It is a constellation where, after an initial increase in hemoglobin of 10-20 g/L and an above expected increase in ferritin concentration, the patient’s condition deteriorates significantly after the infusion and the ferritin level remains high. The most dreaded complication is a situation I call “iron utilization disturbance”. Problems after iron infusions tend to be the more marked the longer the iron deficiency (without anemia) has lasted. The infusion should preferably not be repeated until after at least 30-60 days of the previous infusion. Under optimal conditions, a treatment response may be expected in 3-30 days after the infusion, but only about 25% of the patients respond completely after the first infusion (500 mg) and about 5% of the patients need five infusions or more. However, the truly demanding phase of treatment starts after the infusion: adverse events requiring attention may occur, although they are seldom severe or longstanding (>30 days). Generally, iron infusion is well tolerated and may be provided in any health care unit where allergic reactions can be treated and where the infusion is supervised by a physician with experience in iron infusion therapy. When such reactions occur, the infusion must be stopped. Iron infusions are an exceptional treatment and there is a risk of serious allergic reactions: anaphylaxis (incidence approximately 1/10,000 infusions), serious respiratory failure (1/1000 infusions) and choking with a febrile reaction (1/100 infusions). Intravenous iron is usually resorted to when the patient does not tolerate oral iron at all or at insufficient doses, and when iron deficiency is severe and a rapid treatment response is needed. Iron by infusion may, especially in the beginning of treatment, correct the iron deficiency and iron deficiency related symptoms slightly faster than iron by mouth, but after completion of intravenous iron therapy, follow-up continues for at least two years. If intravenous treatment is considered, this implies that treatment of the patient is a challenge. Intravenous ironĪdministration of iron by infusion is never the primary treatment option for symptomatic iron deficiency. The horizontal arrow indicates the time when the patient took iron pills at the same dose (200 mg/d). The patient’s symptoms began to subside just before the follow-up visit at 7.5 months (30 weeks). After the first 14 weeks of treatment the ferritin value increased by about 0.15 µg/L per week and then by about 9 µg/l per week. Appropriate differential diagnostic procedures were performed with normal results, after which iron therapy was started. The hemoglobin value had been stable for at least 10 years before the patient’s visit.
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Judging from the patient’s history and symptoms, her iron deficiency had prevailed for more than 20 years, although both the ferritin and the hemoglobin values were available only at 2 years before the patient's first office visit (time point -2). This situation is difficult for the patient and treating physician management requires faith and trust of both parts on each other and a reliable doctor-patient relationship. Another difficult situation arises when the initial increase in ferritin is less than 0.2 µg/L per week on treatment despite an oral iron dose of 100 mg twice daily. Paradoxically, the patient may experience symptom exacerbation after treatment start (Figure 4).
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While on therapy, these patients experience a weekly increase in serum ferritin of maybe more than 8–10 µg/L but thus may not be accompanied by clinical improvement.
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In my opinion, iron deficiency with a duration of more than 15–25 years may need years of treatment and follow-up, and complete recovery in terms of symptom recession is still not certain. If iron deficiency has persisted for at least 10–15 years, iron therapy, treatment follow-up and clinical response are often fraught with challenges, and the patient may need treatment and follow-up for up to two years. This situation arises usually among patients who have never had anemia. The longer the iron deficiency has lasted, the more complex treatment usually becomes. The blood count and ferritin concentration should be checked at least twice within the year following discontinuation of iron therapy. 100 µg/L, but it may be even much higher (Fig.