doctor with white lab coat with iron for intravenous iron treatment

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The use of iron by injection (intravenous) can provide a more rapid means of building iron reserves within the body when indicated that can have its advantages when compared to using oral forms of iron.

Besides its use in anemia, the oral use of iron, for some, is poorly tolerated. Some suffer with unpleasant gastro-intestinal side-effects, and as a result absorption and compliance can be problematic. Others may have significant bleeding issues (i.e., severe menstrual bleeding cycles, inflammatory bowel disease, cancer, etc.) that creates ongoing challenges with anemia and maintaining iron stores. Injectable iron bypasses the gut and is directly administered in the blood stream.  

Oral iron, while effective, takes more time. For example, it can take 3-8 weeks to see peak increases in hemoglobin levels with intravenous iron. For comparison it can take 13 weeks for oral iron versus just hours with a blood transfusion in raising hemoglobin to peak levels.

It is important to also highlight there may be risks in using iron by injection that can be different than the use of oral iron. There are different side-effect profiles that are important to know. Severe allergy or anaphylaxis are possible with the injection route and while rare also may include the risk of death.

Risks of a major reaction and death can be 1 in 200,000 while for comparison a blood transfusion can be approximately 1 in 21,000. It has been estimated that there has been approximately 1 death per 5 million doses of injectable iron when the older forms of iron were used (which were more reactive and not used anymore). Some would argue that the newer formulations of intravenous iron are much better tolerated and lower in risk.  As a result, there is growing interest to utilize intravenous iron versus blood transfusion when possible.

Iron can also be involved in immunity when administered by injection creating allergy-like effects that are not life-threatening but can be uncomfortable. It is believed that such reactions may occur in 1 and 200 people. For those who receive ongoing iron treatment may eventually experience such a reaction.

The reactions may include the following: 

  • Nausea

  • Rash

  • Low blood pressure

  • Low levels of phosphorous in your blood

  • Fever & chills

  • Flushing

  • Vomiting

  • Muscle cramps

  • Headache

  • Achiness

  • Skin redness (erythema)

  • High blood pressure

  • Injection site reactions

  • Dizziness

  • Abdominal pain.

Some of the reactions such as chest pain, flushing can occur quickly within minutes (i.e., Fishbane reaction) with some forms of iron preparations.

Many of these reactions are self-limiting, resolve within 15 minutes, and can be easily managed with either stopping the IV, re-trying again, and re-administering at a slower rate.  In the past it was advised to give precautionary treatments such as Benadryl or possibly Epinephrine and it turns out such measures appears to have made matters worse. Stepping back and allowing the reaction to pass has been shown to be the best treatment option for most cases. Low levels of phosphorus can be linked to such complement-immune reactions.

A review and meta-analysis from 2021 also suggest that intravenous iron may increase a person’s risk of infection, and this may need to be considered when looking at the risk vs benefit when using this route of administration.

However, it is also important to keep in mind that being low in iron, or anemic may also increase infection risk as well.  It is not advised to receive iron if you are dealing with a known active infection.

Some patients with a history of asthma, eczema, or reactive immune disease such a rheumatoid arthritis, for more precautionary purposes, may require premedication before starting (i.e., corticosteroid) and which may also be advisable to continue for several days following intravenous iron.  This would be assessed on a case-by-case basis. 

Again, to emphasize that new research suggests that premedication should be minimized whenever possible and reserved for more severe situations.

In about 10% of people muscle-bone aches can occur 24 hours after the treatment. Some have compared the feeling to a full-body workout and appears to be a sign of the body responding to the iron.

Intravenous iron can also create skin staining if there is leakage or extravasation at or around the injection site. The skin stain can be permanent. This is one of the reasons why the intramuscular use of iron has been discouraged. The risks are uncommon with some estimates reported to be 0.68 to 1.3%.  As a result, it is imperative that if any leakage does occur that the IV be stopped immediately and removed just in case. 

Formulations of intravenous iron that are capable to be administered more quickly and stronger in dose (i.e., less time on the chair plus reduced treatment visits) could have advantages in this area (i.e., Monoferric). Signs of leakage can include pain, discomfort, swelling, prickling at or around the injection site and any immediately observable staining.

It will be advised to wait approximately 30 minutes following the infusion to assess for any potential delayed reaction.

Baseline blood tests, along with basic levels of assessment, will be required before starting and following your treatment to help determine your candidacy, initial iron dose and your response to treatment.

Tell the doctor if you:

  • Have ever had any unusual or allergic reaction to any iron given by vein.

  • Have any type of allergy, drug allergy, autoimmune, or sensitivity history (i.e., asthma, eczema, mastocytosis, etc.)

  • Have high blood pressure.

  • Use the medications known as beta-blockers and ACE inhibitors.

  • Are pregnant or plan to become pregnant.

  • Are breastfeeding or plan to breastfeed as the iron passes into the breast milk.

  • Are dealing with an active infection.