Iron Dextran Complex
Medically reviewed on March 25, 2018
(EYE ern DEKS tran KOM pleks)
- High-Molecular-Weight Iron Dextran (Dexferrum)
- Iron Dextran
- Low-Molecular-Weight Iron Dextran (INFeD)
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Dexferrum: 50 mg/mL (1 mL [DSC], 2 mL [DSC])
INFeD: 50 mg/mL (2 mL)
Brand Names: U.S.
- Dexferrum [DSC]
- Iron Salt
The released iron, from the plasma, eventually replenishes the depleted iron stores in the bone marrow where it is incorporated into hemoglobin
IM: 60% absorbed after 3 days; 90% after 1 to 3 weeks, the balance is slowly absorbed over months
IV: Uptake of iron by the reticuloendothelial system appears to be constant at about 10 to 20 mg/hour
Urine and feces via reticuloendothelial system
Onset of Action
Hematologic response to either oral or parenteral iron salts is essentially the same; red blood cell form and color changes within 3 to 10 days
Maximum effect: Peak reticulocytosis occurs in 5 to 10 days, and hemoglobin values increase within 2 to 4 weeks; serum ferritin peak: 7 to 9 days after IV dose
Use: Labeled Indications
Iron deficiency: Treatment of iron deficiency in patients in whom oral administration is unsatisfactory or infeasible
Hypersensitivity to iron dextran or any component of the formulation; any anemia not associated with iron deficiency
Note: Dexferrum has been discontinued in the US for more than 1 year.
Note: A 25 mg test dose should be administered prior to starting iron dextran therapy; observe for at least 1 hour (after test dose) prior to administering the therapeutic dose. Discontinue oral iron products prior to administering iron dextran.
Iron-deficiency anemia: IM (INFeD), IV (Dexferrum, INFeD):
Total dose (mL) = 0.0442 (desired hemoglobin - observed hemoglobin) x LBW + (0.26 x LBW)
Desired hemoglobin: Usually 14.8 g/dL
LBW = Lean body weight in kg
Iron replacement therapy for blood loss: IM (INFeD), IV (Dexferrum, INFeD): Replacement iron (mg) = blood loss (mL) x Hct
Maximum daily dosage (manufacturer's labeling): Replacement of larger estimated iron deficits (total dose) may be achieved by serial administration of smaller incremental daily doses. Daily dosages should usually be limited to 100 mg iron (2 mL).
Cancer-/chemotherapy-associated anemia: IV: Note: Use the iron-deficiency anemia equation for determining a calculated dose, when applicable.
Weekly administration (off-label dosing; INFeD [Auerbach 2004]):
Weeks 1 to 3: Test dose of 25 mg (over 1 to 2 minutes), followed by 75 mg (bolus) once weekly
Weeks 4 and after: 100 mg over 5 minutes once weekly until the calculated dose is reached
Total dose infusion (off-label dosing; INFeD): Test dose of 25 mg (over 1 to 2 minutes), followed 1 hour later by the balance of the calculated total dose mixed in 500 mL NS and infused at 175 mL/hour (Auerbach 2004)
Refer to adult dosing.
Note: Dexferrum has been discontinued in the US for more than 1 year.
Note: A 12.5 to 25 mg test dose should be administered prior to starting iron dextran therapy (Reed 1981; Waraday 2004); observe for at least 1 hour (after test dose) prior to administering the therapeutic dose. Discontinue oral iron products prior to administering iron dextran.
Iron-deficiency anemia: Infants ≥4 months, Children, and Adolescents: IM (INFeD), IV (Dexferrum, INFeD):
5 to 15 kg: Should not normally be given in the first 4 months of life:
Total dose (mL) = 0.0442 (desired hemoglobin - observed hemoglobin) x W + (0.26 x W)
Desired hemoglobin: Usually 12 g/dL
W = Total body weight in kg
>15 kg: Refer to adult dosing.
Iron replacement therapy for blood loss: Infants ≥4 months, Children, and Adolescents: Refer to adult dosing.
Maximum daily dose (manufacturer's labeling): Replacement of larger estimated iron deficits (total dose) may be achieved by serial administration of smaller incremental daily doses. Daily dosages should usually be limited to:
IV (Dexferrum, INFeD): 100 mg (2 mL)
Infants <5 kg: 25 mg iron (0.5 mL)
Infants and Children 5 to 10 kg: 50 mg iron (1 mL)
Children and Adolescents ≥10 kg: Refer to adult dosing.
Dosing: Renal Impairment
Hemodialysis: Nondialyzable. No dosage adjustment provided in manufacturer’s labeling.
Dosing: Hepatic Impairment
No dosage adjustment provided in manufacturer’s labeling.
Solutions for infusion should be diluted in 250 to 1,000 mL NS.
Total dose infusion (off-label dose): Dilute in 500 mL NS (Auerbach 2004)
Note: A test dose should be administered on the first day of therapy; administer slowly over at least 30 seconds and observe for at least 1 hour for hypersensitivity reaction, then administer the remainder of the day's therapeutic dose (dose minus test dose). Resuscitation equipment, medication, and trained personnel should be available. An uneventful test dose does not ensure an anaphylactic-type reaction will not occur during administration of the therapeutic dose.
IM (INFeD): Use Z-track technique (displacement of the skin laterally prior to injection); injection should be deep into the upper outer quadrant of buttock; alternate buttocks with subsequent injections. Administer test dose at same recommended site using the same technique.
IV: Test dose should be administered gradually over at least 30 seconds (INFeD) or 5 minutes (Dexferrum), or over 1 to 2 minutes (INFeD) for cancer-/chemotherapy-associated anemia (Auerbach 2004). Subsequent dose(s) may be administered undiluted at a slow gradual rate not to exceed 50 mg/minute (maximum: 100 mg).
Avoid dilutions with dextrose (increased incidence of local pain and phlebitis).
Total dose infusion (in patients with cancer-/chemotherapy-associated anemia) (off-label administration): 1 hour after the test dose, administer the balance of the dose diluted in 500 mL NS and infuse at 175 mL/hour (Auerbach 2004)
Total dose infusion (in patients with CKD and iron deficiency anemia) (off-label administration): After initial test dose, administer total dose over 4 to 6 hours (Dossabhoy 2014). However, total dose infusions have been associated with an increased incidence of adverse effects 24 to 48 hours after the infusion.
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).
Angiotensin-Converting Enzyme Inhibitors: May enhance the adverse/toxic effect of Iron Dextran Complex. Specifically, patients receiving an ACE inhibitor may be at an increased risk for anaphylactic-type reactions. Management: Follow iron dextran recommendations closely regarding both having resuscitation equipment and trained personnel on-hand prior to iron dextran administration and the use of a test dose prior to the first therapeutic dose. Consider therapy modification
Bictegravir: Iron Salts may decrease the serum concentration of Bictegravir. Management: Bictegravir, emtricitabine, and tenofovir alafenamide can be administered with iron salts under fed conditions, but coadministration with or 2 hours after an iron salt is not recommended under fasting conditions. Consider therapy modification
Dimercaprol: May enhance the nephrotoxic effect of Iron Salts. Avoid combination
May cause falsely elevated values of serum bilirubin and falsely decreased values of serum calcium. Residual iron dextran may remain in reticuloendothelial cells; may affect accuracy of examination of bone marrow iron stores. Bone scans with 99m Tc-labeled bone seeking agents may show reduced bony uptake, marked renal activity, and excess blood pooling and soft tissue accumulation following IV iron dextran infusion or with high serum ferritin levels. Following IM iron dextran, bone scans with 99m Tc-diphosphonate may show dense activity in the buttocks.
Frequency not defined. Adverse event risk is reported to be higher with the high-molecular-weight iron dextran formulation.
Cardiovascular: Bradycardia, cardiac arrhythmia, chest pain, chest tightness, flushing, hypertension, hypotension, shock, syncope, tachycardia
Central nervous system: Chills, disorientation, dizziness, headache, loss of consciousness, malaise, paresthesia, seizure, unresponsive to stimuli
Dermatologic: Diaphoresis, pruritus, skin rash, urticaria
Gastrointestinal: Abdominal pain, diarrhea, dysgeusia, nausea, vomiting
Genitourinary: Hematuria, urine discoloration
Hematologic & oncologic: Leukocytosis, lymphadenopathy, purpura
Hypersensitivity: Anaphylaxis (includes acute respiratory distress, circulatory shock)
Infection: Sterile abscess
Local: Injection site reaction (includes injection site cellulitis, inflammation at injection site, injection site phlebitis, local soreness/soreness at injection site, pain at injection site, swelling at injection site), local discoloration (at the site of intramuscular injection)
Neuromuscular & skeletal: Amyotrophy (with intramuscular injection), arthralgia, arthritis, back pain, exacerbation of arthritis, myalgia, weakness
Respiratory: Bronchospasm, cyanosis, dyspnea, wheezing
Miscellaneous: Fever, fibrosis (with intramuscular injection)
<1%, postmarketing, and/or case reports: Angioedema, neoplasm (at former injection site)
Concerns related to adverse effects:
• Delayed (1 to 2 days) infusion reaction (including arthralgia, back pain, chills, dizziness, fever, headache, malaise, myalgia, nausea, and/or vomiting) may occur with large doses (eg, total dose infusion) of IV iron dextran; symptoms usually subside within 3 to 4 days.
• Hypersensitivity: [US Boxed Warning]: Anaphylactic-type reactions (including fatalities) are associated with parenteral administration of iron dextran. Administer only where resuscitation equipment and personnel trained in detection and treatment of hypersensitivity are available during administration. Administer a test dose prior to the first therapeutic dose. If no signs/symptoms of anaphylactic-type reactions follow the test dose, administer the full therapeutic dose. Monitor for signs/symptoms of hypersensitivity during infusion. Fatal reactions have occurred following a test dose and have occurred in patients who tolerated the test dose. Patients with a history of drug allergy or multiple drug allergies may be at increased risk of anaphylactic-type reactions. Concomitant use of ACE inhibitors may also increase the risk of hypersensitivity. Adverse events (including life-threatening) associated with iron dextran usually occur more with the high-molecular-weight formulation (Dexferrum), compared to low-molecular-weight iron dextran (INFeD) (Chertow 2006).
• Allergies/asthma: Use with caution in patients with a significant history of allergies and/or asthma.
• Cardiovascular disease: Use with caution in patients with pre-existing cardiovascular disease; iron dextran may exacerbate cardiovascular complications.
• Hepatic impairment: Use with extreme caution in patients with serious hepatic impairment.
• Renal disease/impairment: In patients with chronic kidney disease (CKD) requiring iron supplementation, the IV route is preferred for hemodialysis patients; either oral iron or IV iron may be used for nondialysis and peritoneal dialysis CKD patients, although an initial 1- to 3-month trial of oral iron therapy is recommended (KDIGO 2012). Avoid use during acute kidney infection.
• Rheumatoid arthritis: Patients with rheumatoid arthritis may experience acute exacerbation of joint pain and swelling.
Concurrent drug therapy issues:
• Drug-drug/drug-food interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Elderly: Anemia in the elderly is often caused by “anemia of chronic disease” or associated with inflammation rather than blood loss. Iron stores are usually normal or increased, with a serum ferritin >50 ng/mL and a decreased total iron binding capacity. IV administration of iron dextran is often preferred over IM in the elderly secondary to a decreased muscle mass and the need for daily injections.
• Pediatric: Intramuscular iron dextran use in neonates may be associated with an increased incidence of gram-negative sepsis.
Dosage form specific issues:
• Product interchangeability: Iron dextran products differ in chemical characteristics. The high-molecular-weight formulation (Dexferrum) and the low-molecular-weight formulation (INFeD) are not clinically interchangeable.
• Appropriate use: [US Boxed Warning]: Use iron dextran only in patients where clinical and laboratory evidence has established the iron deficient state is not amenable to oral iron therapy. Discontinue oral iron prior to initiating parenteral iron therapy.
• Carcinogenicity: Cases of tumor development at prior intramuscular injection sites of iron-carbohydrate complexes have been reported.
• Iron overload: Exogenous hemosiderosis may result from excess iron stores; patients with refractory anemias and/or hemoglobinopathies may be prone to iron overload with unwarranted iron supplementation.
Monitor hemoglobin, hematocrit, reticulocyte count, serum ferritin, serum iron, TIBC; monitor for anaphylaxis/hypersensitivity reaction (during test dose, for 1 hour after test dose, and during and after therapeutic dose)
Cancer patients with anemia: Monitor iron, total iron-binding capacity, transferrin saturation, or ferritin levels at baseline and periodically (Rizzo 2010).
Chronic kidney disease: Monitor transferrin saturation more frequently following a course of IV iron (KDIGO 2012)
Pregnancy Risk Factor
Adverse events have been observed in animal reproduction studies. It is not known if iron dextran (as iron dextran) crosses the placenta. 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.
• 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 injection site pain, skin discoloration, or irritation; diarrhea; abdominal pain; or change in taste. Have patient report immediately to prescriber severe headache, angina, severe dizziness, passing out, vision changes, severe loss of strength and energy, severe nausea, severe vomiting, burning or numbness feeling, blue/gray skin discoloration, swollen glands, hematuria, back pain, joint pain, chills, seizures, severe muscle pain, sweating a lot, shortness of breath, flushing, bradycardia, tachycardia, or abnormal heartbeat (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.
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- Drug class: iron products