Both the 200- and 300-mg doses of IV iron sucrose administered over 2 hours appear to be safe. The incidence of adverse events with the 400- and 500-mg doses administered as a 2-hour infusion seems too high to recommend their routine use, although it may be possible to administer these doses over a longer period.

Beneficial effects of adopting an aggressive intravenous iron policy in a hemodialysis unit

Iron deficiency is the most common cause of a suboptimal response to epoetin therapy, and the treatment of choice is intravenous (IV) iron. It is also increasingly recognized that IV iron can enhance the response to epoetin, even in iron-replete patients. The aim of the present study was to examine the effects of adopting an aggressive IV iron policy in all patients attending a single-center hemodialysis unit. The protocol was simple and practical, and involved administering a weekly IV bolus of 100 mg iron sucrose to all patients with a serum ferritin level of 150 to 1,000 microg/L. Only patients with a serum ferritin level greater than 1,000 microg/L were excluded; patients with a serum ferritin level below 150 microg/L were given a more aggressive IV dosing regimen to get into range for the standard protocol. Among 116 patients included in the study, the mean serum ferritin level increased from 214 microg/L in November 1997 to 564 microg/L in November 1998 (P < 0.0001). Mean hemoglobin increased modestly from 9.6 g/dL to 10.7 g/dL over the same period, but there was a dramatic reduction in mean epoetin dose from 13,277 U/wk to 8,976 U/wk (P < 0.0005), resulting in cost savings of approximately pound 228,000 ($366,000), or pound 152 ($244) per patient per month. No adverse reactions to IV iron were seen among a total of 4,564 injections, and there was no obvious increase in the incidence of infection. This simple, practical IV iron dosing policy resulted in dramatic savings in epoetin dosage and cost with no significant adverse effects.