Intravenous ferric derisomaltose versus oral iron for persistent iron deficient pregnant women: a randomised controlled trial

Management of iron deficiency in children, adults, and pregnant individuals: evidence-based and expert consensus recommendations

Iron deficiency is the most common micronutrient deficiency worldwide. Oral iron is often recommended as first-line treatment, but there is no consensus on the optimal formulation, dosing strategy, or which patients should be treated preferentially with intravenous iron. To address these challenges, the Iron Consortium at Oregon Health & Science University (OHSU) convened an international panel of 26 experts in haematology, primary care, paediatrics, obstetrics, gastroenterology, cancer, and patient advocacy among its members. This panel was supplemented by insights from a four-person patient focus group to develop current recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel developed clinically relevant questions in five priority topic areas, a systematic literature search was performed, and studies meeting a priori criteria were included to generate evidence tables for recommendation development. Evidence-based and expert opinion-based recommendations were made through a structured anonymous consensus voting process at an in-person meeting in Portland, OR, USA, hosted by OHSU on Feb 16-17, 2024. The expert panel made seven evidence-based recommendations for three demographic groups with iron deficiency: non-pregnant adults, pregnant individuals, and infants, children, and adolescents. Expert opinions supported the recommendations on 21 aspects of care for which there is insufficient evidence. This Review provides evidence-based recommendations and expert consensus on the diagnosis, treatment, and management of iron deficiency, detailing best practices for oral and intravenous iron repletion across diverse patient populations.

Real-world evaluation of an intravenous iron service for the treatment of iron deficiency with or without anemia

Intravenous (IV) iron is a guideline-recommended treatment for iron deficiency when oral iron is contraindicated, ineffective, or not tolerated, or when rapid iron delivery is necessary. However, evidence suggests that some patients receive less IV iron than needed. This retrospective audit assessed the effectiveness and safety of ferric derisomaltose (FDI), a high-dose IV iron, in 2,468 patients. Efficacy outcomes assessed at 4-12 weeks post-infusion included changes in hemoglobin (Hb) and ferritin, proportion of courses (a course was defined as the treatment episode required to administer one total dose) after which patients were non-anemic (Hb ≥ 130 g/L [men] or ≥ 120 g/L [women]), and response rate (proportion of courses after which patients were non-anemic or Hb increased by ≥ 20 g/L). Safety was assessed through adverse events. Across 2,775 FDI courses, the mean dose was 1,244 mg, but mean estimated iron need was 1,580 mg. At follow-up, mean Hb had increased by 20.9 g/L and mean ferritin by 188.8 µg/L. Patients were non-anemic after 33.4% (n = 494/1,478) of courses and responded after 65.1% (n = 962/1,478) of courses. One patient (n = 1/2,468; 0.04%) had a serious allergic reaction. Patients remained anemic after > 65% of courses, demonstrating the need to optimize dosing based on iron need.

Comparing the Treatment Outcomes of Oral and Injectable Iron Therapies for Anemia in Pregnancy: A Meta-Analysis

Iron deficiency anemia (IDA) during pregnancy is a global public health concern, associated with significant maternal and neonatal complications. Intravenous (IV) iron therapy has emerged as a potential alternative to oral iron for rapid correction of anemia, but its impact on clinical outcomes remains unclear. This meta-analysis aimed to evaluate the effectiveness and safety of IV iron compared to oral iron in improving maternal and neonatal outcomes during pregnancy. A systematic review of randomized controlled trials (RCTs) was conducted using major databases. A total of 15 studies, involving 4,215 pregnant women, met the inclusion criteria. Meta-analyses were performed to assess maternal and neonatal complications, adverse events, and hemoglobin (Hb) improvement. The findings demonstrated that IV iron therapy significantly improved Hb levels more rapidly than oral iron, with a mean rise of 2.05 g/dL for IV iron compared to 1.65 g/dL for oral iron. Women receiving IV iron experienced 21% fewer maternal complications, although the difference was not statistically significant for individual complications. Neonatal outcomes, including birth weight, cord Hb levels, and preterm births, showed no significant differences between the two groups. Adverse events were significantly less frequent in the IV group (OR 0.38; 95% CI: 0.24-0.58; p < 0.01), indicating a better safety profile. This study highlights the superior efficacy of IV iron for rapid anemia correction and reduced adverse events in pregnant women. However, no significant advantage was observed for neonatal outcomes or individual maternal complications. The evidence quality for Hb improvement was high, while that for maternal and neonatal clinical outcomes varied from moderate to low. Further research is needed to explore the impact of IV iron on critical clinical outcomes and to determine the most cost-effective regimens for anemia management during pregnancy.

Iron optimisation in pregnancy: a Haematology in Obstetric and Women's Health Collaborative consensus statement

Anaemia is a well-recognised and widely accepted consequence of iron deficiency (ID); however, the two diagnoses are not synonymous with the effects of ID occurring long before the development of anaemia. In adults, ID can cause physical and neuropsychological symptoms, including lethargy, altered mood and poor concentration, reducing an individual's quality of life. Foetal and neonatal ID has been associated with impaired neurocognitive development with lasting effects despite iron replacement in early life. Obstetric ID is common, affecting up to 70% of Australian pregnancies. The impact, at both an individual and a population level, remains underappreciated and consensus on the identification and management of obstetric ID is lacking. This consensus statement was developed by the Haematology in Obstetrics and Women's Health (HOW) Collaborative and utilised the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate evidence and strength of recommendations. Recommendations are as follows: (i) Routine ferritin screening should be performed in all pregnant women (GRADE 1C) at booking and 24-28 weeks. Repeat testing should be performed at 36 weeks if clinically indicated or if the woman is previously unscreened. (ii) ID in pregnancy should be defined as a ferritin level <30 μg/L (GRADE 1D). (iii) An appropriate oral iron formulation should be offered as first-line therapy for obstetric ID (GRADE 1B). (iv) Alternate-day oral dosing can be considered to limit side effects in women with obstetric ID (GRADE 2B). (v) Intravenous iron should be offered to women with ID/ID anaemia who are intolerant of or refractory to oral iron or in the third trimester (GRADE 1B).

Fetal bradycardia and acidosis during maternal parenteral iron: Case reports and literature review

Iron deficiency anemia is an important problem among pregnant women, and intravenous (IV) iron infusions have been increasingly used. Whether fetal monitoring is required during infusion has been debated, with a recent guideline by Hematologists recommending against such. We report two cases of fetal bradycardia after iron isomaltoside (IIM), in women with otherwise good maternal and fetal health. Both developed dyspnea with desaturation minutes from infusion, followed by persistent fetal bradycardia. Both underwent category 1 CS, with cord arterial pH of 7.08 and 6.94 respectively. Upon literature review, only three case reports on fetal bradycardia in IV iron were identified. For older IV iron formulations, a case was reported after IV dextran test dose, while two cases after ferric gluconate were reported. For the new formulation IIM, only one case was reported so far, but in a woman with Crohn's disease and intrauterine growth restriction. IV iron in pregnancy carries risk of anaphylactic or hypersensitivity reactions, even with the newest formulations and in women with good maternal and fetal health. While rarely reported so far, fetal bradycardia is a possible consequence, commonly preceded by respiratory symptoms. Fetal monitoring should therefore be considered during infusion.

Effect and safety of intravenous iron compared to oral iron for treatment of iron deficiency anaemia in pregnancy

RATIONALE

Intravenous iron is increasingly used to treat iron-deficient anaemia (IDA) in pregnancy. A previous network meta-analysis suggested that intravenous irons have a greater effect on haematological parameters than oral irons; however, the impact on serious pregnancy complications such as postpartum haemorrhage (PPH) or the need for blood transfusion was unclear. Since then, several new randomised controlled trials (RCTs) have been conducted.

OBJECTIVES

To evaluate the effect and safety of intravenous versus oral iron preparations for treating IDA in pregnancy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trial registries (ClinicalTrials.gov and the WHO ICTRP) for eligible studies. The latest search was performed on 19 March 2024.

ELIGIBILITY CRITERIA

We included RCTs in pregnant women with confirmed IDA (haemoglobin (Hb) level < 11 g/dL as per World Health Organization (WHO) criteria) comparing intravenous (iron sucrose, ferric carboxymaltose, ferric derisomaltose, ferumoxytol) and oral (ferrous sulfate, ferrous fumarate, ferrous gluconate) iron preparations.

OUTCOMES

Our outcomes were antenatal and postnatal Hb levels, antenatal and postnatal anaemia status, PPH, blood transfusion, maternal satisfaction, maternal well-being, breastfeeding, maternal mortality, maternal morbidity, and adverse events (AEs).

RISK OF BIAS

We used the Cochrane RoB 1 tool to assess risk of bias in the included RCTs.

SYNTHESIS METHODS

We followed standard Cochrane methods. Two review authors independently assessed studies for eligibility and scientific rigour, evaluated the risk of bias of included studies, and extracted data. Where appropriate, we pooled data using a fixed-effect model in the first instance. We reported dichotomous data as risk ratios (RRs) with 95% confidence intervals (CIs) and continuous data as mean differences (MDs) with 95% CIs. We assessed the certainty of the evidence using the GRADE approach.

INCLUDED STUDIES

We included 13 RCTs (3939 participants) mainly conducted in India and Africa (8/13). Gestational age at baseline ranged from 13 to 37 weeks, and Hb levels ranged from 5.0 to just below 11.0 g/dL. The most frequently compared preparations were intravenous iron sucrose versus oral ferrous sulfate (5/13). Most RCTs were at low risk of bias, and the certainty of evidence ranged from moderate to very low, mainly due to concerns over attrition bias, imprecision, and inconsistency.

SYNTHESIS OF RESULTS

Antenatal outcomes Compared with oral iron, intravenous iron likely slightly increases Hb level three to six weeks after treatment start (MD 0.49, 95% CI 0.28 to 0.69; 11 RCTs; 2935 participants; moderate-certainty evidence) and likely reduces anaemia status three to six weeks after treatment start (RR 0.81, 95% CI 0.77 to 0.86; 5 RCTs; 2189 participants; moderate-certainty evidence). Compared with oral iron, intravenous iron likely slightly increases Hb level around birth (MD 0.55, 95% CI 0.33 to 0.77; 6 RCTs; 1574 participants; moderate-certainty evidence) and likely reduces anaemia status around birth (RR 0.85, 95% CI 0.77 to 0.93; 4 RCTs; 1240 participants; moderate-certainty evidence). Postpartum outcomes Compared with oral iron, intravenous iron may slightly increase Hb level postpartum (MD 0.54, 95% CI 0.41 to 0.68; 3 RCTs; 1950 participants; low-certainty evidence). It may also reduce anaemia status (RR 0.66, 95% CI 0.59 to 0.73; 3 RCTs; 1950 participants; low-certainty evidence) and severe anaemia postpartum (RR 0.16, 95% CI 0.03 to 0.84; 2 RCTs; 1581 participants; very low-certainty evidence), although the evidence for the latter outcome is very uncertain. Compared with oral iron, intravenous iron may result in little to no difference in PPH (RR 1.44, 95% CI 0.50 to 4.20; 3 RCTs; 2251 participants; low-certainty evidence) and likely results in little to no difference in the need for blood transfusion (RR 0.97, 95% CI 0.58 to 1.60; 6 RCTs; 2592 participants; moderate-certainty evidence) or rates of breastfeeding (RR 1.04, 95% CI 0.97 to 1.12; 1 RCT; 404 participants; moderate-certainty evidence). No trials reported on maternal satisfaction or maternal well-being. Adverse outcomes Compared with oral iron, intravenous iron may have little to no effect on maternal mortality, but the evidence is very uncertain (RR 0.91, 95% CI 0.13 to 6.39; 4 RCTs; 2152 participants; very low-certainty evidence). Compared with oral iron, intravenous iron likely does not increase maternal morbidity: severe infections (RR 1.01, 95% CI 0.47 to 2.18; 1 RCT; 1881 participants; moderate-certainty evidence) and prolonged hospital stay (RR 0.86, 95% CI 0.62 to 1.21; 1 RCT; 1764 participants; moderate-certainty evidence) and may not increase admissions to the intensive care unit (ICU) (RR 1.99, 95% CI 0.18 to 21.87; 2 RCTs; 2069 participants; low-certainty evidence). Compared with oral iron, intravenous iron likely does not increase AEs (RR 1.05, 95% CI 0.82 to 1.35; 1 RCT; 349 participants; moderate-certainty evidence) and may not increase serious AEs (RR 1.25, 95% CI 0.61 to 2.59; 1 RCT; 1934 participants; low-certainty evidence). However, individual AEs were inconsistently reported across trials.

AUTHORS' CONCLUSIONS

Intravenous iron likely slightly increases Hb levels and likely reduces anaemia in pregnancy compared to oral iron. Hb levels postpartum may be slightly increased with intravenous iron, but the effect on postpartum severe anaemia status is very uncertain. Intravenous iron may result in little to no difference in PPH, and blood transfusion rates are likely unaffected by route of administration. Synthesis of adverse outcomes proved challenging due to their rarity and suboptimal reporting. The effects of intravenous iron on maternal mortality and admissions to the ICU are very uncertain, and there is likely little to no difference between groups in severe infections and prolonged hospital stay. Intravenous iron likely does not increase AEs and may not increase serious AEs; however, the 95% CIs in both cases include potential harm. Furthermore, this finding should be treated cautiously due to the varied adverse event profiles of both types of iron preparations. Data from the ongoing multicentre trials may address some of the identified evidence gaps. However, there is a clear need to strengthen the co-ordination of research efforts around clinically important time points of outcome measure, homogeneity of their definition, and safety reporting.

FUNDING

This Cochrane Review was partially funded by the WHO and was supported by the UK Medical Research Council funding.

REGISTRATION

Registration (2024): PROSPERO, CRD42024523791 via www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024523791.

Clinical outcome post treatment of anemia in pregnancy with intravenous versus oral iron therapy: a systematic review and meta-analysis

Oral iron therapy is often the most common way of treating anaemia; however intravenous iron is considered effective due to rapid iron replenishment. We have dearth of evidence on clinical outcomes post treatment of anaemia. We have searched studies published in English in PubMed, Cochrane, Scopus, ProQuest, and Google Scholar. Our study analysed the clinical outcomes amongst neonates and mother and the adverse events post treatment and assessed the mean change in maternal haemoglobin concentration in both the groups. Forest plots for the clinical outcomes are presented. From a total of 370 studies, 34 Randomized and quasi experimental studies comparing clinical outcomes post-treatment of anaemia in pregnancy were included for quantitative evidence synthesis. Pooled results of maternal clinical outcomes using random effect model [OR: 0.79 (95% CI 0.66; 0.95); 10 outcomes; 17 studies] showed statistically significant difference among both the groups [Moderate quality evidence]; however no significant difference [OR: 0.99 (95% CI 0.86; 1.14); 7 outcomes; 8 studies] have been observed for neonatal complications [Low quality evidence]. The study found that pregnant women receiving IV iron were significantly less likely to experience adverse events as compared with those receiving oral iron [OR 0.39;  (95% CI 0.26-0.60)]; 34 studies; 13,909 women; [Low quality evidence]. Findings from meta-regression analysis showed that IV iron is more likely to reduce maternal complications by 21% compared to oral iron. Increase in odds of adverse maternal outcomes was observed due to increase in gestational age and publication year but no effect for the type of drug used. IV iron increases Hb more and at a higher pace than oral iron. Intravenous iron is more likely to avert adverse maternal outcomes and adverse reactions. However, there is no conclusive evidence on its effectiveness on individual maternal outcome or neonatal outcome/s. Protocol registered with PROSPERO CRD42022368346).

Clinical effectiveness of ferric carboxymaltose (iv) versus iron sucrose (iv) in treatment of iron deficiency anaemia in pregnancy: A systematic review and meta-analysis

BACKGROUND OBJECTIVES

Iron deficiency anaemia (IDA) during pregnancy is treated with oral and parenteral iron. The objective of this review was to compare the clinical effectiveness, safety, pregnancy and neonatal outcomes of intravenous (iv) ferric carboxymaltose (FCM) and iv iron sucrose (IS) in treating IDA in pregnancy.

METHODS

The Department of Health Research funded this study. PubMed, Cochrane Library, EMBASE and Scopus were searched to include studies published till November 2022. The protocol was registered in PROSPERO (CRD42022306092). Pregnant women (15-49 yr) in second and third trimesters, diagnosed with moderate-to-severe iron deficiency anaemia, treated with either of the drugs were included. The included studies were critically assessed using appropriate tools. We conducted a qualitative synthesis of the studies and meta-analysis for improvement in haematological parameters and incidence of adverse events.

RESULTS

A total of 18 studies were included. The risk of bias was low to moderate. A rise in haemoglobin up to four weeks was higher with FCM than IS by 0.57 (0.24, 0.9) g/dl. Intravenous FCM is associated with fewer adverse events than IS [pooled odds ratio: 0.5 (0.32, 0.79)]. The included studies had limited evidence on pregnancy and neonatal outcomes after iv iron treatment.

INTERPRETATION CONCLUSIONS

Intravenous FCM is effective and safer than intravenous IS in terms of haematological parameters, in treating IDA in pregnancy. Further research is required on the effects of iv FCM and iv IS on the pregnancy and neonatal outcomes when used for treating IDA in pregnancy.

Identifying and treating iron deficiency anemia in pregnancy

Anemia is common during pregnancy, and while most anemia is physiologic, the most common pathologic cause is iron deficiency. The American College of Obstetricians and Gynecologists (ACOG) recommends confirmation of iron deficiency anemia with iron studies when anemia is diagnosed during pregnancy but acknowledges that presumptive treatment for suspected iron deficiency anemia is common in practice. Currently ACOG does not recommend treating iron deficiency without anemia during pregnancy. Though the benefits of treating iron deficiency anemia during pregnancy are clear, the optimal route of iron repletion remains uncertain. Results of ongoing large, randomized trials will help define the optimal route of iron treatment for pregnant patients diagnosed with iron deficiency anemia.

Updates on Evaluation and Treatment of Common Complaints in Pregnancy

Patients experience many new and concerning symptoms during pregnancy and it is the role of the obstetric clinician to provide appropriate guidance, recommendations, and treatment options. Often times, these symptoms are related to hormonal and physiologic changes that occur and will resolve in the postpartum period. However, clinicians must be able to recognize more concerning pathologic symptoms that require further evaluation and treatment. This review provides updates on the evaluation and management of some of the common symptoms during pregnancy.

Protocol for a multicenter, double-blinded placebo-controlled randomized controlled trial comparing intravenous ferric derisomaltose to oral ferrous sulfate for the treatment of iron deficiency anemia in pregnancy: The IVIDA2 trial

BACKGROUND

Iron deficiency anemia (IDA) is common during pregnancy and associated with adverse maternal and neonatal outcomes. Treatment with iron supplementation is recommended during pregnancy, but the optimal delivery route is unclear. Oral iron risks has high risk of gastrointestinal side effects and low absorption. Intravenous iron is infused directly but is expensive. The American College of Obstetricians and Gynecologists currently recommends oral iron to treat IDA in pregnancy with intravenous iron reserved as second-line therapy, if needed. This approach is associated with persistent anemia, increasing the risk of peripartum blood transfusion. We aim to provide data on optimal route of iron repletion for IDA in pregnancy.

METHODS

In IVIDA2, a double-blind, placebo controlled, multicenter randomized trial in the United States, 746 pregnant people with moderate-to-severe IDA (hemoglobin <10 g/dL and ferritin <30 ng/mL) at 24-28 weeks' gestation will be randomized 1:1 to either a single 1000 mg dose of intravenous ferric derisomaltose and oral placebo (1-3 times daily) or a single placebo infusion with 1-3 times daily 325 mg ferrous sulfate (65 mg elemental iron) tablet. The primary outcome is peripartum blood transfusion (blood transfusion from delivery to 7 days postpartum). Secondary outcomes include adverse medication reactions, maternal and neonatal hematologic indices, and offspring neurodevelopment.

ETHICS AND DISSEMINATION

A central ethical review board-Advarra-granted ethical approval (Pro00060930). Participating centers-Women & Infants Hospital of Rhode Island, University of Michigan Medical Center, Washington University School of Ethics and dissemination: A central ethical review board-Advarra-granted ethical approval (Pro00060930). Participating centers-Women & Infants Hospital of Rhode Island, University of Michigan Medical Center, Washington University School of.