Section 11. Hematology

Oral Iron

Ferrous fumarate

200 mg (66 mg elemental)

325 mg (106 mg elemental)

• 150–200 mg elemental per day for most patients

• K/DOQI guidelines suggest 200 mg elemental per day for dialysis patients
• Common adverse effects are constipation, diarrhea, nausea, vomiting, and darkened stools
• Food, PPIs, and antacids decrease absorption
• Taking with a vitamin C source (orange juice or 50–100 mg ascorbic acid tablet) can improve tolerability and absorption (Hum Nutr Appl Nutr. 1986;40:97)
• Sustained release formulations may bypass site of absorption
• Hemoglobin will rise slowly, generally 2 g/L over 2–3 weeks
• A trial of IV iron or 1-3 months of PO iron can be considered for any CKD patient with TSAT ≤30% and ferritin ≤500 ng/mL (Kidney Int Suppl. 2012;2:279.)

Ferrous gluconate

246 mg (28 mg elemental)

300 mg (34 mg elemental)

325 mg (36 mg elemental)

Ferrous sulfate

325 mg (65 mg elemental)

220 mg/5 mL (44 mg/5 mL elemental)

300 mg/mL (60 mg/5 mL elemental)

Parental Irona

Ferumoxytol (Feraheme)

30 mg/mL (17 mL)

• CKD: 510 mg IV push every 3–8 days

• Common indications for IV iron therapy include ongoing blood loss, intolerance of or difficulty absorbing PO iron and cancer or dialysis patients taking ESAs who do not respond to or cannot take PO iron
• Anaphylactic reactions have occurred with both irondextran and sodium ferric gluconate, the reported frequency is 8.7 and 3.3 events per million, respectively (Am J Kidney Dis. 1999;33:464)
• A 25 mg test dose is recommended by NCCN guidelines for sodium ferric gluconate in patients with history of anaphylaxis to irondextran
• Delayed (1–2 days) infusion reactions reported with irondextran including arthralgias, dizziness, chills, and fever

Irondextran (INFeD, Dexferrum)

50 mg/ml (1, 2 mL)

• Cancer: 25 mg test dose, followed 1 h later by 100 mg over 5 minutes
• Labeled dosing = 0.0442 (desired Hgb – observed Hgb) × LBW + (0.26 × LBW)b

Iron sucrose (Venofer)

20 mg/mL (5, 10 mL)

• CKD: 100–200 mg over 2–5 minutes 1–3 times per week up to 1 g cumulative dose
• Cancer: 200 mg infused over 1 h every 2–3 weeks

Sodium ferric gluconate (Ferrlecit)

12.5 mg/mL (5 mL)

• CKD: 125 mg over 1 h per dialysis session × 8 doses
• Cancer: 125 mg over 1 h weekly × 8 doses