Preparations and administration of intravenous iron

Information about intravenous iron preparations for adults is given in Intravenous iron preparations used in adults. Intravenous administration is recommended because iron is poorly absorbed from intramuscular injection, and local reactions (particularly pain and subcutaneous discolouration) occur frequently at the injection site.

Note: Intramuscular injection of iron is not recommended because absorption is poor, the skin may become discoloured, and the injection is very painful.

Table 1. Intravenous iron preparations used in adults
ferric carboxymaltose ferric derisomaltose iron polymaltose iron sucrose
ferric carboxymaltose (Ferinject) [NB1]
advantages	rapid administration well tolerated total iron requirement can often be given in a single dose can be given in the community or in aged-care facilities
disadvantages	expensive maximum dose 1000 mg per week; repeat doses may be needed to meet total iron requirement
dosage and administration	total dose of iron required is calculated using body weight, haemoglobin and serum ferritin concentration (see product information); however, a maximum of 1000 mg can be administered per infusion per week can only be administered intravenously, either as an undiluted injection or intravenous infusion intravenous injection: small doses (200 mg or less) can be given as a rapid injection medium doses (201 to 500 mg) can be given via slow intravenous injection at a rate of 100 mg/minute large doses (501 to 1000 mg) must be administered over 15 minutes. intravenous infusion: more than 200 mg and up to 500 mg: dilute in 100 mL of sodium chloride 0.9%; infuse over at least 6 minutes more than 500 mg and up to 1000 mg: dilute in 250 mL of sodium chloride 0.9%; infuse over at least 15 minutes
ferric derisomaltose (Monofer) [NB2]
advantages	well tolerated can be given in the community or ambulatory-care setting rapid administration total iron requirement can often be given in a single dose lower risk of causing hypophosphataemia than ferric carboxymaltose Detlie, 2019) (Wolf, 2020
disadvantages	more expensive than iron polymaltose and iron sucrose
dosage and administration	total dose of iron required is calculated using the Ganzoni formula (see the product information for formula and a simplified table) can only be administered intravenously, either as an injection (diluted or undiluted), intravenous infusion or as an injection into dialyser intravenous rapid injection: a dose of up to 500 mg can be given via slow intravenous injection at a rate of 250 mg/minute intravenous infusion: up to 1000 mg: dilute in up to 500 mL of sodium chloride 0.9%; infuse over at least 20 minutes more than 1000 mg and up to 1500 mg: dilute in up to 500 mL of sodium chloride 0.9%; infuse over at least 30 minutes
iron polymaltose (Ferrosig)
advantages	inexpensive total iron requirement can be given in a single dose
disadvantages	long infusion time monitoring is required (eg blood pressure, pulse, oxygen saturations) only suitable for inpatients
dosage and administration	total dose of iron required is calculated using body weight, haemoglobin and serum ferritin concentration (see product information); however, 1000 mg is generally an appropriate dose intravenous infusion is usually started at a slow rate and increased according to local protocols. Duration of infusion is typically about 5 hours. A rapid infusion protocol has been suggested [NB3]
iron sucrose (Venofer) [NB4]
advantages	lower risk of adverse effects than iron polymaltose
disadvantages	more expensive than iron polymaltose
dosage and administration	administered in specialist settings (eg for patients undergoing chronic haemodialysis) according to local protocols small repeated doses are given to replace total iron requirement
Note: NB1: Ferric carboxymaltose is only registered for use by the Australian Therapeutic Goods Administration (TGA) in patients older than 14 years. NB2: Ferric derisomaltose is only registered for use by the TGA in patients older than 18 years. NB3: Garg M, Morrison G, Friedman A, Lau A, Lau D, Gibson PR. A rapid infusion protocol is safe for total dose iron polymaltose: time for change. Intern Med J 2011;41(7):548-54. URL NB4: Iron sucrose is only registered for use by the TGA in adults.