RESEARCH ARTICLE

A JH
Safety and efficacy of rapid (1,000 mg in 1 hr) intravenous
iron dextran for treatment of maternal iron deficient anemia
of pregnancy
Lee Wong,1 Samuel Smith,1 Marisa Gilstrop,2 Richard Derman,2 Sarah Auerbach,3 Nicola London,1 Steven Lenowitz,1
Huzefa Bahrain,4 Jessica McClintock,1 and Michael Auerbach5*

Maternal iron deficiency anemia (IDA) is associated with risk of adverse perinatal outcomes. Oral iron is
recommended to reverse anemia, but has gastrointestinal toxicity and frequent non-adherence. Intravenous
(IV) iron is reserved for intolerance of, or unresponsiveness to, oral therapy, malabsorption, and severe
anemia (1% with hemoglobin [Hgb] levels <7 g/dL). With rare (<100 per one million) adverse events (AEs)
ability to infuse a sufficient dose of low molecular weight iron dextran (LMWID) over 60 min, LMWID is an
attractive option. This study demonstrated safety and efficacy of rapid IV infusion of 1,000 mg LMWID to
gravidas with moderate to severe IDA. An observational treatment study of 1,000 mg LMWID administered
over 1 hr for IDA in 189 consecutive, unselected second and third trimester gravidas after oral iron failure
was conducted. All received a test dose of 25 mg LMWID and were monitored for AEs during the 60-min
infusion. No premedication was administered unless more than one drug allergy or asthma was present in
which case IV methylprednisolone was administered. All were followed through pregnancy and delivery.
Monitored parameters included Hgb, mean corpuscular volume, serum ferritin, and percent transferrin
saturation. About 189 subjects received 1,000 mg LMWID. No serious AEs occurred. About 2% experienced
transient infusion reactions. Hgb improved by 1–1.9 g/dL in 82% and 2 g/dL in 24%. Second trimester
treatment was not associated with greater Hgb improvement than third trimester treatment. Anemia
resolved in 95%. Administration of a single large dose of IV LMWID was effective, safe, and convenient.
Am. J. Hematol. 91:590–593, 2016. V
C 2016 Wiley Periodicals, Inc.

䊏 Introduction
Iron deficiency anemia (IDA) has been associated with increased risk of adverse perinatal outcomes, including preterm birth, low birth weight,
and small-for-gestational age infants [1–3]. Children born to iron-deficient mothers demonstrate lower cognitive function, memory, and motor
development [4–6] recognizable up to 10 years after iron repletion. Maternal iron deficiency potentially affects fetal, neonatal, and childhood brain
growth and development with adverse effects on myelination, neurotransmitters, and brain programming [7]. The prevalence of IDA in pregnancy
can reach 8.2% in the second trimester and 27.4% in the third trimester, especially in minority, low-income populations [8]. A recent global esti-
mate of anemia reported a prevalence of 38% in pregnant women, 29% in non-pregnant women, and 43% in children [9,10].
Oral iron is standard for preventing and treating iron deficiency in pregnancy. Although daily oral supplementation is simple to use and inex-
pensive, there is a high incidence of gastrointestinal side effects and poor adherence to therapy. Whereas dose reduction and modifications in diet,
both of which require adherence, may partially manage the side effects, up to 70% to whom oral iron is prescribed report gastrointestinal distress
[11]. A study of adherence and side effects of three ferrous sulfate regimens in anemic pregnant women in clinical trials concluded the incidence
of gastrointestinal side effects was unacceptably high [12,13].
While numerous publications report the safety and efficacy of IV iron during pregnancy its use is sporadic at best, largely reserved for women
who are intolerant of, or unresponsive to, oral therapy, with malabsorption syndromes and who are severely anemic [14]. This reluctance is at
least in part due to the fact that no IV formulation had been assigned Pregnancy Category A by the Food and Drug Administration, persistent
fears of anaphylactic reactions to parenteral iron preparations, and the misperception among clinicians that the incidence and severity of infusion
reactions is unacceptably high [15].
The availability of an IV iron preparation with a favorable safety profile that is convenient to administer is likely to result in a decrement in ane-
mia rates in pregnancy and improve maternal and fetal outcomes. The ability to safely infuse up to 1,000 mg over 60 min makes LMWID an attrac-
tive option to treat maternal IDA. A recent analysis of over thirty million doses of IV iron reported that the overall frequency of adverse drug
events is extremely low at less than 100 events per million doses administered [16]. Further analysis revealed that most of these events occurred
with high molecular weight iron dextran as compared with low molecular weight iron dextran (LMWID) (OR 5.5, 95% CI). The Cochrane Review

1
Department of Obstetrics and Gynecology, MedStar Franklin Square Medical Center, Baltimore, Maryland; 2Department of Obstetrics and Gynecology, Christiana Care
Health System, Newark, Delaware; 3West Virginia School of Osteopathic Medicine, Lewisburg, West Virginia; 4Auerbach Hematology and Oncology, Baltimore, Mary-
land; 5Department of Medicine, Georgetown University School of Medicine, Washington, DC
Conflict of interest: Dr. Auerebach and Bahrain have received data management funding (only) for clinical trials from AMAG Pharma and Pharmacosmos.
No principal investigator fees or start-up fees were provided and any travel related to study was paid by the investigators.
*Correspondence to: Michael Auerbach; 5233 King Ave #308, Baltimore, MD 21237. E-mail: mauerbachmd@abhemonc.com
Received for publication: 22 February 2016; Revised: 5 March 2016; Accepted: 7 March 2016
Am. J. Hematol. 91:590–593, 2016.
Published online: 11 March 2016 in Wiley Online Library (wileyonlinelibrary.com).
DOI: 10.1002/ajh.24361

C 2016 Wiley Periodicals, Inc.

V

590 American Journal of Hematology, Vol. 91, No. 6, June 2016 doi:10.1002/ajh.24361
RESEARCH ARTICLE
TABLE I. Descriptive Statistics
Study measure Result
Total number of patients 189
Patients treated in second trimester 27
Patients treated in third trimester 162
Mean days from diagnosis to delivery (SD) 58.6 (42.6)
Mode of delivery
Cesarean section (% of total) 68 (36%)
Vaginal (% of total) 121 (64%)
Gestational age at delivery
<37 weeks (%) 20 (11%)
37–41 weeks (%) 169 (89%)
“Treatment for women with postpartum IDA” meta-analyses reported
compliance was 95%–100% for IV iron, and 50%–100% for oral iron
(RR 1.17; 95% CI 1.01–1.35; five RCTs; 890 women, I2 90%;
P < 0.00001) [17]. Thus, while IV infusions, which in the United
States, cost approximately $300.00 including infusion charges, is a
higher expenditure to the health system than oral therapy if well toler-
ated, there is strong justification for IV iron for women who are unre-
sponsive to, or intolerant of oral iron. In this study, we retrospectively
evaluated the author’s (MA) experience with IV administration of
1,000 mg LMWID for moderate to severe iron deficient anemia of
pregnancy after. Herein we report our safety and efficacy data.
䊏 Methods
The charts of 189 consecutive, non-selected, oral iron intolerant, iron deficient
second and third trimester gravidas who received IV iron were reviewed, identified
by the diagnostic codes of pregnancy and iron deficiency (ICD.9 V22 and 280.9,
ICD.10 Z34.00, and D50.9), respectively. All had an initial Hgb <10.5 g/dL and
were treated using a standardized protocol in the infusion center of one of the
authors (MA) between July 2009 and January 2014, following the publication of the
safety and efficacy of a total dose infusion of 1,000 mg of LMWID over 1 hr [18].
All were followed through pregnancy and delivery by their personal obstetricians.
All received one infusion of LMWID except for one who received a second infusion
in a subsequent pregnancy. All patient data was maintained in a de-identified data-
base created by the author (MA). This study is IRB exempt under the Common
Rule (45CFR46).
All patients received thorough information regarding treatment options for iron
deficiency and the impact of untreated anemia on pregnancy, and all provided
informed consent prior to therapy. The IV iron administered was 1,000 mg of
LMWID diluted in 250 mL of normal saline over 1 hr without premedication
unless more than one drug allergy or asthma was present. Patients so identified
were administered 125 mg of IV methylprednisolone prophylactically. All received
the required test dose of approximately 25 mg and if no minor infusion reactions
occurred after 15 min the treatment was continued and women were monitored
closely for adverse reactions during the infusion for the balance of 1 hr.
Data collected included trimester of presentation, hemoglobin (Hgb), mean cor-
puscular volume (MCV), serum ferritin level, and percent transferrin saturation
(TSAT). Laboratory parameters were collected at diagnosis, prior to therapy, prior
to delivery, and postpartum.
Baseline characteristics, laboratory values, and laboratory parameters pre- and
post-treatment differences were analyzed using chi-square and paired t-tests. Data
was also stratified based upon trimester of therapy and severity of anemia. Pearson
correlations and linear regression analysis were performed to investigate the associ-
ation between the actual days from treatment to delivery and change in Hgb and
MCV.
䊏 Results
Data from 189 consecutive, non-selected, oral iron intolerant, iron
deficient gravidas were reviewed and analyzed. No serious adverse
reactions were observed. Four patients (2%) experienced transient
infusion reactions consisting of sneezing, nasal congestion, or myal-
gias of the back or flank. In these cases, infusions were temporarily
interrupted for 15–30 min. The IV glucocorticoids were administered
prior to resumption of the LMWID infusion. All symptoms resolved
spontaneously without sequelae. All received the remainder of the
1,000 mg dose at the planned infusion rate.
doi:10.1002/ajh.24361
Intravenous Iron for Maternal Iron Deficient Anemia
TABLE II. Change in Mean Hemoglobin and MCV from Diagnosis to Deliv-
ery by Trimester of Treatment
All Second Third
patients trimester trimester
Number of patients 189 27 162
Mean change in 1.40 (0.09)* 1.39 (0.18)* 1.40 (0.07)*
hemoglobin (SE)
Mean change in MCV (SE) 1.61 (0.37)* 3.27 (0.77)* 1.34 (0.30)*
a
*P <0.0001 for change from diagnosis to delivery.
Delivery data are shown in Table I. About 68 (36%) were delivered
by Cesarean section and 10.6% delivered preterm. These numbers are
consistent with overall departmental statistics during the observation
period.
Of the 189 patients, 27 (14.3%) were diagnosed and treated in the
second trimester and the (85.7%) remainder in the third (Table I).
The mean number of days from treatment to delivery was 58.6 6 42.6
with a range from 5 to 190 days. The change in Hgb was positively
correlated with the time from treatment to delivery (r2 5 0.17,
P 5 0.0039). The initial Hgb was 10.1 g/dL (SE 0.075). The mean
Hgb at delivery was 11.5 g/dL (SE 0.076), with the mean change from
diagnosis to delivery of 1.39 g/dL (SE 0.10) (P < 0.0001). The mean
improvement in Hgb was not significantly different for those treated
in the second or third trimesters, although mean corpuscular volume
(MCV) increased by 2.9 fL (SE 0.77) for those treated in the second
compared with 1.27 in the third (SE 0.30, P 5 0.058) (Table II). An
improvement in Hgb was observed in 174 patients (92%). In 110
(58%) the observed increment was 1.00–1.99 g/dL (hemoglobin
response) and in 45 (24%) 2 g/dL (hematopoietic response).
Postpartum Hgb data were available on 64 (34%) patients (Fig. 1).
For this population the mean change in Hgb from diagnosis to deliv-
ery was 1.48 g/dL (SE 0.15), not significantly different than the
observed increment for the entire group of 189 patients. From deliv-
ery to postpartum follow-up, an additional Hgb increment of 0.66 g/
dL (SE 0.13) was observed (P < 0.0001). The increment in Hgb from
diagnosis to delivery and diagnosis to postpartum were similar irre-
spective of trimester of treatment. Postpartum serum ferritin and per-
cent transferrin saturation were available on 43 (23%) patients. The
mean pre-treatment ferritin level increased from 16.2 ng/mL (SE
4.88) to 121.0 (SE 15.8) postpartum (P < 0.00001). The mean pre-
treatment percent transferrin saturation increased from 13.5% (SE
1.6) to 27.6% (SE 2.6) postpartum (P < 0.00001).
䊏 Discussion
Several different intravenous (IV) iron formulations have been
evaluated for the treatment of iron deficient anemia in pregnant and
postpartum women [12,13]. Currently available IV iron preparations
include LMWID, iron sucrose (IS), ferric gluconate, and three newer
formulations which allow a replacement dose to be administered in
15 min: ferric carboxymaltose, iron isomaltoside (approved only in
Europe and currently in clinical trials in the United States), and feru-
moxytol. No data in pregnancy is available for ferumoxytol. Although
rare, all forms of IV iron, including high and LMWID, have been
associated with pain and redness at the injection site [17]. Even more
infrequently, anaphylactic reactions characterized by itching, redness
and in severe cases angioedema, vascular collapse, bronchospasm, and
shock have been reported. Chertow (2004) reported that the higher
molecular weight iron dextran formulation, Dexferrum, has been
associated with substantially higher incidence of anaphylactic-type
reactions than LMWID. Recent research supports the relative safety
of IV iron therapy [12,13,19]. This includes a large observational
American Journal of Hematology, Vol. 91, No. 6, June 2016 591
Wong et al. RESEARCH ARTICLE

Figure 1. Change in mean hemoglobin concentration (g/dL) 6 SE from
diagnosis to delivery to postpartum follow up. [Color figure can be viewed
in the online issue, which is available at wileyonlinelibrary.com.]
study of 1,266 infusions of LMWID (INFeD, Actavis) in 888 subjects,
164 of whom were pregnant. No serious adverse events (AEs) were
observed [18]. Two recent studies in pregnant women greater than 12
weeks gestation with documented iron deficiency found consistent
results, that a total parenteral iron replacement with LMWID or mul-
tiple infusions of iron sucrose are effective and safe in gravidas
[20,21].
Anemia affects up to 42% of pregnant women [14,22]. Iron defi-
ciency during pregnancy is associated with a two-fold increased inci-
dence of preterm labor and three-fold increase in the incidence of
low birth weight [23]. If iron deficiency and heavy vaginal bleeding
are present at the beginning of pregnancy, the incidence of preterm
labor is increased five-fold [1]. About 20 of 189 patients (10.6%)
delivered preterm, similar to the hospital average for this period.
Recent data suggests that iron deficient neonates have delayed growth
and development and a statistically significantly increased incidence
of behavioral and cognitive abnormalities up to 10 years after iron
repletion [3,4]. Whereas routine screening for anemia, with a com-
plete blood count, is recommended by both the American College of
Obstetricians and Gynecologists (ACOG) and United States Preventa-
tive Services Task Force (USPSTF), additional screening studies to
identify iron deficiency are not routinely recommended in the
absence of anemia [24]. It is well recognized that many pregnant
women lack sufficient iron stores. Published evidence reports 58% of
nulliparous college freshman have no stainable iron in their marrows
[25].
Both the Center for Disease Control and ACOG recommend low-
dose iron supplementation for all pregnant women [26]. Oral iron is
front line therapy for iron deficient gravidas. It is inexpensive, easy to
obtain and effective if taken. However, oral iron is associated with
poor absorption and adherence. Up to 70% of patients report gastro-
intestinal side effects, most commonly metallic taste, nausea, vomiting
and constipation [11,27]. In second and third trimester gravidas who
are already constipated due to elevated progesterone levels slowing
bowel transit and the gravid uterus pressing posteriorly on the rec-
tum, constipation with oral iron can be particularly burdensome.
These new formulations have been used in recent years for treat-
ment of iron deficient anemia in oral iron intolerant gravidas [28,29].
The results of our study, as well as the preponderance of published
evidence, corroborate these data, and support the favorable side effect
profile of IV iron.
The IV formulations available for use in pregnancy include iron
sucrose, ferric gluconate, LMW iron dextran, and ferric carboxymal-
tose (FCM). Their safety and efficacy are similar [16,30,31]. Iron
sucrose and ferric gluconate require multiple visits since doses
exceeding 200 mg are associated with frequent unpleasant infusion
reactions [32]. In contrast, LMW iron dextran and FCM can be
administered as a complete replacement dose in a single setting. We
recently reported the safety and efficacy of 1,000 mg of LMW iron
dextran administered over 1 hr in 1,266 infusions to 888 patients,
162 of whom were pregnant [18]. Over a 4-week median follow-up,
the mean hemoglobin increased significantly by 1.5 g/dL (95% CI:
0.79–1.65; P < 0.0001). No red cell transfusions were required. Thir-
teen minor infusion reactions resolved without therapy and no SAEs
were reported. These data are consistent with that reported by Ayub
et al., who treated 100 iron-deficient pregnant women with a total
dose infusion of LMWID without any serious AEs [20].
The safety and efficacy of total dose infusions of iron dextran have
been reported in thousands of pregnant women [33,34]. Recently
Myers et al., compared LMWID and FCM for the treatment of iron
deficiency in 92 oral iron intolerant second and third trimester gravi-
das [29]. All responded with no clinically significant toxicity reported.
These data were consistent with an Australian study reporting similar
efficacy and safety with FCM for ID in pregnancy [35]. The incre-
mental increase in Hb when LMWID was administered in either the
second or third trimester was numerically significant in our study
population, corroborating previous publications [36–39]. Although
there is data to suggest correction of iron deficiency results in
improvements of quality of life measures prior to correction of hemo-
globin, our study was not designed to measure these parameters.
The results of this series support the convenience, safety, and effi-
cacy of a single infusion of 1,000 mg of LMWID as therapy for iron
deficiency of pregnancy. Anemia resolved in 95% of patients. We
believe IV iron should be administered as soon as oral iron intoler-
ance occurs or as front line therapy to those in whom oral iron is
known to be ineffective or harmful.
This study was observational in a single large ambulatory hematol-
ogy practice. While there was no control group, all patients were
intolerant of oral iron and our data supports the preponderance of
published evidence. Many patients in our series were from poor com-
munities and postpartum follow-up with repeat iron parameters was
only partial. The data is limited to those items maintained in the de-
identified data base. To address this limitation we are currently pre-
paring the results of the first United States prospective study of IV
iron in oral iron intolerant gravidas (FDA IND 114696).
䊏 Acknowledgment
Statistical support was provided by Pharmacosmos, Holbaek,
Denmark.

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