Intravenous Iron in Oncology

Authors: Michael Auerbach MDa and Harold Ballard MDa
View More View Less
  • a From Georgetown University, Washington, DC, Private Practice, Baltimore, Maryland, and New York University School of Medicine, Harborview VA Medical Center, New York, New York.
  • | 2 Medical/Scientific Editor, Journal of the National Comprehensive Cancer Network
Editor: Kerrin G. Robinson MA2
View More View Less
  • a From Georgetown University, Washington, DC, Private Practice, Baltimore, Maryland, and New York University School of Medicine, Harborview VA Medical Center, New York, New York.
  • | 2 Medical/Scientific Editor, Journal of the National Comprehensive Cancer Network

Intravenous iron (IV Fe) as an adjunct to therapy with erythropoiesis-stimulatory agents (ESAs) is standard care in dialysis-associated anemia, adding huge increments in hemoglobin and hematopoietic responses and decreased transfusions without significant toxicity. Cost savings, decreased exposure to ESAs, and decreased times to reach target hemoglobins are realized. Although similar benefits have been seen in all studies performed in patients with chemotherapy-induced anemia (CIA), experts are reluctant to incorporate routine use of IV Fe into treatment, largely because of misinterpretation and misunderstanding of the clinical nature of adverse events reportedly associated with its administration. IV Fe is therefore underused in oncology patients with anemia. Published experience with more than 1000 patients in clinical trials involving the use of IV Fe suggests minimal toxicity and substantial benefit are experienced when high molecular weight iron dextran is avoided. This article presents evidence recommending routine incorporation of IV Fe into treatment for CIA.

Correspondence: Michael Auerbach, MD, Private Practice, 9110 Philadelphia Road #314, Baltimore, MD 21237. E-mail: mauerbachmd@aol.com

Disclosure: Kerrin G. Robinson, MA, has disclosed no relevant financial relationships.

  • 1.

    National Institute for Health and Clinical Excellence. Anaemia (cancer-treatment induced) - erythropoietin (alpha and beta) and darbepoetin: appraisal consultation. Available at: http://www.nice.org.uk/guidance/index.jsp?action=article&r=true&o=37607. Accessed May 27, 2008.

    • Search Google Scholar
    • Export Citation
  • 2.

    Henke M, Laszig R, Rube C et al.. Erythropoietin to treat head and neck cancer patients with anaemia undergoing radiotherapy: randomised, double-blind, placebo-controlled trial. Lancet 2003;362:12551260.

    • Search Google Scholar
    • Export Citation
  • 3.

    Leyland-Jones B, Semiglazov V, Pawlicki M et al.. Maintaining normal hemoglobin levels with epoetin alfa in mainly nonanemic patients with metastatic breast cancer receiving first-line chemotherapy: a survival study. J Clin Oncol 2005;23:59605972.

    • Search Google Scholar
    • Export Citation
  • 4.

    Wright JR, Ung YC, Julian JA et al.. Randomized, double-blind, placebo-controlled trial of erythropoietin in non-small-cell lung cancer with disease-related anemia. J Clin Oncol 2007;25:10271032.

    • Search Google Scholar
    • Export Citation
  • 5.

    Glaspy JA. The development of erythropoietic agents in oncology. Expert Opin Emerg Drugs 2005;10:553567.

  • 6.

    Collins A. Trend in iron testing and IV iron dosing in cancer patients receiving chemotherapy and ESA versus dialysis patients. Presented at the American Society of Hematology 45th Annual Meeting and Exposition; San Diego, California; December 6–9, 2003.

    • Search Google Scholar
    • Export Citation
  • 7.

    Chandler G, Harchowal J, Macdougall IC. Intravenous iron sucrose: establishing a safe dose. Am J Kidney Dis 2001;38:988991.

  • 8.

    Rutherford CJ, Schneider TJ, Dempsey H et al.. Efficacy of different dosing regimens for recombinant human erythropoietin in a simulated perisurgical setting: the importance of iron availability in optimizing response. Am J Med 1994;96:139145.

    • Search Google Scholar
    • Export Citation
  • 9.

    Hotta T, Ogawa H, Saito A, Ito A. Iron balance following recombinant human erythropoietin therapy for anemia associated with chronic renal failure. Int J Hematol 1991;54:195200.

    • Search Google Scholar
    • Export Citation
  • 10.

    Ganz T. Hepcidin, a key regulator of iron metabolism and mediator of anemia of inflammation. Blood 2003;102:783788.

  • 11.

    Auerbach M, Ballard H, Trout JR et al.. Intravenous iron optimizes the response to recombinant human erythropoietin in cancer patients with chemotherapy-related anemia: a multicenter, open-label, randomized trial. J Clin Oncol 2004;22:13011307.

    • Search Google Scholar
    • Export Citation
  • 12.

    Auerbach M, Chaudhry M, Goldman H, Ballard H. Value of methyl-prednisolone in prevention of the arthralgia-myalgia syndrome associated with the total dose infusion of iron dextran: a double blind randomized trial. J Lab Clin Med 1998;131:257260.

    • Search Google Scholar
    • Export Citation
  • 13.

    Auerbach M, Witt D, Toler W et al.. Clinical use of the total dose intravenous infusion of iron dextran. J Lab Clin Med 1988;111:566570.

  • 14.

    Henry DH, Dahl NV, Auerbach M et al.. Intravenous ferric gluconate significantly improves response to epoetin alfa versus oral iron or no iron in anemic patients with cancer receiving chemotherapy. Oncologist 2007;12:231242.

    • Search Google Scholar
    • Export Citation
  • 15.

    Henry DH, Dahl NV, Auerbach M. Is thromboembolism in cancer patients treated with erythropoietic stimulating agents related to thrombocytosis and iron restricted erythropoiesis [abstract]? Blood 2007;110:Abstract 1625.

    • Search Google Scholar
    • Export Citation
  • 16.

    Hedenus M, Birgegard G, Nasman P et al.. Addition of intravenous iron to epoetin beta increases hemoglobin response and decreases epoetin dose requirement in anemic patients with lymphoproliferative malignancies: a randomized multicenter study. Leukemia 2007;21:627632.

    • Search Google Scholar
    • Export Citation
  • 17.

    Bastit L, Vandebroek A, Altintas S. A randomized, multicenter, controlled trial comparing the efficacy and safety of darbepoetin alfa administered every 3 weeks with or without intravenous iron in patients with chemotherapy-induced anemia. J Clin Oncol 2008;26:16111618.

    • Search Google Scholar
    • Export Citation
  • 18.

    Pinter T, Mossman T, Suto J, Vansteenkiste J. Effects of intravenous (IV) iron supplementation on responses to every-3-week (Q3W) darbepoetin alfa (DA) by baseline hemoglobin in patients (pts) with chemotherapy-induced anemia (CIA) [abstract]. J Clin Oncol 2007;25(Suppl 1):519s. Abstract 9106.

    • Search Google Scholar
    • Export Citation
  • 19.

    Pedrazzoli P, Farris A, Del Prete S et al.. Randomized trial of intravenous iron supplementation in patients with chemotherapy related anemia without iron deficiency treated with darbepoetin alfa. J Clin Oncol 2008;26:16191625.

    • Search Google Scholar
    • Export Citation
  • 20.

    Bellet RE, Ghazal H, Flam M et al.. A phase 3 randomized controlled study comparing iron sucrose intravenously to no iron treatment of anemia in cancer patients undergoing chemotherapy and erythropoietin stimulating agent therapy [abstract]. J Clin Oncol 2007;25(Suppl 1):519s. Abstract 9109.

    • Search Google Scholar
    • Export Citation
  • 21.

    Case G. Maintaining iron balance with total-dose infusion of intravenous iron dextran. ANNA J 1998;25:6568.

  • 22.

    Fletes R, Lazarus JM, Gage J, Chertow GM. Suspected iron dextran-related adverse drug events in hemodialysis patients. Am J Kidney Dis 2001;37:743749.

    • Search Google Scholar
    • Export Citation
  • 23.

    Mamula P, Piccoli DA, Peck SN et al.. Total dose intravenous infusion of iron dextran for iron-deficiency anemia in children with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2002;34:286290.

    • Search Google Scholar
    • Export Citation
  • 24.

    McCarthy JT, Regnier CE, Loebertmann CL, Bergstralh EJ. Adverse events in chronic hemodialysis patients receiving intravenous iron dextran—a comparison of two products. Am J Nephrol 2000;20:455462.

    • Search Google Scholar
    • Export Citation
  • 25.

    Chertow GM, Mason PD, Vaage-Nilsen O, Ahlmen J. On the relative safety of parenteral iron formulations. Nephrol Dial Transplant 2004;19:15711575.

    • Search Google Scholar
    • Export Citation
  • 26.

    Chertow GM, Mason PD, Vaage-Nilsen O, Ahlmen J. Update on adverse drug events associated with parenteral iron. Nephrol Dial Transplant 2006;21:378382.

    • Search Google Scholar
    • Export Citation
  • 27.

    Auerbach M, Ballard H, Glaspy J. Clinical update: intravenous iron for anaemia. Lancet 2007;369:15021504.

  • 28.

    Monheim K, Bhandari S. Tolerability and efficacy of parenteral iron therapy in hemodialysis patients, a comparison of preparations. Transfusion Alternatives in Transfusion Medicine 2007;9:372.

    • Search Google Scholar
    • Export Citation
  • 29.

    Sav T, Tokgoz B, Sipahioglu MH et al.. Is there a difference between the allergic potencies of the iron sucrose and low molecular weight iron dextran? Ren Fail 2007;29:423426.

    • Search Google Scholar
    • Export Citation
  • 30.

    Critchley J, Dundar Y. Adverse events associated with intravenous iron infusion (low-molecular-weight iron dextran and iron sucrose): a systematic review. Transfusion Alternatives in Transfusion Medicine 2007;9:836.

    • Search Google Scholar
    • Export Citation
  • 31.

    Kalantar-Zadeh K, Regidor DL, McAllister CJ et al.. Time-dependent associations between iron and mortality in hemodialysis patients. J Am Soc Nephrol 2005;16:30703080.

    • Search Google Scholar
    • Export Citation
  • 32.

    Auerbach M, Pappadakis J, Doherty E. Therapeutic and financial optimization of anemia management in cancer patients with chemotherapy-related anemia through low molecular weight (LMW) iron dextran administration. Presented at the Annual Meeting of the American College of Clinical Pharmacy; Denver, Colorado; October 14–17, 2007. Abstract 188.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 345 102 8
PDF Downloads 333 156 5
EPUB Downloads 0 0 0