Infusion Reactions with Alternative Therapies during the National Shortage of Iron Dextran

Introduction

The national shortage of intravenous iron dextran has required patients to receive more alternative iron infusions, such as iron sucrose and sodium ferric gluconate/sucrose, since January 2023. While prior studies have evaluated rates of infusion reactions among some commonly used intravenous iron formulations, data is lacking among differing doses of iron formulations and especially in the setting of this iron dextran shortage. Clinicians at our institution generally observed more adverse reactions with alternative iron infusions during the national shortage of iron dextran compared to prior. Our study examines the infusion reactions of various iron therapies at differing doses and actions providers and patients took thereafter to assess the impact of the iron dextran national shortage on patients.

Methods

Patients were included who received iron infusions in three Henry Ford Hospital clinics in metropolitan Detroit, Michigan, from July 2022-June 2023 with the national iron dextran shortage impacting the health system since January 2023. Age, race, sex, reason for iron infusion, iron infusion formulation received, time of infusion, and dosing schedule of infusion were recorded for all participants. We assessed the symptoms experienced and actions taken for patients who had an infusion reaction. The number and type of infusion reactions between different iron infusion formulations and doses were then compared.

Results

Of the 880 unique patients assessed, 496 (56.4%) received iron dextran, iron sucrose, or sodium ferric gluconate/sucrose between July 2022 and December 2022 prior to the national iron dextran shortage and 384 (43.6%) patients had iron infusions between January 2023 and June 2023 during the shortage. Iron dextran accounted for most of the infusions (n= 356, 71.8%) prior to the shortage whereas iron sucrose was the majority (n=312, 81.3%) during the shortage. Prior to the national shortage, 30 iron infusions reactions occurred, with 18 (60%) associated with iron dextran, 9 (30%) with iron sucrose, and 3 (16.7%) with sodium ferric gluconate/sucrose. During the shortage, 44 reactions occurred, with 1 (2.27%) associated with iron dextran, 41 (93.1%) with iron sucrose, and 2 (4.54%) with sodium ferric gluconate/sucrose. The most reactions (n=41, 55.4%) occurred with iron sucrose at a dose of 500mg across the whole study period. Less reactions (n=9, 12.2%) were reported for iron sucrose at progressively lower doses, comparable to reactions with iron dextran at doses greater than 1000mg (n=8, 10.8%) and at lower doses of iron dextran (n=10, 13.5%). The most common reaction across all infusion types was nausea, vomiting, and/or diarrhea. After an iron infusion reaction, the infusion plan was then most commonly discontinued, with patients either switching to alternative iron infusion formulations, continuing the same infusion type with medications for symptoms, or continuing the same infusion type with lower dose and increased frequency.

Conclusion

More iron infusion reactions occurred after the national shortage of iron dextran since January 2023 in the setting of more frequent use of alternative iron therapies. The most common infusion formulation associated with a reaction was iron sucrose at its higher recommended dose of 500mg, compared with iron dextran and sodium ferric gluconate/sucrose. Providers should be aware of these associated adverse reactions with the different doses of alternative formulations when recommending infusions for patients, and the need for preemptive intervention.