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Purpose of the Review Iron deficiency in heart failure has been associated with impaired functional capacity and quality of life. The purpose of this paper is to review mechanisms of iron homeostasis and current clinical data exploring mechanisms of iron repletion in heart failure. Recent Finding Multiple international societies now advise iron repletion for symptomatic heart failure patients with iron deficiency. Due to the chronic inflammation in heart failure, iron deficiency in heart failure is classically defined as ferritin

Iron deficiency and iron-deficiency anemia are common medical conditions. Management of the etiology and iron supplementation are both necessary to treat this condition. Use of intravenous iron preparations is increasing due to its advantages over oral iron. Indeed, the total dose required can be provided in a single infusion, and it is more effective and increases hemoglobin levels more quickly than oral iron. Hypophosphatemia, sometimes severe, following intravenous iron administration, has been described in literature these past years, in particular with ferric carboxymaltose. We report here a case of severe hypophosphatemia with ferric carboxymaltose and carry out a literature review to determine the incidence of hypophosphatemia and to precise its clinical presentation, its pathophysiological mechanisms and its treatment. We found that hypophosphatemia is frequent with ferric carboxymaltose. Most of the time, there are no clinical manifestations, but cases of symptomatic osteomalacia have been described. Duration of hypophosphatemia is variable, from a few weeks to several months in case of prolonged administration. Hypophosphatemia owing to renal phosphate wasting is caused by an increase in intact fibroblast growth factor 23 (FGF-23) levels. However, the mechanism of ferric carboxymaltose- induced increase in intact FGF-23 is still unknown.

Aims Iron deficiency (ID) is associated with poor prognosis regardless of anaemia. Intravenous iron improves quality of life and outcomes in patients with ID and heart failure (HF) with reduced ejection fraction (HFrEF). In the Swedish HF registry, we assessed (i) frequency and predictors of ID testing; (ii) prevalence and outcomes of ID with/without anaemia; (iii) use of ferric carboxymaltose (FCM) and its predictors in patients with ID. Methods and results We used multivariable logistic regressions to assess patient characteristics independently associated with ID testing/FCM use, and Cox regressions to assess risk of outcomes associated with ID. Of 21 496 patients with HF and any ejection fraction enrolled in 2017-2018, ID testing was performed in 27%. Of these, 49% had ID and more specifically 36% had ID-/anaemia-, 15% ID-/anaemia+, 29% ID+/anaemia-, and 20% ID+/anaemia+ (48%, 39%, 13%, 30% and 18% in HFrEF, respectively). Risk of recurrent all-cause hospitalizations was higher in patients with ID regardless of anaemia. Of 1959 patients with ID, 19% received FCM (24% in HFrEF). Important independent predictors of ID testing and FCM use were anaemia, higher New York Heart Association class, having HFrEF, and referral to HF specialty care. Conclusion In this nationwide HF registry, ID testing occurred in only about a quarter of the patients. Among tested patients, ID was present in one half, but only one in five patients received FCM indicating low adherence to current guidelines on screening and treatment. Funding Agencies|Vifor Pharma

The article reviews the current recommendations on treating anemia in chronic kidney disease. It is emphasized on the priority appointment of iron preparations. The comparative characteristic of iron supplementation efficacy in chronic renal diseas is presented. Advantages of ferric carboxymaltose are discussed.

AIM The aim of this study was to describe the dynamic changes in blood work following individual adjusted dosage of intravenously administered iron(III) isomaltoside in a 4-week period prior to surgery in patients with colorectal cancer. METHODS This was a single-centre, observational cohort study with prospectively collected data, including patients with colorectal cancer receiving preoperative treatment with iron(III) isomaltoside. Blood samples were taken at baseline, 1 week, 2 weeks and 4 weeks after initial treatment. Sixty-two patients were included in the study. RESULTS Sixty-two patients were included for final analysis. The mean increase in haemoglobin was 0.77 g/dl (95% CI 0.52-1.03 g/dl, P 10.31 g/dl) did not show a significant increase (0.66 g/dl, 95% CI -0.29-1.61 g/dl, P = 0.17). The mean of transferrin saturation after 4 weeks was 8% (95% CI 6%-10%, P

BACKGROUND AND OBJECTIVES Patients who undergo total knee arthroplasty (TKA) have a risk of postoperative anaemia. This observational study evaluated whether single-dose intravenous ferric carboxymaltose (FCM) administered immediately after TKA facilitates the correction of anaemia. MATERIALS AND METHODS We retrospectively analysed 722 patients who underwent primary TKA. The FCM group receiving 1000 mg intravenous FCM within one postoperative hour was compared with the non-FCM group that did not receive the medication. A propensity score matching with multiple logistic regression analysis was used to minimize intergroup differences in the baseline characteristics and postoperative blood loss. The rate and severity of postoperative anaemia were compared between the groups, along with haemoglobin (Hb) value, transfusion rate and complications. RESULTS After propensity score matching, 231 patients were included in each group. In the FCM group, the rate of anaemia at postoperative day (POD) 7 (p = 0.021) and postoperative week (POW) 5 (p

Inflammatory bowel disease (IBD) is commonly associated with iron deficiency anemia (IDA), with a multifactorial pathophysiology. Diagnosis of both IDA and IBD places patients at risk for poor quality of life, as well as increased hospitalization and healthcare utilization. Treatment of IDA involves iron repletion with either oral or intravenous iron products. When selecting therapy, the total expenses of care must be considered, including direct and indirect costs, as well as patient clinical outcomes.

Purpose of Review Anemia is a very common complication in the post-operative period. Post-operative anemia is associated with poor outcomes including but not limited to infections, increased length of stay, circulatory overload, and mortality. The strategy of patient blood management focuses on three pillars that include the detection and treatment of pre-operative anemia; reduction of peri-operative blood loss; and harnessing and optimizing the patient-specific physiological reserve of anemia. Recent Findings Multiple studies in surgical patients have been conducted to study various methods of management of post-operative anemia. Recent advances in surgical techniques have also been studied to minimize blood loss. There is a widespread consensus on the use of intravenous iron in hospitalized post-operative patients after major surgery. Summary We discuss the most common causes of post-operative anemia and management focusing on measures to reduce blood loss and measures to increase red blood cell (RBC) mass. In this brief review, we present updates from the most relevant articles in the past 5 years and include updates from the 2018 international consensus statement on the management of post-operative anemia after major surgical procedures.

Importance Perioperative anemia is a common comorbid condition associated with increased risk of morbidity and mortality in patients undergoing elective surgical procedures. Objective We conducted a systematic literature review (SLR) to determine the efficacy and safety of the use of intravenous ferric carboxymaltose (FCM) for the treatment of perioperative anemia in preoperative, intraoperative, and postoperative elective surgical care. Evidence review Studies meeting inclusion criteria for the SLR reported on treatment efficacy in an adult study population randomly allocated to FCM for the treatment of perioperative anemia during the perioperative period. After screening, 10 of 181 identified studies from searches in MEDLINE and EMBASE databases were identified for inclusion in this review. Findings Preoperative treatment was reported in six studies, intraoperative treatment in one study, postoperative treatment in two studies, and both pre- and postoperative treatment in one study. Together, 1975 patients were studied, of whom 943 were randomized to FCM, of whom 914 received FCM treatment. The 10 studies reported elective surgical populations for colorectal, gastric, orthopedic, abdominal, urologic, plastic, neck, gynecologic, and otolaryngologic procedures. Given the clinical and methodological heterogeneity of the studies, the analyses were limited to qualitative assessments without meta-analyses. All 10 studies reported statistically greater changes in hemoglobin concentration, serum ferritin, and/or transferrin saturation with FCM treatment compared with comparators (placebo, oral iron, standard care, or a combination of these). Two studies reported statistically significant differences in transfusion rate and 2 studies reported significant differences in length of hospital stay between FCM and its comparator(s). Conclusions and relevance This SLR adds to existing data that administration of FCM in preoperative and postoperative settings improves hematologic parameters. Several studies in the review supported the beneficial effects of FCM in reducing transfusion rate and length of stay. Larger, well-designed, longer-term studies may be needed to further establish the efficacy and safety of FCM in elective surgery patients with perioperative anemia.

Background Where an ongoing requirement for intravenous iron replacement exists after an index infusion reaction, current recommendations are limited to expert opinion and isolated case reports. Objective To evaluate the safety of recommencing an infusion or subsequent rechallenge following an infusion reaction to intravenous iron. Methods Infusion reactions to intravenous iron occurring between January 1, 2010, and December 31, 2019, at a metropolitan health network were identified. Patient characteristics, reaction type (mild, moderate, or severe hypersensitivity, delayed, or Fishbane: transient flushing and truncal myalgias), and outcomes of recommencing the index infusion or subsequent rechallenge were examined. Results Among 13,509 iron infusions, 195 infusion reactions occurred in 195 patients (1.4% of infusions). Recommencement of the index infusion (generally with a reduced infusion rate and premedication) was tolerated in 33 of 33 patients with Fishbane (20 of 20) or mild (9 of 9) and moderate (4 of 4) hypersensitivity reactions. Subsequent rechallenge (generally at standard infusion rates to an alternative formulation, ferric carboxymaltose) was successful in 68 of 69 patients with Fishbane (23 of 23), mild (26 of 26), moderate (16 of 17), and severe (3 of 3) hypersensitivity, or delayed (2 of 2) reactions. All 9 patients rechallenged to the original formulation (iron polymaltose) completed the infusion. Conclusions Following an infusion reaction to intravenous iron infusion, recommencement of the index infusion is safe for Fishbane or mild and moderate hypersensitivity reactions. Subsequent rechallenge to an alternative formulation is tolerated, including in severe hypersensitivity reactions (albeit based on limited numbers). Where alternative formulations are not available, rechallenge to the same formulation could be considered, depending on the risk-benefit profile.

Background: Concerns exist regarding the pro-oxidant and inflammatory potential of intravenous (IV) iron due to labile plasma iron (LPI) generation. This IRON-CKD trial compared the effects of different IV irons on oxidative stress and inflammation. Methods: In this randomized open-label explorative single-center study in the United Kingdom, non-dialysis-dependent chronic kid ney disease (CKD) patients with iron deficiency were randomized (1:1:1:1) to receive a single infusion of 200 mg iron dextran, or 200 mg iron sucrose (IS), or 200 mg or 1,000 mg ferric derisomaltose (FDI) and were followed up for 3 months. The primary outcomes measured were induction of oxidative stress and inflammation. Secondarily, efficacy, vascular function, quality of life, and safety were monitored. Results: Forty patients were enrolled. No significant rise in oxidative stress existed, regardless of preparation or dose. There was a significant rise in LPI with 1,000 mg FDI at 2 hours that normalized within a week, not impacting oxidative stress or inflammation. A delayed rise in C-reactive protein was noted with IS. High-dose FDI produced a sustained serum ferritin increase (mean ± standard error of the mean of predose: 69.1 ± 18.4 μg/L, 3 months: 271.0 ± 83.3 μg/L; p = 0.007). Hemoglobin remained stable throughout. No adverse drug reactions were recorded during the study. Conclusion: A single dose of IV iron in CKD patients does not trigger oxidative stress or inflammation biomarkers. Third-generation IV irons have a reassuring safety profile, and high-dose FDI produced a sustained serum ferritin rise and more efficient iron repletion, with no significant pro-oxidant or inflammatory signals when compared to a lower dose and other IV irons.

BackgroundThe recent AFFIRM-AHF trial assessing the effect of intravenous (IV) iron on outcomes in patients hospitalised with worsening heart failure who had iron deficiency (ID) narrowly missed its primary efficacy endpoint of recurrent hospitalisations for heart failure (HHF) or cardiovascular (CV) death. We conducted a meta-analysis to determine whether these results were consistent with previous trials.MethodsWe searched for randomised trials of patients with heart failure investigating the effect of IV iron vs placebo/control groups that reported HHF and CV mortality from 1st January 2000 to 5th December 2020. Seven trials were identified and included in this analysis. A fixed effect model was applied to assess the effects of IV iron on the composite of first HHF or CV mortality and individual components of these.ResultsAltogether, 2,166 patients were included (n = 1168 assigned to IV iron;n = 998 assigned to control). IV iron reduced the composite of HHF or CV mortality substantially [OR 0.73; (95% confidence interval 0.59–0.90);p = 0.003]. Outcomes were consistent for the pooled trials prior to AFFIRM-AHF. Whereas first HHF were reduced substantially [OR 0.67; (0.54–0.85);p = 0.0007], the effect on CV mortality was uncertain but appeared smaller [OR 0.89; (0.66–1.21);p = 0.47].ConclusionAdministration of IV iron to patients with heart failure and ID reduces the risk of the composite outcome of first heart failure hospitalisation or cardiovascular mortality, but this outcome may be driven predominantly by an effect on HHF. At least three more substantial trials of intravenous iron are underway.Graphic abstract

Aim: To analyse the outcome of oral and intravenous therapy of iron preparations in treating anaemia in pregnant women. Study Design: Prospective Study. Place and duration of study: Department of Pharmacology and department of Gynaecology and obstetrics, Khawaja Muhammad Safdar Medical College, Sialkot from May 2020 to July 2021. Methods: Between May 2020 and July 2021; A total of 1200 patients presenting to obstetric department with anaemia were included in the study after fulfilling inclusion criteria. Pregnant patients with haemoglobin level 7-8gm/dl at 24th week of gestation were included in the study. The therapy was started on 24th week of gestation. The haemoglobin levels were determined at 24th week and then at 37th week of gestation. The increase in the haemoglobin level was then determined. Serum ferritin levels were done at 37th week of gestation. Results: It was observed that there was an increase in the haemoglobin level after all the treatment regimes. The increase in haemoglobin in the group B and C was statistically significant with P value of < 0.001 when compared with the group A. However, no statistical significant difference was observed between group B and group C. Conclusion: The haemoglobin and serum ferritin level were significantly increased in the subjects after oral ferrous sulphate, however parenteral formulation are more effective in noncompliant patient where quick improvement in haemoglobin levels are to be achieved. Keywords: Anaemia, pregnancy, iron deficiency, pharmacotherapy

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 messagesIron 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.

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.

Background and Objectives While iron deficiency (ID) is the most common cause of anaemia, little is known about the prevalence and type of ID in preoperative surgical patients. The aims of the present study were to investigate the prevalence and types of ID in a large cohort of surgical patients, and how these are related to perioperative blood use after correction for confounders such as haemoglobin level.Materials and MethodsData were retrospectively extracted from electronic case records of all patients who underwent elective surgery between September 2016 and November 2017 (n = 2711). Iron parameters, haemoglobin and details of perioperative red cell transfusions were collected.ResultsOf 2711 patients, 618 (22.8%) were iron deficient (= transferrin saturation [TSAT] < 16%) preoperatively, 173 (6.4% of the cohort) had an absolute iron deficiency (AID; TSAT < 16% and ferritin < 30 mu g/L) and 445 (16.4%) had functional/mixed ID (TSAT < 16% and ferritin >= 30 mu g/L). Corrected for Hb level, iron-deficient patients received significantly more red cell units than patients without ID (p = 0.026). AID was not associated with a significantly higher incidence of transfusions (7.5% of patients transfused; p = 0.12 after correction for Hb) than patients without ID, whereas patients with functional/mixed deficiency did receive significantly more transfusions (6.1%; p = 0.021) as compared to patients without ID (1.7%).ConclusionPreoperative ID, in particular the functional/mixed type, was associated with a higher risk of receiving perioperative red cell transfusions as compared to patients without ID. Adequately treating ID might, therefore, reduce the need for perioperative red cell transfusions.

Clinical question Does intravenous iron given to anaemic patients (haemoglobin [Hb]

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 optim...

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.

Background: Heart failure (HF) is a chronic medical condition that affects approximately 1-2% of the world's population and greater than 10% of those age 65 and older. Among patients with HF, iron deficiency (ID), defined as ferritin Methods: We performed a retrospective analysis of hospital records of patients admitted with HF as a primary or secondary diagnosis to a city-based large academic teaching health system between April 1, 2014 and April 1, 2017. Thereafter, we identified those patients who had sufficient iron studies (hemoglobin, iron, ferritin, transferrin, TSat) during their hospitalization to diagnose ID, as per the criteria above. Patients with ID were then stratified into those that did and did not receive IVFe. Patient charts were evaluated to two primary endpoints, namely one-year readmissions for HF and patient mortality. Results: In total, 390 patients had sufficient iron studies performed to assess ID status, of which 279 met criteria for ID (71.5%). Eighty-four of the 279 patients received IVFe. Amongst patients that received IVFe, 38 patients were readmitted for HF (45.2%) and 6 patient deaths occurred within 1 year (7.14%). Amongst the remaining 195 patients who did not receive IVFe, 93 were readmitted for HF (47.69%) and 15 patient deaths occurred within 1 year (7.69%). Conclusion: These data suggest that despite clinical benefit in patient functional outcomes and overall quality of life in chronic heart failure patients treated with IVFe, treatment of ID in acute HF patients does not result in a reduction in admissions for HF or improvements in patient mortality. Disclosures No relevant conflicts of interest to declare.

Background: Anemia is common in cardiac surgery affecting 25-40% of patients and associated with increased blood transfusions, morbidity, mortality, and higher hospital costs. Higher rates of stroke, acute renal injury, and total number of adverse postoperative outcomes have also been reported to be associated with preoperative anemia. This systematic review assessed the current evidence for preoperative intravenous iron on major outcomes following cardiac surgery. Methods: Outcome measures included postoperative hemoglobin, transfusion rates, major adverse events, and mortality. The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and articles were identified using PubMed, Cochrane, CLINAHL, WOS, and EMBASE databases. Articles were included if they compared patients with and without preoperative anemia based on treatment with intravenous iron. Quality was assessed using Cochrane Risk of Bias Tool and Newcastle-Ottawa scale, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results: Of the articles reviewed, six met inclusion criteria. These included four randomized double-blind prospective cohort studies, one randomized non-blinded prospective study, and one non-randomized non-blinded prospective study with historical control. Across studies, 1,038 patients were enrolled. Two studies showed higher hemoglobin with iron therapy, and only one study showed significant differences in multiple outcomes such as transfusion and morbidity. Conclusions: Given the paucity of studies and biases within them, the current evidence for treatment with intravenous iron prior to cardiac surgery is weak. More evidence is needed to support the administration of preoperative intravenous iron in cardiac surgery patients. J Hematol. 2020;9(4):97-108 doi: https://doi.org/10.14740/jh696

Introduction and objectives: Treatment with intravenous iron in patients with heart failure (HF) and iron deficiency (ID) improves symptoms, however its impact on survival and safety is unknown. We aimed to evaluate the management of ID and anemia with intravenous iron in patients with HF and long-term safety of intravenous iron. Methods: We evaluated anemia and ID in patients with chronic HF at 3 university hospitals. Anemia was defined using the World Health Organization definition and ID was defined as ferritin

Elektif cerrrahi planmalasında hastada bulunan demir eksikliği anemisinin preoperatif tedavi edilmesi morbidite ve mortalitede azalma ile ilişkili bulunmuştur. Oral demir tedavisinin yetersiz kaldığı ya da operasyon öncesi sürenin kısıtlı olduğu durumlarda İV demir tedavisi uygulanmalıdır. Gebelerde preoperatif dönemde klinik semptomu olmasa bile intraoperatif ya da postoperatif dönemde peripartum kardiyomyopati (PPKMP) gelişebileceği her zaman akılda bulundurulmalıdır.Bu olgu sunumuyla plasental invazyon anomalisi bulunan, sezaryen operasyonu sırasında ani KMP gelişen, peroperatif anemi tedavisi için intravenöz demir tedavisi uyguladığımız gebe hastayı güncel literatür ışığında tartışmayı amaçladık.

Aim Preoperative iron is frequently used for the correction of anaemia in colorectal cancer surgery. However, enteral iron intake may promote tumour growth and progression which could influence cancer recurrence and patient survival. We explore the long-term outcomes of patients receiving either oral or intravenous iron replacement therapy as part of a previous randomized controlled trial. Methods The IVICA trial randomized anaemic colorectal cancer patients to receive either oral (OI, control) or intravenous (IVI, treatment) iron prior to their elective operation. Follow-up analysis of all patients recruited to this multicentre trial who underwent surgical resection with curative intent was performed. Kaplan-Meier survival estimates and Cox proportional hazard models were used to compare groups. A pooled group multivariable analysis comparing patients who achieved resolution of anaemia preoperatively to those who did not was also undertaken. Results In all, 110 of the 116 patients previously enrolled were eligible for analysis (OI n = 56, IVI n = 54). Median overall follow-up duration was 61 months (interquartile range 46-67). No significant difference in 5-year overall survival (hazard ratio (HR) 1.22, 95% CI 0.65-2.28, P = 0.522) or disease-free survival (HR 1.08, 95% CI 0.61-1.92, P = 0.79) was observed between OI and IVI. A pooled analysis of treatment groups found that preoperative resolution of anaemia led to improved 5-year overall survival on multivariable analysis (HR 3.38, 95% CI 1.07-11.56, P = 0.044). Conclusion We recommend IVI for the preoperative correction of anaemia. Route of iron therapy did not significantly influence survival. Preoperative anaemia correction may lead to an overall survival advantage following elective colorectal cancer surgery.

Objectives: To compare the mean hemoglobin level before and six weeks after giving intravenous iron sucrose therapy in malnourished children having iron deficiency anemia. Study Design: Quasi Experimental Study. Setting: Nutritional Stabilization Centre, Children Hospital and Institute of Child Health, Multan. Period: From July 2018 to December 2018. Material & Methods: A total of 80 patients were enrolled in the study. Hemoglobin level at baseline was recorded. IV iron sucrose therapy was divided into 3 equal doses and administered on 3 consecutive days. After 6 weeks of administration of iron sucrose, hemoglobin level was noted. Independent sample T-test was applied to compare Hb level before and after therapy with p-value≤0.05 as significant. Results: Overall, mean age was 13.39±6.11months. There were 54 (67.5%) males and 28 (32.5%) females. The mean weight of patients was 5.06±1.45kg and mean height was 64.59±8.72cm. The weight for height ratio was

Introduction: Injectable iron sucrose and oral ferrous sulfate both are used for the correctionof anaemia in second and third trimester of pregnancy. But injectable iron is supposed to bemore effective than oral iron, as it needs less time for correction of anaemia and efficacy ismore. Oral iron is cost effective but more time consuming.The objective of the study was to compare the safety of intravenous iron sucrose complex inthe treatment of iron deficiency anemia in third trimester of pregnancy. To compare theefficacy of intravenous iron with oral iron. Method: A randomised controlled trial was conducted in which pregnant women with irondeficiency were sequentially selected from the pregnant women attended antenatal clinic ofOPD of Institute of Child and Maternal Health (ICMH) and assigned either to injectable or tooral ferrous sulfate by random number table. Each study patient was given the total calculatedamount of injectable iron sucrose {Hb deficit (gm/l) × body weight (kg) × 0.24+ storage ironmg } in divided dose 200 mg in 200 ml normal saline intravenously over 1 hour everyalternate day . Each patient of the control group was given ferrous sulfate 200mg orally threetimes a day for 4 weeks. Pregnant women follow up at 4 weeks and 8 weeks after gettreatment by oral and injectable iron. During follow up monitored for adverse effects, clinicaland laboratory response and haemoglobin percentage were observed. Result: There were 75 patients in injectable group and 75 patients in oral group. Injectablegroup achieved a significantly higher Hb level (11.49 ± 0.39) than oral group Hb level (10.39± 0.75) after 8 weeks of treatment. Injectable group showed no major side effects, only twopatient had complains .One patient complain of epigastic pain and one patient complain oftachycardia while in oral group complain of nausea and vomiting, epigastic pain, constipation,allergic reaction was found in 42.0%, 39.3%,35.7% and 3.6% respectively. Conclusion: Iron sucrose complex appears to be a safe and effective in the treatment ofiron deficiency anemia. Bangladesh J Obstet Gynaecol, 2018; Vol. 33(1) : 40-44

Background Reluctance to use intravenous (IV) iron for the treatment of iron deficiency continues due to a perceived high risk of severe hypersensitivity reactions (HSRs). Additionally, it has been hypothesized that 'dextran-derived' IV iron products (e.g., ferumoxytol [FER] and ferric derisomaltose/iron isomaltoside 1000 [FDI]) have a higher risk of severe HSRs than 'non-dextran-derived' products (e.g., ferric carboxymaltose [FCM] and iron sucrose [IS]). In the present analysis, HSR data from head-to-head randomized controlled trials (RCTs) with IV iron products were evaluated to determine if differences in safety signals are present among these IV iron formulations. Study design and methods Reported serious or moderate-to-severe HSR incidence data from five RCTs (FIRM; FERWON-NEPHRO/-IDA; PHOSPHARE-IDA04/-IDA05) were used to calculate risk differences with 95% confidence intervals (CIs) for FER, FCM, FDI, and IS. The rates and risk differences for these HSRs were compared. Results The analysis included data for 5247 patients: FER (n = 997), FCM (n = 1117), FDI (n = 2133) and IS (n = 1000). Overall rates of serious or moderate to severe HSRs were low (0.2%-1.7%). The risk differences (95% CIs) showed small differences between the IV iron formulations: FER versus FCM, -0.1 (-0.8 to 0.6); FDI versus IS, 0.1 (-0.3 to 0.5); FDI versus FCM, -0.9 (-3.7 to 1.9). Conclusion RCT evidence confirms a low risk of serious or moderate to severe HSRs with newer IV iron formulations and no significant differences among existing commercially available products. Thus, RCT data show that the supposed classification of dextran-derived versus non-dextran-derived IV iron products has no clinical relevance.

Background: Iron deficiency anemia (IDA) is one of the most frequent nutritional deficiency leading to morbidity and mortality in whole world. Oral iron therapy as well as intravenous (IV) iron therapy can be given to treat the IDA patients. Objective: To compare the efficacy and hematological changes of Oral and IV iron preparation in patients with uncomplicated iron deficiency anemia. Method: An interventional, prospective study in patients with uncomplicated IDA anemia receiving IV iron sucrose and Oral iron ferrous sulfate were included. Clinical history, baseline hemoglobin, anemia indices data were recorded in a case record form. A total number of 80 patients were enrolled in this study. 40 patients (Group A) were treated with IV iron sucrose and another 40 patients (Group B) were treated with oral iron ferrous sulfate. After therapy Hemoglobin level, RBC indices and adverse drug reactions (ADRs) were observed. Place and period of Study: Study was carried out in the Department of Hematology at Dhaka Medical College Hospital (DMCH), from July 2015 to June 2016. Results: The mean age of total participants was 35.77 ± 16.08 (range of 13 – 75 years). In this study female (72.5%) is predominant than male (27.5%). Oral and IV iron preparations significantly (P

PurposeTo implement a safe and effective intravenous iron infusion protocol to prevent skin staining.Design/methodology/approachMixed methods approach was utilised including education, auditing, self-reported survey, patient information leaflet and patient feedback. In total 25 healthcare professionals completed the survey and 15 patients provided feedback.FindingsNo skin staining or severe adverse reactions were observed over eight weeks. Audit results found 53 per cent of staff were compliant with the recommended IV iron infusion protocol and 46 per cent informed patients of skin staining risk. Self-report surveys indicated 92 per cent flushed the cannula with sodium chloride before starting the infusion, 88 per cent flushed the cannula after the infusion and 76 per cent informed patients of skin staining risk. Patient feedback was largely positive and constructive.Research limitationsLimitations include self-reported bias, short audit time interval, missing data and discrepancy between audit and survey results.Originality/valueThis quality improvement project was developed following two skin staining incidences at our maternity hospital. Although rare, skin staining after intravenous iron infusion is potentially permanent and may be distressing for some patients. Intravenous iron is considered safe and effective to treat anaemia during pregnancy and is often prescribed for this patient cohort. To avoid medicolegal action and patient dissatisfaction, it is essential that patients are informed of potential skin staining and an evidence-based administration protocol is utilised.

Highlights • Intravenous iron supplementation provides symptomatic relief in patients with heart failure and concomitant iron deficiency. • The current definition of iron deficiency based on ferritin, Summary To date, 3 clinical trials have shown symptomatic benefit from the use of intravenous (IV) iron in patients with heart failure (HF) with low serum iron. This has led to recommendations in support of the use of IV iron in this population. However, the systemic and cellular mechanisms of iron homeostasis in cardiomyocyte health and disease are distinct, complex, and poorly understood. Iron metabolism in HF appears dysregulated, but it is still unclear whether the changes are maladaptive and pathologic or compensatory and protective for the cardiomyocytes. The serum markers of iron deficiency in HF do not accurately reflect cellular and mitochondrial iron levels, and the current definition based on the ferritin and transferrin saturation values is broad and inclusive of patients who do not need IV iron. This is particularly relevant in view of the potential risks that are associated with the use of IV iron. Reliable markers of cellular iron status may differentiate subgroups of HF patients who would benefit from cellular and mitochondrial iron chelation rather than IV iron.

Iron deficiency is the leading cause of anemia worldwide and is common in many clinical settings. There are a variety of different iron replacement products available in both oral and intravenous forms. However, many characteristics distinguish each product from one another. This review discusses the profiles of commonly used iron replacement products approved for use in the United States and provides nurse practitioners with safety and valuable clinical information to help and guide their use in everyday clinical practice.

Objective To analyze changes in substantia nigra (SN) iron deposits, assessed by quantitative transcranial sonography (TCS), to obtain and compare substantia nigra echogenicity indices (SNEI) at baseline and after intravenous (IV) iron therapy in patients with restless legs syndrome (RLS)/Willis−Ekbom disease (WED). Methods A total of 30 consecutive subjects diagnosed with RLS/WED were recruited and underwent IV iron treatment. The SNEI, total daily dose of dopamine equivalents, and International Restless Legs Syndrome Rating Scale (IRLS) scores were obtained at baseline and following IV iron administration. Comparative statistics were performed by means of nonparametric testing. Results The sample was stratified into two groups according to the median baseline SNEI and the grade of SN hypoechogenicity: severely hypoechogenic (HE) (n = 13) and moderately HE (n = 17). Following IV iron, the increase in SNEI among severely HE subjects was 19% (0.038 ± 0.046 cm2; P Conclusion Intravenous iron caused changes in SNEI in both groups of patients, reflecting an increase in brain iron stores. However, the increase in SNEI was greater in patients previously defined as severely HE. Furthermore, RLS/WED symptoms also improved more in severely HE subjects, and there was a greater reduction in TDR. This study highlights the role of TCS in quantifying brain iron deposits and in predicting which patients will likely benefit from IV iron.

Key Clinical Message Hypophosphatemia postintravenous iron is frequent but under‐recognized. If prolonged or recurrent, it can cause osteomalacia. The likely mechanisms are direct toxicity to proximal tubular cells causing phosphate wasting, elevated Fibroblast growth factor‐23 (FGF‐23), and reduced 1,25‐dihydroxyvitamin D (1,25(OH)2D). Hypophosphatemia may be severe and persist for months, necessitating phosphate replacement until normalization of serum levels occurs., Hypophosphatemia postintravenous iron is frequent but under‐recognized. If prolonged or recurrent, it can cause osteomalacia. The likely mechanisms are direct toxicity to proximal tubular cells causing phosphate wasting, elevated Fibroblast growth factor‐23 (FGF‐23), and reduced 1,25‐dihydroxyvitamin D (1,25(OH)2D). Hypophosphatemia may be severe and persist for months, necessitating phosphate replacement until normalization of serum levels occurs.

INTRODUCTION: Perioperative anemia commonly occurs in patients undoing major surgery. We aimed to assess the efficacy and safety of intravenous iron therapy (IVIT) given compared to standard practice of oral iron in the perioperative period. DESIGN: We conducted a Cochrane style systematic review. The search strategy included common search engines: Medline, Embase, Cochrane, and Google Scholar for only eligible clinical trials (randomized controlled trials) comparing IV over oral iron therapy up to July 2019. The primary outcome was the effect of IVIT on the change of hemoglobin level. The secondary outcomes were the effects of IVIT compared to oral iron on ferritin level, mean corpuscular volume, and adverse side effects. Data were collected from each trial and where applicable meta-analyzed using RevMan. RESULTS: Six randomized clinical trials that fit our inclusion criteria were included in the study. We found that IVIT increases the level of hemoglobin compared to oral iron (MD: Mean difference 0.90, 95% confidence interval [CI]: 0.44–1.36, P = 0.000). Serum ferritin levels increased significantly in favor of the IV iron group compared to the oral iron group at posttreatment (MD: 106.95, 95% CI: 73.29, 140.62 ng/mL). In addition, marked increases in the pooled mean corpuscular volume (MCV) level were observed in favor of the IVIT (MD: 6.07, 95% CI: −0.88–13.02). There was no significant difference in the rate of adverse effects in both the groups. CONCLUSION: IV iron therapy is more effective than oral iron on increasing hemoglobin, ferritin, and MCV in the perioperative period and is also as safe with no diffidence in the risk of developing adverse side effects.

Background Iron absorption is disturbed after Roux-en-Y gastric bypass (RYGB) and iron deficiency with or without anaemia affects almost half of all patients. Intravenous iron is an option when per oral iron is insufficient or not tolerated. This study explores whether routinely offering intravenous iron treatment when iron stores are empty can prevent anaemia and iron deficiency after RYGB. Methods This is a study of prospectively registered data on clinical information, haematological tests and intravenous iron treatment from 644 RYGB patients who underwent surgery between 2004 and 2013, postoperatively followed more than 5 years. Intravenous iron treatment was offered to patients with ferritin ≤ 15 μg/L. Results Clinical information was available for all patients at baseline and for 553/644 patients at 5 years; laboratory results were available for 540/644 patients at baseline and 411/644 patients after 5 years. The mean age was 39.8 (± 9.7) years. Overall, 187/483 (38.7%) women and 9/161 (5.6%) men were given intravenous iron treatment in the observation period. From baseline to 5 years, mean haemoglobin decreased by 0.3 g/dL in both men and women. Anaemia occurred in 18/311 (5.8%) women and 9/100 (9%) men at 5 years. Depleted iron stores (ferritin ≤ 15 μg/L) were seen among 44/323(13.6%) women and 3/102 (2.9%) men, and low iron stores (ferritin 16–50 μg/L) occurred in 144/326 (44.6%) women and 38/102 (37.3%) men 5 years after RYGB. Conclusion By routinely offering intravenous iron treatment to patients with depleted iron stores after RYGB, haemoglobin levels were preserved. Half of the patients experienced low or depleted iron stores at 5 years. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Iron deficiency due to blood loss, absorption disorders and dietary deficiencies causes iron-deficiency anaemia, whose treatment seeks to eliminate the underlying cause and restore haemoglobin and iron deposits. Typically, the latter 2 of these objectives can be achieved through oral iron therapy. Intravenous iron administration (IIA) should be limited to those patients refractory or intolerant to oral preparations or who require rapid repletion. The indiscriminate use of IIA can increase morbidity and mortality due to iatrogenic overload. This fact, coupled with the growing popularity of IIA and the lack of reference guidelines in Spanish, led the Spanish Erythropathology Group of the Spanish Society of Haematology and Haemotherapy to develop this study, which presents the main recommendations on the optimal use of IIA in iron deficiency and attempts to constitute reference guidelines on good practices for the clinical management of these conditions.

To describe the prevalence of perioperative blood transfusion (BT) for patients with preoperative iron deficiency anaemia and undergoing major elective surgery, included in an intravenous iron protocol (IV Fe) led by the pre-anaesthesia nurse.Observational, descriptive, longitudinal and retrospective study in a population of patients undergoing major elective surgery, seen in anaesthesia nursing consultation in a tertiary hospital between April 2014 and January 2017. The patients with iron deficiency anaemia, included in the study, were included in a protocol of treatment with preoperative IV Fe.Fifty patients were studied. Twelve percent required a BT. A statistically significant association was observed between the need for intraoperative BT and the number of days between the first administration of IV Fe and date of surgery (P.01) and also the number of days between the last administration of IV Fe and the surgical intervention (P=.04). The increase in haemoglobin was greater in patients who received more than one dose compared to those who received only one dose of 1,000mg (P.01).In our study, we estimated an increase in haemoglobin greater than in other studies and a low administration rate of BT (12%). The role of the nurse is fundamental for the preselection of these patients.

Background: The use of intravenous (IV) iron sucrose was approved for the obstetric and gynecologic (OBGYN) population at our mother–child teaching hospital in 2006 for intolerance or nonresponse to oral iron supplements, contraindication to intramuscular (IM) iron, and rapid increase of the hemoglobin desired in iron-deficient patients. Objectives: ( a) To describe the indications and doses of IV iron sucrose used in OBGYN, ( b) to assess monitoring, and ( c) to describe the adverse effect profile. Methods: A retrospective study of patients admitted to the OBGYN wards with at least one prescription of IV iron from January 1, 2006, to March 31, 2010, was conducted. A standardized data collection sheet was used to record data. Results: A total of 164 prescriptions of IV iron were reviewed in 128 women. The indications for IV iron were anemia before delivery (n = 76), intolerance or no response to oral iron (n = 61), or intolerance or contraindication to IM iron (n = 27). Fourteen doses (9%) were appropriate, and the others were too low. Prior to prescription, ferritin or serum iron levels were assessed in 31% of women and hemoglobin electrophoresis in nearly all of Black or Asian women. One-week follow-up hemoglobin levels were measured after 66 prescriptions (40.2%). Adverse effects, mostly pain at the injection site, were reported in 18 (11%) occasions. Conclusions: IV iron is prescribed in OBGYN patients to obtain a rapid hemoglobin increase or when oral iron is not tolerated or inefficacious. The dose prescribed is generally too low, baseline essential testing often omitted, and appropriate follow-up monitoring incomplete. IV iron is well tolerated.