Use Of Parenteral Iron Research Articles

Pharmacoeconomics and Utilization of Intravenous Iron Sucrose in a Tertiary Care Hospital

Background: Rational utilization of parenteral iron with meticulous calculated doses will promote appropriate utilization of healthcare resources. The aim is to study utilization of intravenous Iron Sucrose at patient level and hospital level Methods: This prospective-observational study was conducted over 6 months. Case-records of 125 indoor patients were reviewed for intravenous (IV) Iron Sucrose prescription and patient details and treatment details for patients were procured. Results: 125 patient records were divided in (Antenatal care and Non Antenatal care) ANC and Non ANC groups; and their Mean age was 36(S.D ± 16) years. IV Iron Sucrose was prescribed the most in anemic pregnant patients 41(32.8%) followed by severely debilitated patients on other injectable drugs 37(6%). The Total administered dose was more than the Standard calculated dose in an alarming 84(67.2%) of the patients. Utilisation of IV iron sucrose in Defined Daily Dose per 100 bed days (DDD/100 bed days) was found to be 0.42 in total patients whereas it was 0.59 in ANC and 0.36 in Non ANC groups. Conclusion: This research highlighted that overutilization and administering more than the required dose of IV iron sucrose, could be effectively tackled by calculation of its standard dose by Ganzoni’s formula. Studying the monthly trends and comparing utilization of parenteral iron with the help of DDD/100 bed days by hospitals can help in comparing utilization and also assist for budgetary preparedness of hospitals. There is also a dire need to formulate universally accepted guidelines for the use of parenteral iron in general adult population.

Describing and Comparing Patient Factors Associated with Use of Parenteral Iron before and after Implementation of an Order Set for Parenteral Iron (DECODE IRON).

In select clinical scenarios, IV administration of iron is suitable for management of iron deficiency anemia; however, for most patients, oral administration of iron is the mainstay of treatment. At the Red Deer Regional Hospital Centre, in Red Deer, Alberta, high utilization of IV iron has resulted in limited access to this medication for the treatment of ambulatory patients, as well as significant usage of health care resources. The primary objective was to compare patient characteristics, specifically pretreatment laboratory test results and previous use of oral iron, among those receiving IV iron therapy in an ambulatory setting before and after implementation of an iron sucrose order set. For secondary objectives, the aforementioned groups were compared with regard to meeting the diagnostic criteria for iron deficiency anemia, with or without pretreatment oral iron or blood transfusion, and the dosing characteristics for IV iron. A retrospective electronic chart review was performed for ambulatory patients who received IV iron between January 1, 2020, and January 31, 2022. A total of 436 unique treatment courses were included in the analysis. The following pretreatment laboratory results were observed before and after implementation of the iron sucrose order set: mean hemoglobin 105.8 (standard deviation [SD] 21.9) g/L versus 102.2 (SD 18.5) g/L; mean of mean corpuscular volume (MCV) 82.2 (SD 9.4) fL versus 79.2 (SD 8.9) fL; and median ferritin 7 (interquartile range [IQR] 4-12) μg/L versus 6 (IQR 4-11) μg/L. Only the difference in MCV values was statistically significant (p = 0.001). The implementation of an iron sucrose order set for ambulatory patients did not have a significant effect on pretreatment laboratory parameters among patients for whom IV iron was prescribed. Further stewardship initiatives could be beneficial in improving the appropriateness of IV iron use.

Parenteral Iron Therapy: Examining Current Evidence for Use in Athletes.

A high prevalence of iron deficiency exists in athlete populations. Various mechanisms, including increased losses through sweat, haemolysis, haematuria, and gastrointestinal micro-ischemia; inadequate dietary intake; and transient exercise-induced increases in the regulatory hormone, hepcidin, contribute to the increased prevalence in athletes. Indeed, hepcidin has been shown to peak around 3-6 hours post-exercise, limiting iron absorption from the gut. As the practitioner's ability to control losses is limited, the key to treatment of iron deficiency in athletes is optimal timing of dietary and oral iron supplementation around these periods of reduced gut absorption. While timing and dosing schedule strategies might be sufficient to treat iron deficiency non-anaemia, the significant lag to impact iron status is relatively long. Therefore, in iron deficiency anaemia, the use of parenteral iron has the benefit of rapid repletion of iron stores and normalisation of haemoglobin status, while bypassing the action of hepcidin at the gut. Furthermore, newer intravenous formulations can be administered as a single total dose over 15-60 min and have a similar safety profile to oral treatment. This review discusses the existing evidence for parenteral iron use in athletes and the unique context for consideration when choosing the parenteral route in this population.

Relationship between bone marrow iron load and liver iron concentration in dialysis-associated haemosiderosis

Iron overload due to the excessive use of parenteral iron in haemodialysis is now an increasingly recognised clinical issue. Before erythropoiesis-stimulating agents (ESA) were introduced, a specific feature of patients treated by dialysis and having iron overload was that iron levels in the bone marrow were paradoxically low in most of them, despite severe hepatosplenic siderosis. Whether or not this paradox persists in the actual ESA era was unknown until recently, when an autopsy study in 21 patients treated by haemodialysis revealed similarities between liver and bone marrow iron content. The aim of this study was to further explore these recent findings in a cohort of alive patients on dialysis and to analyse the determinants of iron bone marrow. Liver iron concentration (LIC) and vertebral T2∗ (a surrogate marker of bone marrow iron) were analysed retrospectively in 152 alive patients on dialysis (38.8% female) of whom 47.4% had iron overload by quantitative magnetic resonance imaging (MRI). Vertebral T2∗ differed significantly between patients classified according to liver iron content at MRI: those with mild or moderate and severe liver iron overload had increased vertebral iron content at R2∗ relaxometry MRI (mild: vertebral T2∗=9.9ms (4-24.8); moderate and severe: vertebral T2∗=8.5ms (4.9-22.8)) when compared to patients with normal LIC (vertebral T2∗=13.2ms (6.6-30.5) (p<0.0001 Kruskal-Wallis test)). The paradoxical discrepancy between bone marrow and liver iron-storage compartments observed in the pre-ESA era has disappeared today, as shown by a recent autopsy study and the present study in a cohort of alive patients treated by dialysis. None.

Management of Severe Iron Deficiency Anemia in the Pediatric Emergency Department: A Comparison of IV Iron Vs Transfusions

▪Introduction: Severe iron deficiency anemia (IDA) is a problem that often presents to the pediatric emergency department (ED). Recently published ASH-ASPHO Choosing Wisely recommendations suggest avoidance of transfusion in hemodynamically stable, asymptomatic children with IDA 1. Little is known about the use of parenteral iron in this pediatric setting.Methods: We undertook a retrospective review of patients with severe IDA treated in the pediatric ED at the Children's Hospital of Eastern Ontario (CHEO) from September 2017 to June 2021. During this period there were an estimated 75000 patients seen annually. Patients with severe IDA were defined as those presenting with hemoglobin (Hb) less than <70 g/L and low mean corpuscular volume.Results: There were 56 patients that met this criterion with presenting Hb ranging from 17-69 g/L (IQR 41- 62). Median age at presentation was 3.75 yrs (IQR 1.68- 15.5), with a bimodal peak at age 1 yr and again in the teen years (Fig 1). 42 (75%) patients were female. The most common causes of IDA were nutritional and heavy menstrual bleeding. 14 (24.6%) received packed red blood cell (PRBC) transfusion with or without parenteral iron (iron sucrose), and 11 (19.3%) were treated with parenteral iron alone. Almost all (55, 98.2%) were prescribed oral iron supplementation. The lower the presenting Hb, the more likely that transfusion or parenteral iron was used as initial therapy (Fig 2). 19 (33.9%) patients were admitted to hospital and 37 (66.1%) were discharged home from the ED. Nine recipients of parenteral iron alone had follow-up at CHEO, six had follow-up within 10 days with Hb increases of at least 20 g/L and all nine patients had follow-up by day 41 showing increases ranging from 20-97 g/L. Three recipients of parenteral iron alone had presenting Hb <30 g/L and by 9 days following ED encounter all three had increased their Hb by at least 20 (20-32) g/L. Three patients were discharged from ED after IV iron, and none presented to the ED again. Six recipients of PRBCs had follow up within 10 days showing Hb increase ranging from 33-62 g/L, only five had follow-up by day 41 showing increases of 42-79 g/L. Five patients received >1 transfusion, and transfused volumes ranged from 5-25 mL/kg. Minor infusion reactions occurred in 2 (17%) recipients of parenteral iron, and no patient was suspected to have anaphylaxis. Four (28.5%) patients experienced minor transfusion reactions to packed cells. One recipient of multiple PRBC transfusions had transfusion-associated cardiac overload (TACO) requiring ICU admission.Conclusions: This study demonstrates that patients with severe IDA can be safely and effectively managed in the ED setting with parenteral iron therapy alone without PRBC transfusion. The use of parenteral iron avoids the potential short and long-term complications associated with transfusion, whilst ensuring rapid restoration of iron stores without the tolerability issues associated with oral iron. [Display omitted] DisclosuresNo relevant conflicts of interest to declare. OffLabel Disclosure:IV iron sucrose is indicated for treatment of iron deficiency in patients 2 and older with CKD. The use of it outside of this context would be considered off label.

Role of Parenteral Iron Therapy in Gynaecologic Malignancies: A Review of Literature and Recommendations for Practice in a Cancer Centre in a Developing Country

Anaemia causes morbidity and mortality in cancer patients with negative impact on treatment outcome and prognosis. It has been a common practice to offer blood transfusion which comes with its own disadvantages. Therefore, alternative strategies are required to obviate the recurrent need for blood transfusion. Currently, the best treatment decisions for anaemia might be based on measurements of serum ferritin (SF), transferrin saturation (TSAT), soluble transferrin receptor (sTfR), ferritin index (FI = sTfR/log SF), hypochromic reticulocytes (CHR) and C-reactive protein (CRP). Parenteral iron therapy has advantages over oral route as compliance is the limiting factor in oral iron therapy and gastro-intestinal side effects are increased by oral route. A patient’s total body iron deficit can be calculated using the Ganzoni formula. Options for use of parenteral iron are iron dextran, iron sucrose and ferric gluconate. There are numerous trials which evaluate parenteral iron in cancer patients, but only a few evaluate them in gynaecologic malignancies. These trials conclude that usage leads to decreased transfusion rate and slow, steady and sustained rise in Hb level. Certain recommendations include safe and effective use of parenteral iron. Lowest Hb level for injectable iron should be 10 gm/dl. Post-surgical patients should be haemodynamically stable. Preparations can be given according to individual availability, cost and feasibility. Parenteral iron therapies improve time to target haemoglobin levels. They decrease need of blood transfusion. We recommend the use of intravenous iron therapy under supervision wherever feasible.

A Brief Review for Clinicians of Iron Metabolism and the Safety, Efficacy, and Rationale for Use of Intravenous Iron Products

Iron is an abundant element that is essential for multiple biologic processes. Iron metabolism is not entirely understood, but since the discovery of hepcidin, much progress has been made especially in the last five years. This article is intended to enhance clinician understanding of iron metabolism which may inform decisions about parenteral iron use in iron-restricted erythropoiesis (IResE). This article briefly discusses intravenous (IV) iron utilization in iron deficiency, anemia of chronic inflammation (ACI), functional iron deficiency (FID), and anemia associated with chronic kidney disease, heart failure, pregnancy, inflammatory bowel disease and cancer. Oral iron therapy is valuable in mild to moderate pure iron deficiency. Intravenous iron is required when a prompt response is needed in severe pure iron deficiency. ACI is a hypoferremic state resulting from altered iron metabolism. In ACI, IV iron is needed to overcome the blocking effects of hepcidin on intestinal absorption. ESAs stimulate erythropoiesis increasing iron utilization. This surge in iron requirement can result in FID, especially when ESAs are used in patients with ACI. Intravenous iron is required to treat or avoid iron deficiency in FID when inflammation is present. Parenteral iron maximizes ESA response and can make using erythropoiesis-stimulating agents (ESAs) safer by being ESA sparing. The complex and seemingly ubiquitous nature of iron in humans and the inadequate methods of assessment of iron status in inflammatory states means clinical and laboratory monitoring and individualization of care remain essential. The decision to administer intravenous iron is complex as it often lacks robust consensus guidelines; despite this we can expect utilization of these products to increase as they are safe, effective and necessary.

Infectious complications and mortality associated with the use of IV iron therapy: a systematic review and meta-analysis.

Parental iron is used to optimize hemoglobin and enhance erythropoiesis in end-stage renal disease along with erythropoietin-stimulating agents. Safety of iron has been debated extensively and there is no definite evidence whether parenteral iron increases the risk of infections and mortality. We performed this meta-analysis to evaluate the incidence of infectious complications, hospitalizations and mortality with use of parenteral iron. Medical electronic databases [PubMed, EMBASE, Scopus, Web of Science, and cochrane central register for controlled clinical trials (CENTRAL)] were queried for studies that investigated the association between intravenous iron administration and infection in hemodialysis patients. 24 studies (8 Randomized control trials (RCTs) and 16 observational studies) were considered for qualitative and quantitative analysis. All-cause mortality Data from 6 RCTs show that high-dose IV iron conferred 17% less all-cause mortality compared to controls; however, this outcome was not statistically significant (OR = 0.83, CI [0.7, 1.01], p = 0.07). Nine observational studies were pooled under the random effects model due to significant heterogeneity (I2 = 83%, p < 0.001). The overall HR showed increased risk of all-cause mortality in the high-dose group but was statistically non-significant (HR = 1.1, CI [1, 1.22], p = 0.06). Infections Four RCTs with no heterogeneity among their data (I2 = 0%, p = 0.61). Under the fixed effect model, there was no difference in the infection rate between high-dose iron and control group (OR = 0.97, CI [0.82, 1.16], p = 0.77); eight observational studies with significant heterogeneity and utilizing random effects model. Summary HR showed increased yet non-significant risk of infection in the high-dose group (HR = 1.13, CI [0.99, 1.28], p = 0.07) Hospitalization 1 RCT and six observational studies provided data for the rate of all-cause hospitalization. There was marked heterogeneity among observational studies. RCT showed no significant difference between high-dose iron and controls in the rate of hospitalization (OR = 1.03, CI [0.87, 1.23], p = 0.71). Summary HR for observational data showed increased rate of hospitalization in the high-dose group; however, this effect was not statistically significant (HR = 1.11, CI [0.99, 1.24], p = 0.07). Cardiovascular events One RCT compared the rate of adverse cardiovascular events between high-dose and low-dose iron. No significant difference was observed between the two groups (22.3% vs 25.6%, p = 0.12). Six heterogeneous observational studies (I2 = 65%, p < 0.001) reported on the rate of cardiovascular events. No significant difference was observed between high-dose iron and controls (HR = 1.18, CI [0.89, 1.57], p = 0.24). High-dose parenteral iron does not seem to be associated with higher risk of infection, all-cause mortality, increased hospitalization or increased cardiovascular events on analysis of RCTs. Observational studies show increased risk for all-cause mortality, infections and hospitalizations that were not statistically significant and were associated with significant heterogeneity.

Iron deficiency anemia in chronic kidney disease: Uncertainties and cautions.

Anemia in chronic kidney disease is common and iron deficiency is an important cause. To repair iron-deficiency anemia, replacement of iron is needed. Iron can be replaced either by the oral route or by the intravenous route. In a meta-analysis, 5 of the 6 trials were short-term, 1 to 3 months, and compared to oral iron, the mean increase in hemoglobin with intravenous iron was only 0.31 g/dL. However, one of the studies included in this meta-analysis was 6 months long and had a mean decline in hemoglobin of 0.52 g/dL associated with intravenous iron administration. Given the short duration of most of the clinical trials comparing oral with intravenous administration of iron the long-term safety of these modes of administration of supplemental iron could not be assessed. Replacement of iron by the oral route is associated with mostly minor complications such as black stools, constipation, and abdominal discomfort. In contrast, intravenous administration of iron may lead to severe adverse events such as anaphylaxis and, as a more recent randomized trial has suggested, delayed complications such as infections and cardiovascular disease. Delayed complications of repeated intravenous iron use are difficult to recognize at an individual level therefore inpatients who have had recent cardiovascular events or are infected, intravenous iron should probably be avoided. Balancing safety and efficacy would require clinical judgment because 1 size may not fit all till we have better data to support the liberal use of parenteral iron.

Study of parenteral iron use in a health facility and its impact in terms of hospital economics

Administration of parenteral iron is a mainstay of iron deficiency treatment. Evaluation and control of this element is an issue for healthcare facilities. Study of parenteral iron use is thus to be evaluated in its impact in terms of hospital economics. Parenteral iron administrations that took place on 2014in our healthcare facility were retrospectively identified by pharmacists. Following data were extracted from Pharma™ and Crossway™ softwares: indication, diagnostic coding and total dose of iron received. They were then compared to the summary of product characteristics. Of 198analyzed prescriptions, iron deficiency was known or suspected for 97% of patients. However, the total dose of iron administered was not in compliance for three quarters of prescriptions. Sixty-eight percent of patients appear under-dosed. Administration's traceability was found for two-thirds. Eighty-five hospital discharges did not have the right coding and 34stays were charged like an external act instead sessions. Financial loss for the hospital is estimated at 49,300euros. As part of improving practice, close pharmaceutical monitoring of parenteral iron prescribed dosing regimen is essential. Effective communication with the medical information department and regular awareness raising of prescribers should also allow to give more value to this act. Hospital economics is a real tool to aid decision-making.

Iron deficiency in children.

A search (MEDLINE/PubMed) was conducted of recent and relevant articles on iron deficiency in childhood. Iron deficiency remains a global health problem. In South Africa, multiple interventions, including mandatory fortification and a programme for deworming and supplementation, have significantly reduced the prevalence of anaemia. Studies continue to show that iron deficiency in infancy and early childhood is associated with negative neurocognitive, motor and behavioural effects, some of which persist despite treatment. Maternal iron deficiency has negative effects during pregnancy and in the postpartum period, which affects maternal health (e.g. depression, stress, interaction) and has negative effects on the baby (e.g. behavioural and immunological effects). Newer tests include the soluble transferrin receptor, reticulocyte haemoglobin and hepcidin assays. The hepcidin level is useful in differentiating iron deficiency from anaemia of chronic disease with and without iron deficiency. Screening is a challenge and no firm recommendations have been made. The mainstay of treatment remains oral iron (commonly ferrous sulphate). Failure to respond to treatment, refractory iron deficiency and use of parenteral iron are briefly covered.

The Use of Parenteral Iron Therapy for the Treatment of Postpartum Anemia.

Rates of postpartum hemorrhage have been increasing in Canada over the last 10 years, with postpartum iron deficiency anemia as the most common consequence. Postpartum anemia is treated with oral iron supplementation and/or blood transfusion. Recent studies have evaluated the use of parenteral iron as a better tolerated treatment modality. Compared with oral iron supplements, parenteral iron is associated with a more rapid rise in serum ferritin and hemoglobin and improved maternal fatigue scores in the postpartum period. It may also decrease rates of blood transfusion. Parenteral iron may be considered in select clinical situations for the treatment of postpartum anemia.

Considerations and challenges in defining optimal iron utilization in hemodialysis.

Trials raising concerns about erythropoiesis-stimulating agents, revisions to their labeling, and changes to practice guidelines and dialysis payment systems have provided strong stimuli to decrease erythropoiesis-stimulating agent use and increase intravenous iron administration in recent years. These factors have been associated with a rise in iron utilization, particularly among hemodialysis patients, and an unprecedented increase in serum ferritin concentrations. The mean serum ferritin concentration among United States dialysis patients in 2013 exceeded 800 ng/ml, with 18% of patients exceeding 1200 ng/ml. Although these changes are broad based, the wisdom of these practices is uncertain. Herein, we examine influences on and trends in intravenous iron utilization and assess the clinical trial, epidemiologic, and experimental evidence relevant to its safety and efficacy in the setting of maintenance dialysis. These data suggest a potential for harm from increasing use of parenteral iron in dialysis-dependent patients. In the absence of well powered, randomized clinical trials, available evidence will remain inadequate for making reliable conclusions about the effect of a ubiquitous therapy on mortality or other outcomes of importance to dialysis patients. Nephrology stakeholders have an urgent obligation to initiate well designed investigations of intravenous iron in order to ensure the safety of the dialysis population.

Blood Conservation Techniques

Blood conservation techniques are used to reduce the need for allogeneic blood transfusion. One of the most important blood conservation techniques is the optimization of blood counts prior to invasive procedures with anticipated blood loss. Infusion nurses need to understand the importance of treating patients who require the use of parenteral iron to attempt to optimize their blood counts before procedures. Infusion nurses provide a vital link to patient safety and treatment. This article will also discuss other methods of blood conservation frequently used to protect a scarce resource and reduce inappropriate transfusions.

Becoming smarter about parenteral iron use in the oncology clinic

Becoming smarter about parenteral iron use in the oncology clinic

Intravenous iron sucrose for children with iron deficiency failing to respond to oral iron therapy

For decades, parenteral iron has been used in patients with iron deficiency unresponsive to oral iron therapy and in hemodialysis-dependent patients receiving erythropoietin. Newer intravenous (IV) iron formulations such as iron sucrose have replaced high-molecular weight iron (HMW) dextran in dialysis patients; however, the use of parenteral iron in children without renal disease has not been well defined. Pharmacy records were reviewed on children (≤ 18 years of age) who received IV iron sucrose at Children's Medical Center Dallas between January 1, 2004 and June 30, 2009. Patients who received iron sucrose for chronic renal disease were excluded from analysis. Thirty-eight children received iron sucrose for non-renal indications, 13 with iron deficiency refractory to oral iron therapy, 13 with iron malabsorption or dependence on parenteral nutrition, 7 for chronic gastrointestinal blood loss, and 5 for miscellaneous indications. Among these 38 children, who received a total of 510 doses of IV iron sucrose, there were only six adverse reactions. Patients in all categories had a good response to the iron sucrose, with a median hemoglobin rise of 1.9-3.1 g/dl depending on the indication. Parenteral iron is a safe and effective means to treat iron deficiency in children who cannot receive or do not respond to oral iron due to intolerance, poor adherence, or iron malabsorption.

Blood transfusion use in non-dialysis-dependent chronic kidney disease patients aged 65 years and older

Erythropoiesis stimulating agents (ESA) have alleviated the need for blood transfusions in dialysis patients. Their impact on transfusion frequency in elderly chronic kidney disease (CKD) patients aged 65 years and older with non-dialysis-dependent CKD has not been studied. We conducted a retrospective cohort study of Medicare beneficiaries with CKD, point prevalent as of 1 January of each calendar year 1992-2004 (n = 301 000), and a concurrent group of beneficiaries without CKD (n = 15 772 039). During the entry year, we used administrative claim data to assemble a comorbidity profile for each participant. Transfusion event rates, ESA use and parenteral iron use were of primary interest. CKD patients were at least four times more likely than non-CKD patients to receive transfusions. Transfusion rates adjusted for case mix fell from 194.2 transfusions per 1000 patient-years in 1992 to 112.2 in 2004. The decline in transfusions was highest for anaemic CKD patients receiving ESAs, which were given to 0.8% of CKD patients in 1992 and to 7.5% in 2004. Transfusion use in non-dialysis-dependent CKD patients has decreased considerably but continues to be common. ESA use and possibly changed attitudes towards transfusion use explain most of the reduction noted.

Parenteral Iron Use

Use of parenteral iron for anemia management in dialysis patients has greatly increased. Exceeding hemoglobin target levels is not without risk, and whether parenteral iron administration contributes to exceeding targets has not been tested. The authors aimed to determine prevalence of parenteral iron administration and its contribution to exceeding hemoglobin target levels. The authors performed a retrospective observational study of 149,292 hemodialysis patients using Centers for Medicaid & Medicare Services data. All patients were point prevalent on January 1, 2004; survived through June 30, 2004; had Medicare as primary payer; were treated with erythropoiesis stimulating agents (ESAs); and had valid hemoglobin values in April, May, and June, 2004. Of the cohort, 58% received parenteral iron; use was more likely among men, whites, younger patients, and patients with end-stage renal disease as a result of diabetes. Age > 75 yr, African American and other races, baseline hemoglobin > 12 g/dl, higher ESA dose, and iron use in months 1 to 4 of the study period were independently associated with the risk of exceeding hemoglobin levels of 12, 13, and 14 g/dl. Receiving iron in month 4 of the study period showed the highest probability of exceeding targets (odds ratios 1.49, 1.43, 1.50 for hemoglobin levels 12, 13, 14 g/dl, respectively). Parenteral iron use is prevalent, and although adequate iron stores are central to ESA response, iron use may contribute to exceeding recommended hemoglobin levels. Only data from a prospective trial can confirm this association.

Iron in the Brain

After completing this article, readers should be able to: 1. Describe the role of iron in proteins involved in neuronal and glial energy metabolism, myelin production, and monoamine neurotransmitter metabolism. 2. Indicate the neonates who are at risk for iron deficiency. 3. Explain how iron deficiency affects the biochemistry, structure, signaling molecules, and electrophysiology of the hippocampus. 4. Describe the primary causes of iron overload in the neonate. 5. Explain why the preterm infant is at particular risk for iron deficiency. This article is designed to acquaint readers with the role of iron in early brain development. Several important principles that govern the effects of nutrients on the immature brain are discussed, followed by an explanation of the roles of iron during development. Because the developing brain is sensitive to iron overload as well as iron deficiency, both are discussed in the context of human studies and in model systems. The first guiding principle of nutrient-brain interactions during development is the concept of timing, dose, and duration. (1) The positive or negative effects of any nutrient depend on which brain regions or processes are developing at the time that nutrient status is altered and the requirements of those regions for the nutrient during that time of development. Generally, the more rapidly an area is developing, the more vulnerable it is. Dependence on specific nutrients during phases of rapid proliferation or differentiation results in the second principle, a regionalization of brain effects during periods of nutrient deficiency. In the case of iron deficiency, certain brain areas that are dependent on iron for proper development are more vulnerable than areas that are less dependent on iron. Additionally, these same brain areas are likely to be more vulnerable at certain time points than at others. To exert a maximal effect on regional brain development, the timing of iron …

Update on Parenteral Iron Therapy

The role of parenteral iron therapy has been expanding with the growing use of erythropoietin therapy. Much of the clinical experience regarding the use of IV iron therapy in combination with erythropoietin therapy is based on the hemodialysis patient, but the combination therapy has been used in other patient populations as well. In addition, parenteral iron may be indicated in patients receiving long-term parenteral nutrition and in other clinical situations of iron deficiency when the absorption of iron is impaired or tolerance limited. Once the indication for parenteral iron therapy is established, a selection of the most appropriate agent is required. There are currently 3 parenteral iron preparations available, including iron dextran, sodium ferric gluconate, and iron sucrose. Although all agents have been shown to be effective in correcting iron deficiency, there are differences that exist between them. Both sodium ferric gluconate and iron sucrose have been associated with lower rates of serious adverse reactions than iron dextran, although comparative studies are lacking. In patients with previously documented intolerance to iron dextran, sodium ferric gluconate and iron sucrose have been safely administered. In addition to the immediate and delayed reactions associated with the use of parenteral iron, the risk of iron overload and the potential increased risk of infection are of concern. This article will review the clinical experience of the 3 parenteral iron preparations, discuss safety issues, and provide guidelines on proper dosing and administration.