7 responses to “Identifying and treating iron deficiency in patients hospitalized for heart failure”

  1. Just wondering what your approach is if the ferritin is high due to an acute inflammatory response but you still suspect iron deficiency. Do you just go by the transferrin saturation in that case? Thanks

  2. Thank you for the review.

    One suggestion is to not order the ferritin and transferrin saturation in patients with a hgb >150 as they do not qualify for therapy.

    Also, please provide an updated review once all cause mortality is noted There is a potential increased risk of infection with IV iron therapy, for example, which could negate some of the intended gains.

  3. I agree with screening all anemic patients admitted to hospital for iron deficiency, or patients with normal Hb and reduced MCV and/or increased RDW. However, I don’t feel the data is adequate to support ordering ferritin, serum iron and transferrin saturation in patients with normal Hb. Did you take into account the cost of these additional lab tests and the time they require from short staffed lab facilities?

    Most hospitals limit IV iron therapy because it is extremely expensive. In previous years, IV iron constituted the no. 1 medication expenditure- millions of dollars for the health authority I work at, per year. I can appreciate that IV iron reduces heart failure hospitalizations, but it is a limited resource and there’s lots of CKD patients, IBD patients, pregnant vegetarian ladies, and others who need this therapy. Most outpatients- including many who are already anemic- end up waiting weeks for their infusions.

    A cost benefit analysis would be helpful. Your protocol is not practical IMHO. Hard to justify 3 doses of IV iron to every patient with CHF and normal Hb when so many of them are not optimally treated with standard heart failure meds, SGLT2 inhibitors, screened for sleep apnea, etc.

    Thank you for this article, it is certainly very interesting and well researched even if I disagree with points listed above.

  4. I agree with the overall approach and take a fairly similar approach in my practice. One concern I do have is around the safety of x3 daily doses of IV iron sucrose during a heart failure hospitalization, as there is very literature to support this. I often use Q2D dosing as has been studied in the CKD population. I appreciate the limitations of applying this new literature without access to the newer, higher dose iron formulations for inpatients in BC.

  5. Thank you for the comments and questions.

    With regards to our approach in patients with an acute inflammatory response, we would defer back to the trial inclusion criteria used by AFFIRM-AHF (ie. iron deficient defined as serum ferritin <100 ng/mL or 100 ng/mL ≤ serum ferritin ≤299 ng/mL if TSAT 1000 ng/mL) and the TSAT is low, we would consider IV iron and re-test in 3-4 months.

    With regards to the comment about providing an updated review once all cause mortality is noted due to a concern with the risk of infection with IV iron, not only was the concern with infection risk not seen in the meta-analyses of IV iron in HF discussed in our article, a much larger meta-analysis on the safety of IV iron preparations in general found no increased risk of infection.
    – Avni T, Bieber A, Grossman A, Green H, Leibovici L, Gafter-Gvili A. The safety of intravenous iron preparations: systematic review and meta-analysis. In Mayo clinic proceedings 2015 Jan 1 (Vol. 90, No. 1, pp. 12-23). Elsevier.

    Finally, with regards to the comment about the practicality and feasibility of IV iron in all HF patients, we hoped to impress upon readers the burden of heart failure hospitalizations currently has on the Canadian Healthcare system. While it’s clear that CKD patients, IBD patients, pregnant patients, and other numerous patient groups may benefit from IV iron, we feel that the data around IV iron is convincing enough to stoke discussions on the redistribution of healthcare resources given the benefits in HF patients.
    Furthermore, comparing the costs of some GDMT treatments (eg. Sacubitril-Valsartan) compared to IV iron (eg. Iron Isomaltoside 2000 mg, the higher end used in the IRONMAN trial), the yearly costs would be approximately $3200 vs $1050, respectively, in drug cost alone. Of course, there are other costs associated with IV infusion therapy that have yet to be quantified in a cost-benefit analysis in Canada.
    As the benefits, and risks, of IV iron become clearer through ongoing research, perhaps we can start seeing IV iron being utilized in a more effective manner for all comers.

  6. Can you reference your algorithm pertaining to giving iron sucrose 300 mg daily x 3 doses?

  7. Has the efficacy of oral heme iron been tested?

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