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Ferric Gluconate

Medically reviewed on Nov 15, 2018

Pronunciation

(FER ik GLOO koe nate)

Index Terms

  • Sodium Ferric Gluconate
  • Sodium Ferric Gluconate Complex

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous:

Ferrlecit: 12.5 mg/mL (5 mL) [contains benzyl alcohol, sucrose]

Generic: 12.5 mg/mL (5 mL)

Brand Names: U.S.

  • Ferrlecit

Pharmacologic Category

  • Iron Salt

Pharmacology

Supplies a source to elemental iron necessary to the function of hemoglobin, myoglobin and specific enzyme systems; allows transport of oxygen via hemoglobin

Half-Life Elimination

Bound iron: 1 hour

Use: Labeled Indications

Iron deficiency anemia: Treatment of iron-deficiency anemia in patients 6 years and older with chronic kidney disease undergoing hemodialysis in conjunction with supplemental erythropoietin therapy

Off Label Uses

Iron deficiency anemia (in nondialysis patients unresponsive to or poorly tolerant of oral iron therapy)

Clinical experience supports the use of IV iron preparations, including ferric gluconate, for the treatment of iron deficiency anemia in patients who are not responding to or do not tolerate oral iron therapy [DeLoughery 2017]. A meta-analysis supports the use of ferric gluconate in patients with chronic kidney disease (CKD) not on dialysis; randomized controlled trials of oral versus intravenous iron in patients with CKD (dialysis and nondialysis dependent) were analyzed and found that patients receiving IV iron products were more likely to reach desired hemoglobin levels with an associated slightly higher risk of hypotension and fewer gastrointestinal side effects [Shepshelovich 2016]. Data from two randomized, multicenter trials support the use of ferric gluconate in the management of chemotherapy-associated anemia in patients with cancer [Henry 2007], [Pedrazzoli 2008]. IV ferric gluconate may be of benefit in patients whose absorption of oral iron may be impaired (eg, inflammatory bowel disease [IBD]) or in patients in whom IV iron therapy may provide more expeditious improvement in hematologic parameters [Gomollón 2013], [Reed 2015].

Contraindications

Known hypersensitivity to ferric gluconate or any component of the formulation

Dosing: Adult

Note: A test dose of 2 mL diluted in NS 50 mL administered over 60 minutes was previously recommended (not in current manufacturer labeling [consider a test dose in patients with a history of drug allergies]).

Iron-deficiency anemia, hemodialysis patients: IV: 125 mg (elemental iron) per dialysis session. For repletion treatment, most patients may require a cumulative dose of 1,000 mg (elemental iron) over ~8 dialysis sessions.

Off-label dosing (based on limited data): After establishing tolerance of the 125 mg dose (elemental iron), single doses of up to 250 mg (elemental iron) have been reported to be safe and well-tolerated in hemodialysis patients (Folkert 2003; Pandey 2016).

Iron-deficiency anemia (in nondialysis patients unresponsive to or poorly tolerant of oral iron therapy) (off-label use): IV: 125 to 250 mg elemental iron per dose; repeated until hematologic parameters or total iron requirements are met (DeLoughery 2017; Gomollón 2013; Reed 2015)

Chemotherapy-associated anemia (off-label use): IV infusion: 125 mg once every week for 6 doses (Pedrazzoli 2008) or for 8 doses (Henry 2007)

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Iron-deficiency anemia, hemodialysis patients: Children ≥6 years and Adolescents: IV: 1.5 mg/kg of elemental iron (maximum: 125 mg/dose) per dialysis session

Dosing: Renal Impairment

No dosage adjustment necessary. The ferric gluconate iron complex is not dialyzable.

Dosing: Hepatic Impairment

No dosage adjustment necessary.

Reconstitution

For IV infusion, dilute ferric gluconate in NS (children: 25 mL NS, adults: 100 mL NS).

Administration

IV:

Children: Administer diluted over 1 hour per dialysis session.

Adults: Administer diluted over 1 hour or undiluted (slowly) at a rate of up to 12.5 mg/minute per dialysis session. The 250 mg dose (off-label) has been infused (diluted) over 1 to 2 hours (Folkert 2003; Reed 2015).

Storage

Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Do not freeze. Use immediately after dilution in NS.

Drug Interactions

Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. Consider therapy modification

Angiotensin-Converting Enzyme Inhibitors: May enhance the adverse/toxic effect of Ferric Gluconate. Monitor therapy

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Monitor therapy

Baloxavir Marboxil: Iron Salts may decrease the serum concentration of Baloxavir Marboxil. Avoid combination

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Blood Pressure Lowering Agents: May enhance the hypotensive effect of Hypotension-Associated Agents. Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Bromperidol: Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Bromperidol may diminish the hypotensive effect of Blood Pressure Lowering Agents. Avoid combination

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Dimercaprol: May enhance the nephrotoxic effect of Iron Salts. Avoid combination

DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Monitor therapy

Herbs (Hypotensive Properties): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Monitor therapy

Levodopa: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa. Monitor therapy

Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Monitor therapy

Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Consider therapy modification

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Test Interactions

Serum or transferrin bound iron levels may be falsely elevated if assessed within 24 hours of ferric gluconate administration. Serum ferritin levels may be falsely elevated for 5 days after ferric gluconate administration.

Adverse Reactions

Percentages reported in adults unless otherwise noted.

>10%:

Cardiovascular: Hypotension (children: 35%; adults: 29%), hypertension (children: 23%; adults: 13%), tachycardia (children: 17%; adults: 5%)

Central nervous system: Headache (children: 24%; adults: 7%), dizziness (13%)

Gastrointestinal: Vomiting (adults: ≤35%; children: 11%), nausea (adults: ≤35%; children: 9%), diarrhea (adults: ≤35%; children: 8%)

Hematologic & oncologic: Abnormal erythrocytes (11%; changes in color, morphology, or number)

Local: Injection site reaction (33%)

Neuromuscular & skeletal: Muscle cramps (25%)

Respiratory: Dyspnea (11%)

1% to 10%:

Cardiovascular: Chest pain (10%), syncope (6%), thrombosis (children: 6%), edema (5%), angina pectoris, bradycardia, myocardial infarction, peripheral edema (including leg edema), vasodilatation

Central nervous system: Pain (10%), fatigue (6%), paresthesia (6%), agitation, chills, drowsiness, impaired consciousness, malaise, rigors

Dermatologic: Pruritus (6%), diaphoresis, skin rash

Endocrine & metabolic: Hyperkalemia (6%), hypermenorrhea, hypervolemia, hypoglycemia, hypokalemia

Gastrointestinal: Abdominal pain (children: 9%; adults: 6%), anorexia, dyspepsia, eructation, flatulence, gastrointestinal disease, melena, rectal disease

Genitourinary: Urinary tract infection

Hematologic & oncologic: Anemia, carcinoma, leukocytosis, lymphadenopathy

Infection: Abscess, infection, sepsis

Neuromuscular & skeletal: Leg cramps (10%), weakness (7%), arm pain, arthralgia, back pain, myalgia

Ophthalmic: Conjunctivitis, corneal changes (arcus senilis), diplopia, eye redness, eyelid edema, nystagmus, watery eyes

Otic: Deafness

Respiratory: Pharyngitis (children: 9%), cough (6%), rhinitis (children: 6%), upper respiratory tract infection (6%), flu-like symptoms, pneumonia, pulmonary edema

Miscellaneous: Fever (children: 9%; adults: 5%)

<1%, postmarketing, and/or case reports: Anaphylaxis, convulsions, dysgeusia, facial flushing, hemorrhage, hypersensitivity reaction, hypertonia, hypoesthesia, loss of consciousness, nervousness, pallor, phlebitis, shock, skin discoloration, xerostomia

Warnings/Precautions

Concerns related to adverse effects:

• Hypotension: Clinically significant hypotension may occur; usually resolves within 1-2 hours. May augment hemodialysis-induced hypotension.

• Hypersensitivity reactions: Serious hypersensitivity reactions, including anaphylactic-type reactions, have occurred (may be life-threatening). May present with shock, clinically significant hypotension, loss of consciousness, or collapse. Monitor during administration and for ≥30 minutes after administration and until clinically stable after infusion. Avoid rapid administration. Equipment for resuscitation and trained personnel experienced in handling medical emergencies should always be immediately available.

Special populations:

• Elderly: Use with caution in the elderly.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer’s labeling.

Other warnings/precautions:

• Appropriate use: Use only in patients with documented iron deficiency; caution with hemoglobinopathies or other refractory anemias as iron overload may occur.

Monitoring Parameters

Monitor hemoglobin and hematocrit, serum ferritin, iron saturation; vital signs; monitor for signs and symptoms of hypersensitivity (monitor for at least 30 minutes following the end of administration and until clinically stable)

Chronic kidney disease: Monitor transferrin saturation and ferritin more frequently following a course of IV iron (KDIGO 2013)

Chemotherapy-associated anemia (off-label use): Iron, total iron-binding capacity, transferrin saturation, or ferritin levels at baseline and periodically (Rizzo 2010)

Pregnancy Risk Factor

B

Pregnancy Considerations

Adverse events were not observed in animal reproduction studies. It is recommended that pregnant women meet the dietary requirements of iron with diet and/or supplements in order to prevent adverse events associated with iron deficiency anemia in pregnancy. Treatment of iron deficiency anemia in pregnant women is the same as in nonpregnant women and in most cases, oral iron preparations may be used. Except in severe cases of maternal anemia, the fetus achieves normal iron stores regardless of maternal concentrations (IOM 2001).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience diarrhea, cramps, abdominal pain, lack of appetite, or injection site irritation. Have patient report immediately to prescriber signs of high potassium (abnormal heartbeat, confusion, dizziness, passing out, weakness, shortness of breath, numbness or tingling feeling), angina, severe dizziness, passing out, burning or numbness feeling, cough, tachycardia, edema, chills, flushing, severe back pain, severe groin pain, severe thigh pain, sweating a lot, severe nausea, severe vomiting, severe headache, shortness of breath, or severe loss of strength and energy (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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