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CORRESPONDENCE Parenteral supplementation of iron is required in some patients
with iron deficiency, including those with oral iron intolerance, chronic uncorrected bleeding, malabsorption, gastrointestinal inflammatory disease, dialysis dependence, or failure to take prescribed oral iron. A more rapid increase in hemoglobin production occurs after intravenous administration, which may be valuable in
anemic patients and chronic bleeding patients. Unlike oral iron, the
full dose of intravenous iron is delivered to the bone marrow and
saturates tissue stores.1,2 The 2 popular forms of available parenteral iron in the United States
are iron dextran and iron gluconate. Despite their value, intravenous
iron therapy carries the potential for serious allergic reactions. In
1980, Hamstra et al examined over 2000 infusions of iron dextran among
481 patients and reported that 26% of patients experienced side
effects, of which the majority were mild and self-limited. Of
the reactions, 2% were considered "severe" allergic and 0.6% were
classified as anaphylactoid. Most reactions were reported to occur
immediately during the infusion of a test dose. As a result,
administration of a test dose is now recommended to monitor patients
for reactions.1 In contrast, iron gluconate is considered to have a lower
reaction rate and a test dose is not recommended by the manufacturer. During the years of 1992 to 1996, Faich and Strobos reported 3.3 allergic events per million doses per year with iron gluconate and 8.7 allergic events per million doses per year with iron
dextran.3 No fatalities were associated with iron
gluconate between 1976 to 1996. However, 31 fatalities among 196 allergy/anaphylactic cases were recorded between 1976 to 1996 for iron
dextran, translating into a case fatality rate of 15.8% for iron
dextran.3 Other studies have reported similar high rates
of allergic reactions for iron dextran.4-6 As a result,
several authors have advocated the use of iron gluconate over iron
dextran, in order to avoid serious reactions. For example, The
University of Iowa Health Care Center uses only iron gluconate despite
the need for multiple dosing.7 We report here a chart review of recorded reactions over the past 3 years (1999-2002) to intravenous infusions of iron dextran and iron
gluconate administered in the outpatient Blood Transfusion Center at
Massachusetts General Hospital, Boston. A total of 65 infusions of
either iron dextran (INFeD, Schein) or iron gluconate (Ferrlecit, Schein, Morristown, NJ) were performed among 35 patients over the 3-year period. All patients were directly observed
for allergic reactions and reactions were recorded. We grouped the resulting reactions into 3 categories:
severe (reactions such as anaphylactoid, shock, and
cardiovascular collapse); moderate (reactions such as dyspnea, severe
urticaria, and neck and back spasm in which the infusion was stopped
and patient did not tolerate further infusion); and mild (reactions
such as headache, dizziness, tachycardia, and hypertension in which the
infusion was stopped but the patient subsequently completed the
infusion). Over the 3-year period, an average of 21.5% (14/65) of
infusions demonstrated some form of mild, moderate, or severe reaction. Of these reactions, only 1 reaction was severe, 4 were moderate, and
the remainder were mild. As shown in Table
1,
the rate of acute allergic reactions was comparable with the 2 preparations.
As previously reported by others, our data suggest a high rate of acute reactions to intravenous iron. When compared with other commonly prescribed medications, intravenous iron has an extremely high rate of adverse events. In contrast to previous reports, we have found that acute allergic reactions appear to be as common with iron gluconate as with iron dextran. Our findings are not explained by a selection bias (use of iron gluconate in patients with prior reactions to iron dextran) because only one patient who reacted to iron gluconate had had a prior reaction to iron dextran.7 Our results challenge the notion that iron gluconate, which requires 8 infusions in place of the single infusion of iron dextran, is a safer alternative treatment to iron dextran. Because our data set is small, further studies are needed to determine more conclusively the rates of reaction to different iron preparations.
Quentin Eichbaum, Stacy Foran, and Sunny Dzik
References 1. Hamstra RD, Block MH, Schokert AL. Intravenous iron dextran in clinical medicine. JAMA. 1980;243:1726-1731[Abstract].
2.
Andrews NC.
Disorders of iron metabolism.
N Engl J Med.
1999;341:1986-1995 3. Faich G, Strobos J. Sodium ferric gluconate complex in sucrose: safer intravenous iron therapy than iron dextrans. Am J Kid Dis. 1999;33:464-470[Medline] [Order article via Infotrieve]. 4. Burns DL, Pomposelli JJ. Toxicity of parenteral iron dextran therapy. Kidney Int Suppl. 1999;69:S119-S123[Medline] [Order article via Infotrieve]. 5. Michael B, Coyne DW, Fishbane S, et al. Sodium ferric gluconate complex in hemodialysis patients: adverse reactions compared to placebo and iron dextran. Kid Int. 2000;61:1830-1839. 6. Fishbane S, Kowalski EA. Comparative safety of intravenous iron dextran, iron saccharate and sodium ferric gluconate. Semin Dial. 2000;13:381-384[CrossRef][Medline] [Order article via Infotrieve]. 7. Schrand LM, Johnson SJ, Berkowski SS. New intravenous iron products: increasing safety at UIHC [letter]. P T News. 2001.   CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati What's this?
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| Copyright © 2003 by American Society of Hematology Online ISSN: 1528-0020 | |||||||||
