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Roganovic J. Parenteral iron therapy in children with iron deficiency anemia. World J Clin Cases 2024; 12:2138-2142. [PMID: 38808346 PMCID: PMC11129126 DOI: 10.12998/wjcc.v12.i13.2138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/10/2024] [Accepted: 04/07/2024] [Indexed: 04/25/2024] Open
Abstract
Iron deficiency anemia (IDA) continues to be a global public health problem. Oral iron is the universally accepted first-line therapy, and most children have a prompt and favorable response to oral formulations. In subsets of children who fail to respond due to intolerance, poor adherence, or inadequate intestinal absorption, parenteral iron is indicated. Despite numerous studies in adults with IDA of diverse etiologies, pediatric studies on parenteral iron use are very limited. Although mostly retrospective and small, these studies have documented the efficacy and safety profile of intravenous iron formulations. In this editorial the author comments on the most important published data and underscores the need to seriously consider parenteral iron use in children unresponsive to oral therapy.
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Affiliation(s)
- Jelena Roganovic
- Department of Pediatric Hematology and Oncology, Children’s Hospital Zagreb, 10000 Zagreb, Croatia
- Faculty of Biotechnology and Drug Development, University of Rijeka, Rijeka 51000, Croatia
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Gale SE, Willeford A, Sandquist K, Watson K. Intravenous iron in patients with iron deficiency and heart failure: a review of modern evidence. Curr Opin Cardiol 2024; 39:178-187. [PMID: 38353280 DOI: 10.1097/hco.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW Iron deficiency is common in patients with heart failure, affecting up to half of ambulatory patients and an even greater percentage of patients admitted for acute decompensation. Iron deficiency in this population is also associated with poor outcomes, including worse quality of life in addition to increased hospitalizations for heart failure and mortality. Evidence suggests that patients with iron deficiency in heart failure may benefit from repletion with IV iron. RECENT FINDINGS In this review, we outline the etiology and pathophysiology of iron deficiency in heart failure as well as various iron formulations available. We discuss evidence for intravenous iron repletion with a particular focus on recent studies that have evaluated its effects on hospitalizations and mortality. Finally, we discuss areas of uncertainty and future study and provide practical guidance for iron repletion. SUMMARY In summary, there is overwhelming evidence that intravenous iron repletion in patients with iron deficiency in heart failure is both beneficial and safe. However, further evidence is needed to better identify which patients would most benefit from iron repletion as well as the ideal repletion strategy.
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Affiliation(s)
- Stormi E Gale
- Novant Health Heart and Vascular Institute, Huntersville, North Carolina
| | - Andrew Willeford
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, California
| | | | - Kristin Watson
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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Belmont A, Liao J, Hsu FI, Kwah J. A safe, effective, and single-day protocol for rapid drug desensitization to intravenous iron dextran. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3242-3244.e1. [PMID: 37329952 DOI: 10.1016/j.jaip.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/17/2023] [Accepted: 06/08/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Ami Belmont
- Section of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Jane Liao
- Section of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Florence Ida Hsu
- Section of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Jason Kwah
- Section of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn.
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Dottori L, Corleone Tsar'kov D, Dilaghi E, Pivetta G, Scalamonti S, Ligato I, Esposito G, Annibale B, Lahner E. Efficacy and Safety of Intravenous Ferric Carboxymaltose Treatment of Iron Deficiency Anaemia in Patients with Corpus Atrophic Gastritis: A Retrospective Study. Nutrients 2023; 15:4199. [PMID: 37836482 PMCID: PMC10574262 DOI: 10.3390/nu15194199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Corpus Atrophic Gastritis (CAG) is characterised by iron malabsorption leading to iron deficiency anaemia (IDA), which rarely responds to oral therapy. Ferric carboxymaltose (FCM), shown to be a safe and effective intravenous iron therapy in other diseases, has not been investigated yet in CAG. Thus, we aimed to assess the safety and efficacy of FCM in CAG-related IDA. A retrospective study on 91 patients identified CAG as the only cause of IDA treated with FCM. Twenty-three were excluded for incomplete follow-up. Sixty-eight were evaluated for safety and efficacy, while three were evaluated for safety only due to infusion interruption for side effects. Haemoglobin and iron storage were evaluated pre-infusion (T0), at 4 weeks (T4) and 12 weeks (T12) after infusion. An eventual IDA relapse was analysed. Two cases reported mild side effects. Haemoglobin significantly increased at T4, and T12, reaching +3.1 g/dL. Ferritin increased at T4, decreasing at T12, while transferrin saturation increased progressively until reaching a plateau. IDA relapsed in 55.4% of patients at a mean of 24.6 months. The only factor associated with relapse was female gender [OR (95% CI): 6.6 (1.5-28.6)]. FCM proved to be safe and effective in treating CAG-related IDA, ensuring quick and long-lasting recovery.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Edith Lahner
- Department of Medical-Surgical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy (G.E.); (B.A.)
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Pasricha SR, Mwangi MN, Moya E, Ataide R, Mzembe G, Harding R, Zinenani T, Larson LM, Demir AY, Nkhono W, Chinkhumba J, Simpson JA, Clucas D, Stones W, Braat S, Phiri KS. Ferric carboxymaltose versus standard-of-care oral iron to treat second-trimester anaemia in Malawian pregnant women: a randomised controlled trial. Lancet 2023; 401:1595-1609. [PMID: 37088092 PMCID: PMC10193370 DOI: 10.1016/s0140-6736(23)00278-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/22/2023] [Accepted: 02/02/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Anaemia affects 46% of pregnancies in Africa; oral iron is recommended by WHO but uptake and adherence are suboptimal. We tested a single dose of a modern intravenous iron formulation, ferric carboxymaltose, for anaemia treatment in Malawian pregnant women. METHODS In this open-label, individually randomised controlled trial, we enrolled women with a singleton pregnancy of 13-26 weeks' gestation in primary care and outpatient settings across two regions in southern Malawi. Women were eligible if they had capillary haemoglobin of less than 10·0 g/dL and negative malaria rapid diagnostic test. Participants were randomised by sealed envelope 1:1. Assessors for efficacy outcomes (laboratory parameters and birthweight) were masked to intervention; participants and study nurses were not masked. Participants were given ferric carboxymaltose up to 1000 mg (given once at enrolment in an outpatient primary care setting), or standard of care (60 mg elemental iron twice daily for 90 days), along with intermittent preventive malaria treatment. The primary maternal outcome was anaemia at 36 weeks' gestation. The primary neonatal outcome was birthweight. Analyses were performed in the intention-to-treat population for mothers and liveborn neonates, according to their randomisation group. Safety outcomes included incidence of adverse events during infusion and all adverse events from randomisation to 4 weeks' post partum. The trial is registered with ANZCTR, ACTRN12618001268235. The trial has completed follow-up. FINDINGS Between Nov 12, 2018, and March 2, 2021, 21 258 women were screened, and 862 randomly assigned to ferric carboxymaltose (n=430) or standard of care (n=432). Ferric carboxymaltose did not reduce anaemia prevalence at 36 weeks' gestation compared with standard of care (179 [52%] of 341 in the ferric carboxymaltose group vs 189 [57%] of 333 in the standard of care group; prevalence ratio [PR] 0·92, 95% CI 0·81 to 1·06; p=0·27). Anaemia prevalence was numerically lower in mothers randomly assigned to ferric carboxymaltose compared with standard of care at all timepoints, although significance was only observed at 4 weeks' post-treatment (PR 0·91 [0·85 to 0·97]). Birthweight did not differ between groups (mean difference -3·1 g [-75·0 to 68·9, p=0·93). There were no infusion-related serious adverse events or differences in adverse events by any organ class (including malaria; ≥1 adverse event: ferric carboxymaltose 183 [43%] of 430 vs standard of care 170 [39%] of 432; risk ratio 1·08 [0·92 to 1·27]; p=0·34). INTERPRETATION In this malaria-endemic sub-Saharan African setting, treatment of anaemic pregnant women with ferric carboxymaltose was safe but did not reduce anaemia prevalence at 36 weeks' gestation or increase birthweight. FUNDING Bill & Melinda Gates Foundation (INV-010612).
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Affiliation(s)
- Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Clinical Haematology, The Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.
| | - Martin N Mwangi
- Training and Research Unit of Excellence, Blantyre, Malawi; Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi; The Micronutrient Forum, Healthy Mothers Healthy Babies Consortium, Washington, DC, USA
| | - Ernest Moya
- Training and Research Unit of Excellence, Blantyre, Malawi; Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ricardo Ataide
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medicine at the Peter Doherty Institute, University of Melbourne, Parkville, VIC, Australia
| | - Glory Mzembe
- Training and Research Unit of Excellence, Blantyre, Malawi; Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Rebecca Harding
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Truwah Zinenani
- Training and Research Unit of Excellence, Blantyre, Malawi; Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Leila M Larson
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Ayse Y Demir
- Laboratory for Clinical Chemistry and Haematology, Meander Medical Centre, Amersfoort, Netherlands
| | - William Nkhono
- Training and Research Unit of Excellence, Blantyre, Malawi; Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jobiba Chinkhumba
- Training and Research Unit of Excellence, Blantyre, Malawi; Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia
| | - Danielle Clucas
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - William Stones
- Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sabine Braat
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medicine at the Peter Doherty Institute, University of Melbourne, Parkville, VIC, Australia
| | - Kamija S Phiri
- Training and Research Unit of Excellence, Blantyre, Malawi; Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi.
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Houry M, Tohme J, Sleilaty G, Jabbour K, Bou Gebrael W, Jebara V, Madi-Jebara S. Effects of ferric carboxymaltose on hemoglobin level after cardiac surgery: A randomized controlled trial. Anaesth Crit Care Pain Med 2023; 42:101171. [PMID: 36375780 DOI: 10.1016/j.accpm.2022.101171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 09/02/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Perioperative anemia is common in cardiac surgery. Few studies investigated the effect of postoperative intravenous (IV) iron supplementation and were mostly inconclusive. METHODS Design: A randomized single-center, double-blind, placebo-controlled, parallel-group trial. PARTICIPANTS 195 non-anemic patients were recruited from December 2018 to December 2020: 97 patients received 1 g of ferric carboxymaltose (FCM) and 98 patients received 100 mL of physiological serum on postoperative day 1. MEASUREMENTS hemoglobin levels, reticulocyte count, serum iron, serum ferritin, and transferrin saturation were measured at induction of anesthesia, postoperative days 1, 5, and 30. Transfusion rate, duration of mechanical ventilation, critical care unit length of stay, and side effects associated with IV iron administration were measured. The primary outcome was hemoglobin level on day 30. Secondary outcomes included iron balance, transfused red cell packs, and critical care unit length of stay. RESULTS At day 30, the hemoglobine level was higher in the FCM group than in the placebo group (mean 12.9 ± 1.2 vs. 12.1 ± 1.3 g/dL (95%CI 0.41-1.23, p-value <0.001)). Patients in the FCM group received fewer blood units (median 1[0-2] unit vs. 2 [0-3] units, p-value = 0.037) and had significant improvement in iron balance compared to the control group. No side effects associated with FCM administration were reported. CONCLUSION In this randomized controlled trial, administration of FCM on postoperative day 1 in non-anemic patients undergoing cardiac surgery increased hemoglobin levels by 0.8 g/dL on postoperative day 30, leading to reduced transfusion rate, and improved iron levels on postoperative day 5 and 30. CLINICAL TRIAL REGISTRY NUMBER NCT03759964.
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Affiliation(s)
- Maha Houry
- Department of Anesthesia and Critical Care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Joanna Tohme
- Department of Anesthesia and Critical Care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon.
| | - Ghassan Sleilaty
- Department of Cardiovascular and Thoracic Surgery, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon; Clinical Research Center, Faculty of Medicine, Université Saint-Joseph, Beirut, Lebanon
| | - Khalil Jabbour
- Department of Anesthesia and Critical Care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Wissam Bou Gebrael
- Department of Anesthesia and Critical Care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Victor Jebara
- Department of Cardiovascular and Thoracic Surgery, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Samia Madi-Jebara
- Department of Anesthesia and Critical Care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
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Faysal H, Araji T, Ahmadzia HK. Recognizing who is at risk for postpartum hemorrhage: targeting anemic women and scoring systems for clinical use. Am J Obstet Gynecol MFM 2023; 5:100745. [PMID: 36075528 DOI: 10.1016/j.ajogmf.2022.100745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/29/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
Iron deficiency anemia during pregnancy is a common concern, affecting 38% of women worldwide and up to 50% in developing countries. It is defined differently throughout all 3 trimesters. It has several detrimental effects on pregnancy outcomes for both the mother and the fetus, such as increasing the risk for postpartum depression, preterm delivery, cesarean delivery, preeclampsia, and low birthweight. Management of iron deficiency anemia is done classically via oral iron supplementation. However, recent evidence has shown that intravenous iron is a good alternative to oral iron if patients are unable to tolerate it, not responding, or present with a new diagnosis very late in pregnancy. Management of iron deficiency anemia was demonstrated to be protective against postpartum hemorrhage. Other ways to prevent postpartum hemorrhage include improving prediction tools that can identify those at risk. Several risk assessment kits have been developed to estimate the risk for postpartum hemorrhage among patients and have been proven useful in the prediction of patients at high risk for postpartum hemorrhage despite limitations among low-risk groups. More comprehensive tools are also being explored by determining clinically relevant factors through nomograms, with some proving their efficacy after implementation. Machine learning is also being used to develop more complete tools by including risk factors previously not accounted for. These newer tools, however, still require external validation before being adopted despite promising results under testing conditions.
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Affiliation(s)
- Hani Faysal
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Tarek Araji
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Homa K Ahmadzia
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC.
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Caimmi S, Crisafulli G, Franceschini F, Liotti L, Bianchi A, Bottau P, Mori F, Triggiano P, Paglialunga C, Saretta F, Giannetti A, Ricci G, Caffarelli C. Hypersensitivity to Intravenous Iron Preparations. CHILDREN 2022; 9:children9101473. [PMID: 36291409 PMCID: PMC9600424 DOI: 10.3390/children9101473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/10/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022]
Abstract
Intravenous iron is widely used for the treatment of iron deficiency anemia when adherence to oral iron replacement is poor. Acute hypersensitivity reactions during iron infusions are very rare but can be life threatening. Major risk factors for hypersensitivity reactions include a previous reaction to an iron infusion, a fast iron infusion rate, multiple drug allergies, atopic diseases, high serum tryptase levels, asthma, and urticaria. The management of iron infusions requires meticulous observation, and, in the event of an adverse reaction, prompt recognition and severity-related interventions by well-trained medical and nursing staff. Avoidance of IV iron products in patients with iron hypersensitivity reactions may not be considered as a standard practice.
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Affiliation(s)
- Silvia Caimmi
- UOC Pediatria, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Fabrizio Franceschini
- UOC Pediatria, Azienda Ospedaliero-Universitaria “Ospedali Riuniti”, 60020 Ancona, Italy
| | - Lucia Liotti
- UOC Pediatria, Azienda Ospedaliero-Universitaria “Ospedali Riuniti”, 60020 Ancona, Italy
| | - Annamaria Bianchi
- UOC Pediatria, Azienda Ospedaliera San Camillo Forlanini, 00152 Roma, Italy
| | - Paolo Bottau
- Dipartimento di Pediatria e Neonatologia, Ospedale di Imola, 40026 Imola, Italy
| | - Francesca Mori
- Allergy Unit, Meyer Children’s Hospital, 50139 Florence, Italy
| | - Paolo Triggiano
- UOC Pediatria, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Claudia Paglialunga
- UOC di Pediatria, Azienda Ospedaliera-Universitaria “Consorziale-Policlinico”, Ospedale Pediatrico Giovanni XXIII, 70123 Bari, Italy
| | - Francesca Saretta
- SC Pediatria, Ospedale Latisana-Palmanova, Dipartimento Materno-Infantile Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy
| | - Arianna Giannetti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giampaolo Ricci
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Carlo Caffarelli
- Clinica Pediatrica, Azienda Ospedaliero-Universitaria, Dipartimento Medicina e Chirurgia, Università di Parma, 43126 Parma, Italy
- Correspondence:
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Dave CV, Brittenham GM, Carson JL, Setoguchi S. Risks for Anaphylaxis With Intravenous Iron Formulations : A Retrospective Cohort Study. Ann Intern Med 2022; 175:656-664. [PMID: 35344378 DOI: 10.7326/m21-4009] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The risks for anaphylaxis among intravenous (IV) iron products currently in use have not been assessed. OBJECTIVE To compare risks for anaphylaxis among 5 IV iron products that are used frequently. DESIGN Retrospective cohort study using a target trial emulation framework. SETTING Medicare fee-for-service data with Part D coverage between July 2013 and December 2018. PARTICIPANTS Older adults receiving their first administration of IV iron. MEASUREMENTS The primary outcome was the occurrence of anaphylaxis within 1 day of IV iron administration, ascertained using a validated case definition. Analysis was adjusted for 40 baseline covariates using inverse probability of treatment weighting. The adjusted incidence rates (IRs) for anaphylaxis per 10 000 first administrations and odds ratios (ORs) were computed. RESULTS The adjusted IRs for anaphylaxis per 10 000 first administrations were 9.8 cases (95% CI, 6.2 to 15.3 cases) for iron dextran, 4.0 cases (CI, 2.5 to 6.6 cases) for ferumoxytol, 1.5 cases (CI, 0.3 to 6.6 cases) for ferric gluconate, 1.2 cases (CI, 0.6 to 2.5 cases) for iron sucrose, and 0.8 cases (CI, 0.3 to 2.6 cases) for ferric carboxymaltose. Using iron sucrose as the referent category, the adjusted ORs for anaphylaxis were 8.3 (CI, 3.5 to 19.8) for iron dextran and 3.4 (CI, 1.4 to 8.3) for ferumoxytol. When cohort entry was restricted to the period after withdrawal of high-molecular-weight iron dextran from the U.S. market in 2014, the risk for anaphylaxis associated with low-molecular-weight iron dextran (OR, 8.4 [CI, 2.8 to 24.7]) did not change appreciably. Anaphylactic reactions requiring hospitalizations were observed only among patients using iron dextran or ferumoxytol. LIMITATION Generalizability to non-Medicare populations. CONCLUSION The rates of anaphylaxis were very low with all IV iron products but were 3- to 8-fold greater for iron dextran and ferumoxytol than for iron sucrose. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Chintan V Dave
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, and Department of Veterans Affairs New Jersey Health Care System, East Orange, New Jersey (C.V.D.)
| | - Gary M Brittenham
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York (G.M.B.)
| | - Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J.L.C.)
| | - Soko Setoguchi
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, and Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey (S.S.)
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Safety of Ferric Carboxymaltose in Children: Report of a Case Series from Greece and Review of the Literature. Paediatr Drugs 2022; 24:137-146. [PMID: 35083718 DOI: 10.1007/s40272-022-00491-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Parenteral iron is generally considered safe in adults, and severe adverse events are extremely rare. Ferric carboxymaltose (FCM), a third-generation parenteral iron product, is not licensed for pediatric use. OBJECTIVE The aim of this study was to present our data on the safety of FCM in children with iron deficiency (ID) and/or iron deficiency anemia (IDA) and to investigate through a systematic literature review articles reporting on the safety of FCM use in children with ID/IDA. PATIENTS AND METHODS Safety data regarding children treated with FCM for ID/IDA from four pediatric departments in Greece over a 26-month period are presented. Additionally, a literature search was performed in PubMed, Scopus, and Google Scholar on December 4, 2021 for articles reporting on the use of FCM in children with ID/IDA. Review articles, guidelines, case reports/case series, and reports on the use of FCM for conditions other than ID/IDA were excluded. Identified articles were screened for all reported adverse events (AE) that were graded according to the Common Terminology Criteria for Adverse Events, version 5.0. RESULTS In our cohort, 37 children with ID/IDA received 41 FCM infusions. All infusions were tolerated well. In addition, 11 articles reporting 1231 infusions of FCM in 866 children were identified in the literature. Among them, 52 (6%) children developed AE that were graded as mild or moderate (grades I-III). CONCLUSIONS Our patient cohort and this literature review provide further evidence for the good safety profile of FCM in children, although well-designed prospective clinical trials with appropriate safety endpoints are still required.
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Arastu AH, Elstrott BK, Martens KL, Cohen JL, Oakes MH, Rub ZT, Aslan JJ, DeLoughery TG, Shatzel J. Analysis of Adverse Events and Intravenous Iron Infusion Formulations in Adults With and Without Prior Infusion Reactions. JAMA Netw Open 2022; 5:e224488. [PMID: 35353168 PMCID: PMC8968468 DOI: 10.1001/jamanetworkopen.2022.4488] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Although iron deficiency is common, it remains unclear which iron repletion strategy is associated with the lowest rate of infusion-related adverse events, and how patients with history of infusion reaction should be managed. OBJECTIVE To evaluate rates of infusion reactions among 4 commonly used intravenous iron repletion strategies and determine how readministration was managed in patients with history of reaction. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all patients receiving intravenous iron infusion from January 1, 2015, to September 7, 2021, at 6 centers in Portland, Oregon. Participants included a total of 12 237 patients with iron deficiency, not restricted by etiology. Statistical analysis was performed from September to October 2021. EXPOSURES Type of intravenous iron formulation and concurrent administration of diphenhydramine, epinephrine, famotidine, and/or hydrocortisone, used as surrogate maker of infusion reaction. MAIN OUTCOMES AND MEASURES Incidence of adverse events, including severe events requiring epinephrine, stratified by type of iron formulation, and in patients who received premedication or with history of infusion-related reaction receiving subsequent doses. RESULTS Among 35 737 unique iron infusions (12 237 patients [9480 (77.5%) women; 717 (5.9%) Black; 10 250 (83.7%) White; mean (SD) age of 51 (20) years]), comprising 22 309 iron sucrose doses, 9067 iron dextran total doses (1771 preceded by test dose, 56 test doses alone), 3147 ferumoxytol doses, and 1214 ferric carboxymaltose doses, incidence of adverse events was 3.9% (n = 1389; 95% CI, 3.7%-4.1%). Rate of infusion events differed among iron formulations: 4.3% (n = 970; 95% CI, 4.1%-4.6%) iron sucrose, 3.8% (n = 345, 95% CI: 3.4%-4.2%) iron dextran (test and full doses or test dose alone), 1.8% (n = 57; 95% CI, 1.4%-2.3%) ferumoxytol, and 1.4% (n = 17, 95% CI, 0.8%-2.3%) ferric carboxymaltose (P < .001). Severe adverse events were exceedingly rare with only 2 documented epinephrine administrations, both associated with iron dextran. Incidence of adverse events among those who received premedication was 23-fold higher compared with those who did not (38.6% vs 1.7%, χ21 = 7324.8; P < .001). Among 873 patients with history of infusion reaction who underwent readministration, the majority received the same formulation, which was associated with significantly higher reaction rate particularly if premedication was administered (68% [95% CI, 64%-72%] vs 32% [95% CI, 26%-41%], respectively), compared with those who received an alternate formulation (21% [95% CI, 11%-35%] vs 5% [95% CI, 2%-12%], respectively) (P < .001). CONCLUSIONS AND RELEVANCE These data, and the preponderance of published evidence, suggest that intravenous iron is generally well tolerated with exceedingly low risk of severe reaction, use of premedication and test doses are unnecessary, and that optimal prevention and management of infusion-related reactions warrant further study.
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Affiliation(s)
- Asad H. Arastu
- Department of Medicine, Oregon Health & Science University, Portland
| | | | - Kylee L. Martens
- Department of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland
| | - Jonathan L. Cohen
- Department of Pharmacy, Oregon Health & Science University, Portland
| | - Michael H. Oakes
- Department of Medicine, Oregon Health & Science University, Portland
| | - Zhoe T. Rub
- Department of Medicine, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | - Joseph J. Aslan
- Department of Biomedical Engineering, Oregon Health & Science University, Portland
| | - Thomas G. DeLoughery
- Department of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland
| | - Joseph Shatzel
- Department of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland
- Department of Biomedical Engineering, Oregon Health & Science University, Portland
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Richards T, Breymann C, Brookes MJ, Lindgren S, Macdougall IC, McMahon LP, Munro MG, Nemeth E, Rosano GMC, Schiefke I, Weiss G. Questions and answers on iron deficiency treatment selection and the use of intravenous iron in routine clinical practice. Ann Med 2021; 53:274-285. [PMID: 33426933 PMCID: PMC7877947 DOI: 10.1080/07853890.2020.1867323] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023] Open
Abstract
Iron deficiency is a common cause of morbidity and can arise as a consequence or complication from many diseases. The use of intravenous iron has increased significantly in the last decade, but concerns remain about indications and administration. Modern intravenous iron preparations can facilitate rapid iron repletion in one or two doses, both for absolute iron deficiency and, in the presence of inflammation, functional iron deficiency, where oral iron therapy is ineffective or has not worked. A multidisciplinary team of experts experienced in iron deficiency undertook a consensus review to support healthcare professionals with practical advice on managing iron deficiency in gastrointestinal, renal and cardiac disease, as well as; pregnancy, heavy menstrual bleeding, and surgery. We explain how intravenous iron may work where oral iron has not. We provide context on how and when intravenous iron should be administered, and informed opinion on potential benefits balanced with potential side-effects. We propose how intravenous iron side-effects can be anticipated in terms of what they may be and when they may occur. The aim of this consensus is to provide a practical basis for educating and preparing staff and patients on when and how iron infusions can be administered safely and efficiently. Key messages Iron deficiency treatment selection is driven by several factors, including the presence of inflammation, the time available for iron replenishment, and the anticipated risk of side-effects or intolerance. Intravenous iron preparations are indicated for the treatment of iron deficiency when oral preparations are ineffective or cannot be used, and therefore have applicability in a wide range of clinical contexts, including chronic inflammatory conditions, perioperative settings, and disorders associated with chronic blood loss. Adverse events occurring with intravenous iron can be anticipated according to when they typically occur, which provides a basis for educating and preparing staff and patients on how iron infusions can be administered safely and efficiently.
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Affiliation(s)
- Toby Richards
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Christian Breymann
- Obstetric Research-Feto Maternal Haematology Unit, University Hospital Zurich, Zurich, Switzerland
| | - Matthew J. Brookes
- Gastroenterology Unit, Royal Wolverhampton NHS Trust, Wolverhampton, UK
- Research Institute in Healthcare Science (RIHS), University of Wolverhampton, Wolverhampton, UK
| | - Stefan Lindgren
- Department of Gastroenterology and Hepatology, Lund University, Skåne University Hospital, Malmö, Sweden
| | | | - Lawrence P. McMahon
- Departments of Renal Medicine and Obstetric Medicine, Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Malcolm G. Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Obstetrics and Gynecology, Kaiser-Permanente, Los Angeles Medical Center, Los Angeles, CA, USA
| | - Elizabeta Nemeth
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | - Ingolf Schiefke
- Department of Gastroenterology, Hepatology, Diabetology and Endocrinology, Klinikum St. Georg, Leipzig, Germany
| | - Günter Weiss
- Department of Internal Medicine II, Medical University Innsbruck, Innsbruck, Austria
- Christian Doppler Laboratory for Iron Metabolism and Anemia Research, University of Innsbruck, Innsbruck, Austria
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Boucher AA, Bedel A, Jones S, Lenahan SF, Geer R, McGann PT. A retrospective study of the safety and efficacy of low molecular weight iron dextran for children with iron deficiency anemia. Pediatr Blood Cancer 2021; 68:e29024. [PMID: 33769677 DOI: 10.1002/pbc.29024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Iron deficiency anemia (IDA) affects millions of children worldwide. Oral iron replacement is effective but often poorly tolerated. Intravenous iron has been demonstrated to have utility in all ages, but pediatric use remains limited. Low molecular weight iron dextran (LMWID) has a dosing range capable of replacing iron deficits in a single infusion and has been evaluated in small pediatric cohorts, but additional safety and efficacy data are limited. Here, we evaluate the safety and efficacy of LMWID in association with an electronic medical record (EMR)-based effort to optimize dosing. PROCEDURE A retrospective IRB-approved investigation of LMWID utilization at a tertiary pediatric hospital between January 1, 2016 and March 31, 2020 was undertaken to evaluate the therapeutic efficacy and frequency/severity of infusion-related adverse event (AE) in children and adolescents receiving LMWID. Patient demographics and LMWID dosing characteristics were collected, and primary outcome measures included laboratory response and the incidence/severity of any infusion-related events. The utilization of an EMR-based nomogram for LMWID dosing was also evaluated. RESULTS A total of 254 infusions for 191 patients were included (ages 0.7-20.9 years), most with IDA. LMWID replaced at least 75% of the estimated iron deficit in a single infusion for 76% of patients. The mean hemoglobin and ferritin increases were 2.1 g/dl and >100 ng/ml, respectively. Infusion-related AEs were rare, occurring in only 12/254 (4.7%) of infusions and 67% during the test dose; each rapidly resolved without long-term sequelae. No AEs occurred in those <10 years of age. Premedication use markedly decreased with nomogram use without a change in AE rate. CONCLUSIONS In a large institutional cohort, LMWID was well tolerated in children and adolescents, with most patients having their total iron deficits relieved in a single infusion. These data support expanded use of LMWID in the management of pediatric iron deficiency.
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Affiliation(s)
- Alexander A Boucher
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ashley Bedel
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sommer Jones
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stephanie F Lenahan
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rebecca Geer
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick T McGann
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Iron infusion and newer intravenous iron formulations. Chin Med J (Engl) 2021; 134:1889-1890. [PMID: 34054020 PMCID: PMC8367050 DOI: 10.1097/cm9.0000000000001525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Karwasra R, Singh S, Raza K, Sharma N, Varma S. A brief overview on current status of nanomedicines for treatment of pancytopenia: Focusing on chemotherapeutic regime. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2020.102159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Steveling-Klein EH, Mateluna CM, Meienberg A, Hartmann K, Bircher A, Scherer Hofmeier K. Management of Hypersensitivity Reactions to Nondextran Iron Products: New Insights Into Predisposing Risk Factors. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2406-2414.e2. [PMID: 33486145 DOI: 10.1016/j.jaip.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 12/14/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hypersensitivity reactions (HSRs) to nondextran iron products (NDIPs) are rare, but can manifest with severe signs and symptoms. Predisposing risk factors are not well understood. OBJECTIVE To characterize patients with HSRs to NDIPs, with a special focus on possible risk factors. METHODS We analyzed clinical characteristics of patients with HSRs to NDIPs referred to our allergy division between 2007 and 2019 compared with tolerant controls, including the type of the eliciting NDIP, severity and characteristics of the HSR, atopy status, history of allergies and urticaria, laboratory and skin test results, and outcome of reexposure with NDIPs. RESULTS We evaluated the data of 59 patients and 21 controls. Sixteen patients and 4 controls received the NDIP iron sucrose and 41 patients and 15 controls received ferric carboxymaltose. In 2 patients and in 2 controls, the culprit NDIP was not known. Twenty-seven patients (46%) experienced an anaphylactic reaction grade I, 15 (25%) a grade II reaction, and 17 (29%) a grade III reaction according to Ring and Messmer. On analyzing the history, we found that 22 patients (37%) and 3 controls (14%) reported previous HSRs to other medications. Interestingly, more than half the patients (n = 35 [59%]) compared with only 7 controls (33%) reported an episode of any type of urticaria in their previous history. Most patients (n = 15 [79%]) tolerated reexposure of an NDIP using a low-reactogenic administration protocol. CONCLUSIONS A history of drug hypersensitivity and urticaria represent potential risk factors for HSRs to NDIPs. On the basis of our findings, we propose an algorithm for practical management of patients receiving NDIPs aiming to prevent HSRs.
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Affiliation(s)
- Esther Helen Steveling-Klein
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland.
| | - Carlos Morales Mateluna
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andrea Meienberg
- Department of Internal Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas Bircher
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Kathrin Scherer Hofmeier
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
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Țigliș M, Neagu TP, Niculae A, Lascăr I, Grințescu IM. Incidence of Iron Deficiency and the Role of Intravenous Iron Use in Perioperative Periods. MEDICINA-LITHUANIA 2020; 56:medicina56100528. [PMID: 33053625 PMCID: PMC7601561 DOI: 10.3390/medicina56100528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 01/01/2023]
Abstract
Iron deficiency is a major problem in worldwide populations, being more alarming in surgical patients. In the presence of absolute iron deficiency (depletion of body iron), functional iron deficiency (during intense bone marrow stimulation by endogenous or exogenous factors), or iron sequestration (acute or chronic inflammatory conditions), iron-restricted erythropoiesis can develop. This systemic review was conducted to draw attention to the delicate problem of perioperative anemia, and to provide solutions to optimize the management of anemic surgical patients. Systemic reviews and meta-analyses, clinical studies and trials, case reports and international guidelines were studied, from a database of 50 articles. Bone marrow biopsy, serum ferritin levels, transferrin saturation, the mean corpuscular volume, and mean corpuscular hemoglobin concentration were used in the diagnosis of iron deficiency. There are various intravenous iron formulations, with different pharmacological profiles used for restoring iron. In surgical patients, anemia is an independent risk factor for morbidity and mortality. Therefore, anemia correction should be rapid, with parenteral iron formulations—the oral ones—being inefficient. Various studies showed the safety and efficacy of parenteral iron formulations in correcting hemoglobin levels and decreasing the blood transfusion rate, the overall mortality, the postoperative infections incidence, hospitalization days, and the general costs.
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Affiliation(s)
- Mirela Țigliș
- Department of Anaesthesiology and Intensive Care, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (M.Ț.); (I.M.G.)
- Clinical Department No. 14, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Tiberiu Paul Neagu
- Department of Plastic Surgery and Reconstructive Microsurgery, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania;
- Clinical Department No. 11, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Correspondence:
| | - Andrei Niculae
- Department of Nephrology and Dialysis, “St. John” Emergency Clinical Hospital, 042122 Bucharest, Romania;
- Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ioan Lascăr
- Department of Plastic Surgery and Reconstructive Microsurgery, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania;
- Clinical Department No. 11, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ioana Marina Grințescu
- Department of Anaesthesiology and Intensive Care, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (M.Ț.); (I.M.G.)
- Clinical Department No. 14, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Zhabchenko I. FOR A FEW STEPS TO..., OR HOW TO AVOID FOR IRON DEFICIENCY AT PREGNANCY. LITERATURE REVIEW. REPRODUCTIVE MEDICINE 2020. [DOI: 10.37800/rm2020-1-19(2)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The article presents modern data on the etiology, pathogenesis, diagnosis, prevention and treatment of iron deficiency anemia (IDA) and anemia of chronic disease, as well as their combination on the eve of and during pregnancy. The emphasis is made on the role of iron deficiency of any etiology in the development of obstetric and perinatal complications, especially its impact on the central nervous system formation and further psychophysical child development. Need for prevention of iron deficiency states in risk groups which includes all women of reproductive age who have menstruation is shown based on evidence-based medicine data. Effectiveness and safety of modern drugs containing iron in oral and parenteral forms has analyzed. The paper presents data on the safety and effectiveness of an innovative form of ferric iron in the form of liposomal iron, which differs in the mechanism of action, digestibility and the absence of side effects typical for this group of drugs. According to various authors the frequency of IDA in pregnant women ranges up to 80%, in puerperas up to 40%. It is unimpossible to stop IDA without iron supplementation only with an iron-rich diet. Two main groups of iron preparations are used to correct iron deficiency differing in the valence of iron atoms – bivalent iron salts and trivalent complexes. These drugs differ in the tolerability and bioavailability of atomic iron. Liposomal iron is a new drug for treatment of iron deficiency and IDA today; it has an innovative way of iron delivery to the body. Liposomal iron has advantages for the prevention of anemia in patients with anemia of chronic disease or its combination with IDA (inflammatory bowel diseases, obesity, after resection of the stomach and intestines, etc.). An innovative form of liposomal iron in Ukraine is represented by a dietary supplement Ferroview containing 30 mg of elemental iron, that is corresponds to the average prophylactic dose recommended in WHO documents.
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Penicillin causes non-allergic anaphylaxis by activating the contact system. Sci Rep 2020; 10:14160. [PMID: 32843685 PMCID: PMC7447753 DOI: 10.1038/s41598-020-71083-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 08/02/2020] [Indexed: 12/18/2022] Open
Abstract
Immediate hypersensitivity reaction (IHR) can be divided into allergic- and non-allergic-mediated, while “anaphylaxis” is reserved for severe IHR. Clinically, true penicillin allergy is rare and most reported penicillin allergy is “spurious”. Penicillin-initiated anaphylaxis is possible to occur in skin test- and specific IgE-negative patients. The contact system is a plasma protease cascade initiated by activation of factor XII (FXII). Many agents with negative ion surface can activate FXII to drive contact system. Our data showed that penicillin significantly induced hypothermia in propranolol- or pertussis toxin-pretreated mice. It also caused a rapid and reversible drop in rat blood pressure, which did not overlap with IgE-mediated hypotension. These effects could be countered by a bradykinin-B2 receptor antagonist icatibant, and consistently, penicillin indeed increased rat plasma bradykinin. Moreover, penicillin not only directly activated contact system FXII-dependently, but also promoted bradykinin release in plasma incubated-human umbilical vein endothelial cells. In fact, besides penicillin, other beta-lactams also activated the contact system in vitro. Since the autoactivation of FXII can be affected by multiple-factors, plasma from different healthy individuals showed vastly different amidolytic activity in response to penicillin, suggesting the necessity of determining the potency of penicillin to induce individual plasma FXII activation. These results clarify that penicillin-initiated non-allergic anaphylaxis is attributed to contact system activation, which might bring more effective diagnosis options for predicting penicillin-induced fatal risk and avoiding costly and inappropriate treatment clinically.
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Iron Deficiency Anemia in Children Residing in High and Low-Income Countries: Risk Factors, Prevention, Diagnosis and Therapy. Mediterr J Hematol Infect Dis 2020; 12:e2020041. [PMID: 32670519 PMCID: PMC7340216 DOI: 10.4084/mjhid.2020.041] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/12/2020] [Indexed: 12/22/2022] Open
Abstract
Iron deficiency and iron-deficiency anemia (IDA) affects approximately two billion people worldwide, and most of them reside in low- and middle-income countries. In these nations, additional causes of anemia include parasitic infections like malaria, other nutritional deficiencies, chronic diseases, hemoglobinopathies, and lead poisoning. Maternal anemia in resource-poor nations is associated with low birth weight, increased perinatal mortality, and decreased work productivity. Maintaining a normal iron balance in these settings is challenging, as iron-rich foods with good bioavailability are of animal origin and either expensive and/or available in short supply. Apart from infrequent consumption of meat, inadequate vitamin C intake, and diets rich in inhibitors of iron absorption are additional important risk factors for IDA in low-income countries. In-home iron fortification of complementary foods with micronutrient powders has been shown to effectively reduce the risk of iron deficiency and IDA in infants and young children in developing countries but is associated with unfavorable changes in gut flora and induction of intestinal inflammation that may lead to diarrhea and hospitalization. In developed countries, iron deficiency is the only frequent micronutrient deficiency. In the industrialized world, IDA is more common in infants beyond the sixth month of life, in adolescent females with heavy menstrual bleeding, in women of childbearing age and older people. Other special at-risk populations for IDA in developed countries are regular blood donors, endurance athletes, and vegetarians. Several medicinal ferrous or ferric oral iron products exist, and their use is not associated with harmful effects on the overall incidence of infectious illnesses in sideropenic and/or anemic subjects. However, further research is needed to clarify the risks and benefits of supplemental iron for children exposed to parasitic infections in low-income countries, and for children genetically predisposed to iron overload.
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Achebe M, DeLoughery TG. Clinical data for intravenous iron - debunking the hype around hypersensitivity. Transfusion 2020; 60:1154-1159. [PMID: 32479668 PMCID: PMC7384172 DOI: 10.1111/trf.15837] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/13/2020] [Accepted: 02/26/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Reluctance to use intravenous (IV) iron for the treatment of iron deficiency continues due to a perceived high risk of severe hypersensitivity reactions (HSRs). Additionally, it has been hypothesized that 'dextran-derived' IV iron products (e.g., ferumoxytol [FER] and ferric derisomaltose/iron isomaltoside 1000 [FDI]) have a higher risk of severe HSRs than 'non-dextran-derived' products (e.g., ferric carboxymaltose [FCM] and iron sucrose [IS]). In the present analysis, HSR data from head-to-head randomized controlled trials (RCTs) with IV iron products were evaluated to determine if differences in safety signals are present among these IV iron formulations. STUDY DESIGN AND METHODS Reported serious or moderate-to-severe HSR incidence data from five RCTs (FIRM; FERWON-NEPHRO/-IDA; PHOSPHARE-IDA04/-IDA05) were used to calculate risk differences with 95% confidence intervals (CIs) for FER, FCM, FDI, and IS. The rates and risk differences for these HSRs were compared. RESULTS The analysis included data for 5247 patients: FER (n = 997), FCM (n = 1117), FDI (n = 2133) and IS (n = 1000). Overall rates of serious or moderate to severe HSRs were low (0.2%-1.7%). The risk differences (95% CIs) showed small differences between the IV iron formulations: FER versus FCM, -0.1 (-0.8 to 0.6); FDI versus IS, 0.1 (-0.3 to 0.5); FDI versus FCM, -0.9 (-3.7 to 1.9). CONCLUSION RCT evidence confirms a low risk of serious or moderate to severe HSRs with newer IV iron formulations and no significant differences among existing commercially available products. Thus, RCT data show that the supposed classification of dextran-derived versus non-dextran-derived IV iron products has no clinical relevance.
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Affiliation(s)
- Maureen Achebe
- Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Thomas G DeLoughery
- Department of Hematology and Medical Oncology, Knight Cancer Center, Oregon Health Sciences University, Portland, Oregon
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Wesström J. Safety of intravenous iron isomaltoside for iron deficiency and iron deficiency anemia in pregnancy. Arch Gynecol Obstet 2020; 301:1127-1131. [PMID: 32270330 PMCID: PMC7181549 DOI: 10.1007/s00404-020-05509-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/12/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the efficacy and safety for mother and child of using intravenous iron isomaltoside (IV-IIM) during pregnancy. METHODS Using an appointment register, we retrospectively identified all pregnant women who received a single dose of 1000 or 1500 mg IV-IIM in the maternity ward of Falu Hospital and subsequently gave birth between August 6, 2013 and July 31, 2018. Women who received IV-IIM (case group) were individually matched with pregnant women who did not receive IV-IIM (control group) by delivery date, maternal age (± 2 years), and parity. Adverse drug reactions (ADRs), demographic characteristics, hemoglobin and s-ferritin counts, pregnancy and delivery complications, and infant data (APGAR score, pH at umbilical artery, birthweight, birth length, intrauterine growth restriction and neonatal ward admission). Data were obtained from electronic patient charts. SPSS was used for descriptive statistics. RESULTS During the 5-year period, 213 women each received a single administration of IV-IIM. Ten (4.7%) ADRs occurred during IV-IIM administration. All ADRs were mild hypersensitivity reactions, abated spontaneously within a few minutes, and did not recur on rechallenge. No association between IIM dose and ADR frequency was noted. Maternal and fetal outcomes, including hemoglobin counts at delivery and postpartum, were similar in the case and control groups. CONCLUSION These results support the convenience, safety, and efficacy of a single high-dose (up to 1500 mg) infusion of IV-IIM for iron deficiency or iron deficiency anemia during pregnancy.
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Affiliation(s)
- Jan Wesström
- Department of Obstetrics and Gynecology, Center for Clinical Research Dalarna, Falun Hospital, Falun, Sweden.
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
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Elstrott B, Khan L, Olson S, Raghunathan V, DeLoughery T, Shatzel JJ. The role of iron repletion in adult iron deficiency anemia and other diseases. Eur J Haematol 2020; 104:153-161. [PMID: 31715055 PMCID: PMC7031048 DOI: 10.1111/ejh.13345] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/26/2019] [Accepted: 10/29/2019] [Indexed: 12/21/2022]
Abstract
Iron deficiency anemia (IDA) is the most prevalent and treatable form of anemia worldwide. The clinical management of patients with IDA requires a comprehensive understanding of the many etiologies that can lead to iron deficiency including pregnancy, blood loss, renal disease, heavy menstrual bleeding, inflammatory bowel disease, bariatric surgery, or extremely rare genetic disorders. The treatment landscape for many causes of IDA is currently shifting toward more abundant use of intravenous (IV) iron due to its effectiveness and improved formulations that decrease the likelihood of adverse effects. IV iron has found applications beyond treatment of IDA, and there is accruing data about its efficacy in patients with heart failure, restless leg syndrome, fatigue, and prevention of acute mountain sickness. This review provides a framework to diagnose, manage, and treat patients presenting with IDA and discusses other conditions that benefit from iron supplementation.
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Affiliation(s)
- Benjamin Elstrott
- Division of Hematology-Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Lubna Khan
- Division of Hematology-Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Sven Olson
- Division of Hematology-Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Vikram Raghunathan
- Division of Hematology-Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Thomas DeLoughery
- Division of Hematology-Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Joseph J. Shatzel
- Division of Hematology-Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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A Review of Intravenous Iron Replacement Medications for Nurse Practitioners. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2019.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Nguyen KL, Yoshida T, Kathuria-Prakash N, Zaki IH, Varallyay CG, Semple SI, Saouaf R, Rigsby CK, Stoumpos S, Whitehead KK, Griffin LM, Saloner D, Hope MD, Prince MR, Fogel MA, Schiebler ML, Roditi GH, Radjenovic A, Newby DE, Neuwelt EA, Bashir MR, Hu P, Finn JP. Multicenter Safety and Practice for Off-Label Diagnostic Use of Ferumoxytol in MRI. Radiology 2019; 293:554-564. [PMID: 31638489 PMCID: PMC6884068 DOI: 10.1148/radiol.2019190477] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/01/2019] [Accepted: 08/26/2019] [Indexed: 01/29/2023]
Abstract
Background Ferumoxytol is approved for use in the treatment of iron deficiency anemia, but it can serve as an alternative to gadolinium-based contrast agents. On the basis of postmarketing surveillance data, the Food and Drug Administration issued a black box warning regarding the risks of rare but serious acute hypersensitivity reactions during fast high-dose injection (510 mg iron in 17 seconds) for therapeutic use. Whereas single-center safety data for diagnostic use have been positive, multicenter data are lacking. Purpose To report multicenter safety data for off-label diagnostic ferumoxytol use. Materials and Methods The multicenter ferumoxytol MRI registry was established as an open-label nonrandomized surveillance databank without industry involvement. Each center monitored all ferumoxytol administrations, classified adverse events (AEs) using the National Cancer Institute Common Terminology Criteria for Adverse Events (grade 1-5), and assessed the relationship of AEs to ferumoxytol administration. AEs related to or possibly related to ferumoxytol injection were considered adverse reactions. The core laboratory adjudicated the AEs and classified them with the American College of Radiology (ACR) classification. Analysis of variance was used to compare vital signs. Results Between January 2003 and October 2018, 3215 patients (median age, 58 years; range, 1 day to 96 years; 1897 male patients) received 4240 ferumoxytol injections for MRI. Ferumoxytol dose ranged from 1 to 11 mg per kilogram of body weight (≤510 mg iron; rate ≤45 mg iron/sec). There were no systematic changes in vital signs after ferumoxytol administration (P > .05). No severe, life-threatening, or fatal AEs occurred. Eighty-three (1.9%) of 4240 AEs were related or possibly related to ferumoxytol infusions (75 mild [1.8%], eight moderate [0.2%]). Thirty-one AEs were classified as allergiclike reactions using ACR criteria but were consistent with minor infusion reactions observed with parenteral iron. Conclusion Diagnostic ferumoxytol use was well tolerated, associated with no serious adverse events, and implicated in few adverse reactions. Registry results indicate a positive safety profile for ferumoxytol use in MRI. © RSNA, 2019 Online supplemental material is available for this article.
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Affiliation(s)
- Kim-Lien Nguyen
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Takegawa Yoshida
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Nikhita Kathuria-Prakash
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Islam H. Zaki
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Csanad G. Varallyay
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Scott I. Semple
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Rola Saouaf
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Cynthia K. Rigsby
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Sokratis Stoumpos
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Kevin K. Whitehead
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Lindsay M. Griffin
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - David Saloner
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Michael D. Hope
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Martin R. Prince
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Mark A. Fogel
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Mark L. Schiebler
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Giles H. Roditi
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Aleksandra Radjenovic
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - David E. Newby
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Edward A. Neuwelt
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Mustafa R. Bashir
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - Peng Hu
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
| | - J. Paul Finn
- From the Diagnostic Cardiovascular Imaging Research Laboratory, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 300 Medical Plaza, Suite B119, Los Angeles, CA 90095 (K.L.N., T.Y., P.H., J.P.F.); Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, Calif (K.L.N., N.K.); Department of Radiology (I.H.Z., M.R.B.), Center for Advanced Magnetic Resonance Development (I.H.Z., M.R.B.), and Division of Gastroenterology, Department of Medicine (M.R.B.), Duke University Medical Center, Durham, NC; Department of Diagnostic Radiology and Neurology, Oregon Health Sciences University, Portland, Ore (C.G.V.); British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland (S.I.S., D.E.N.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (R.S.); Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Ill (C.K.R., L.M.G.); Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (C.K.R., L.M.G.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (S.S., A.R.); Division of Cardiology, Department of Pediatrics and Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (K.K.W., M.A.F.); Department of Radiology, University of Wisconsin, Madison, Wis (L.M.G., M.L.S.); Department of Radiology, University of California, San Francisco and VA San Francisco Healthcare System, San Francisco, Calif (D.S., M.D.H.); Department of Radiology, Weill Medical College of Cornell University, New York, NY (M.R.P.); Department of Radiology, NHS Greater Glasgow and Clyde, and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland (G.H.R.); and Department of Neurology and Neurosurgery, Oregon Health Sciences University and VA Portland Healthcare System, Portland, Ore (E.A.N.)
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Strategy to prevent cardiac toxicity induced by polyacrylic acid decorated iron MRI contrast agent and investigation of its mechanism. Biomaterials 2019; 222:119442. [DOI: 10.1016/j.biomaterials.2019.119442] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/30/2019] [Accepted: 08/20/2019] [Indexed: 12/11/2022]
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Karki NR, Auerbach M. Single total dose infusion of ferumoxytol (1020 mg in 30 minutes) is an improved method of administration of intravenous iron. Am J Hematol 2019; 94:E229-E231. [PMID: 31155744 DOI: 10.1002/ajh.25548] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 05/29/2019] [Accepted: 05/29/2019] [Indexed: 12/13/2022]
Affiliation(s)
| | - Michael Auerbach
- Auerbach Hematology and Oncology Baltimore Maryland
- Department of MedicineGeorgetown University School of Medicine Washington District of Columbia
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Lim W, Afif W, Knowles S, Lim G, Lin Y, Mothersill C, Nistor I, Rehman F, Song C, Xenodemetropoulos T. Canadian expert consensus: management of hypersensitivity reactions to intravenous iron in adults. Vox Sang 2019; 114:363-373. [PMID: 30937914 PMCID: PMC6850285 DOI: 10.1111/vox.12773] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/31/2019] [Accepted: 02/25/2019] [Indexed: 12/11/2022]
Abstract
Background and Objectives Rare but potentially life‐threatening hypersensitivity reactions can occur during the administration of intravenous iron. To provide guidance to healthcare professionals caring for adults receiving intravenous iron, a panel of 10 Canadian clinical experts developed a practical algorithm for the identification and management of hypersensitivity reactions to intravenous iron. Materials and methods A systematic search of PubMed to February 2018 was performed. Articles related to hypersensitivity reactions were selected for review. The algorithm was developed during a 1‐day live meeting based on the literature review and clinical expertise where evidence was lacking. The algorithm was then refined through an iterative process involving a web‐based platform and virtual meetings. Results The algorithm provides guidance to healthcare professionals in preparing for and administering IV iron, as well as recognizing and managing hypersensitivity reactions to intravenous iron. Considerations for re‐challenging patients who have experienced prior reactions are provided. Conclusion Healthcare professionals who are involved in the care of patients receiving intravenous iron should be trained to anticipate, recognize and manage hypersensitivity reactions to intravenous iron to optimize patient care.
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Affiliation(s)
- Wendy Lim
- Department of Medicine, Division of Hematology and Thromboembolism, St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | - Waqqas Afif
- Department of Medicine, Division of Gastroenterology and Hepatology, Montreal General Hospital, McGill University, Montreal, QC, Canada
| | - Sandra Knowles
- Department of Pharmacy, Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Gloria Lim
- Department of Medicine, Division of Hematology and Oncology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Charmaine Mothersill
- Department of Medicine, Division of Hematology and Oncology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Irina Nistor
- Department of Gastroenterology and Hepatology, Halton Healthcare Services, Oakville, ON, Canada.,Queen's University, Kingston, ON, Canada
| | - Faisal Rehman
- Department of Medicine, Division of Nephrology, University Hospital, London Health Sciences Centre, Western University, London, ON, Canada
| | - Christine Song
- Department of Medicine, Division of Allergy and Immunology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Ted Xenodemetropoulos
- Department of Medicine, Division of Gastroenterology, McMaster University Medical Centre, McMaster University, Hamilton, ON, Canada
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Ferumoxytol magnetic resonance angiography: a dose-finding study in patients with chronic kidney disease. Eur Radiol 2019; 29:3543-3552. [PMID: 30919067 PMCID: PMC6554242 DOI: 10.1007/s00330-019-06137-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 02/17/2019] [Accepted: 03/07/2019] [Indexed: 12/24/2022]
Abstract
Objectives Ferumoxytol is an alternative to gadolinium-based compounds as a vascular contrast agent for magnetic resonance angiography (MRA), particularly for patients with chronic kidney disease (CKD). However, dose-related efficacy data are lacking. We aimed to determine the optimal (minimum effective) dose of ferumoxytol for MRA in patients with CKD. Methods Ferumoxytol-enhanced MRA (FeMRA) was performed at 3.0 T in patients with CKD after dose increments up to a total of 4 mg/kg. Image quality was assessed by contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) in the abdominal aorta and inferior vena cava. Quadratic regression analyses were performed to estimate the effects of dose increments on CNR and SNR. Results Twenty-three patients underwent FeMRA (mean age 60 [SD 13] years, 87% men, 48% had diabetic nephropathy) with cumulative doses of 0, 1, 2, 3 and 4 mg/kg of ferumoxytol. On regression analyses, a parabolic relationship was observed between ferumoxytol dose and signal with progressive signal loss using doses exceeding 4 mg/kg. A dose of 3 mg/kg achieved ≥ 75% of predicted peak CNR and SNR and images were deemed of excellent diagnostic quality. Conclusions In patients with CKD undergoing FeMRA, a dose of 3 mg/kg provides excellent arterial and venous enhancement. The benefits of increasing the dose to a theoretically optimal value of 4 mg/kg appear to be negligible and likely of minimal, if any, diagnostic value. Key Points • Ferumoxytol is used off-label as an MRI contrast agent but dose-related data are lacking. • In patients with CKD requiring MR angiography, a dose of 3 mg/kg provides excellent vascular enhancement. Electronic supplementary material The online version of this article (10.1007/s00330-019-06137-4) contains supplementary material, which is available to authorized users.
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Mulder MB, van den Hoek HL, Birnie E, van Tilburg AJP, Westerman EM. Comparison of hypersensitivity reactions of intravenous iron: iron isomaltoside-1000 (Monofer ® ) versus ferric carboxy-maltose (Ferinject ® ). A single center, cohort study. Br J Clin Pharmacol 2018; 85:385-392. [PMID: 30393904 DOI: 10.1111/bcp.13805] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 10/06/2018] [Accepted: 10/24/2018] [Indexed: 12/16/2022] Open
Abstract
AIMS Intravenous iron supplementation is widely used to treat iron deficiency and iron deficiency anemia when oral iron administration is ineffective or poorly tolerated. Hypersensitivity reactions (HSRs) during infusions are rare, but can be life-threatening. This study aimed to compare the risk for HSRs with the intravenous administration of iron isomaltoside-1000 and ferric carboxymaltose for the treatment of iron deficiency and iron deficiency anemia. METHODS This was a single-centre cohort study. Nurses and physicians were instructed to fill out an HSR registration form with every administration of intravenous iron. HSRs were distinguished into serious and non-serious HSRs using the Ring and Messmer classification. RESULTS HSRs occurred in 18/836 (2.1%) ferric carboxymaltose and 43/496 (8.7%) iron isomaltoside-1000 administrations. The crude risk for HSRs was 75% lower after ferric carboxymaltose treatment (RR = 0.248, 95% CI: 0.145-0.426, P < 0.0001). The risk for grade II HSRs was 88% lower after ferric carboxymaltoside (RR = 0.123, 95% CI: 0.051-0.294). The likelihood of HSRs was 3.4 times higher after the administration of iron isomaltoside-1000 (95% CI: 1.910-6.093, P < 0.0001). Regardless of the type of intravenous iron, patients with comorbidities have a factor 3.6 higher risk (95% CI: 1.899-6.739, P < 0.0001). CONCLUSIONS Ferric carboxymaltose is associated with a 75% lower risk for HSRs compared with iron isomaltoside-1000 in our population. The presence of a comorbidity raises the likelihood of an HSR by a factor of three regardless of the type of intravenous iron infusion. Further research is needed to clarify the underlying mechanism in various patient groups.
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Affiliation(s)
- Midas B Mulder
- Department of Clinical Pharmacy, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Hester L van den Hoek
- Central Hospital Pharmacy, The Hague, The Netherlands.,Department of Clinical Pharmacy, Haaglanden Medical Center, The Hague, the Netherlands
| | - Erwin Birnie
- Department of Statistics and Education, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.,Department of Obstetrics, Division Women and Baby, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Elsbeth M Westerman
- Department of Clinical Pharmacy, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
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Prevention and management of acute reactions to intravenous iron in surgical patients. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 17:137-145. [PMID: 30418128 DOI: 10.2450/2018.0156-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/26/2018] [Indexed: 12/17/2022]
Abstract
Absolute or functional iron deficiency is the most prevalent cause of anaemia in surgical patients, and its correction is a fundamental strategy within "Patient Blood Management" programmes. Offering perioperative oral iron for treating iron deficiency anaemia is still recommended, but intravenous iron has been demonstrated to be superior in most cases. However, the long-standing prejudice against intravenous iron administration, which is thought to induce anaphylaxis, hypotension and shock, still persists. With currently available intravenous iron formulations, minor infusion reactions are not common. These self-limited reactions are due to labile iron and not hypersensitivity. Aggressively treating infusion reactions with H1-antihistamines or vasopressors should be avoided. Self-limited hypotension during intravenous iron infusion could be considered to be due to hypersensitivity or vascular reaction to labile iron. Acute hypersensitivity reactions to current intravenous iron formulation are believed to be caused by complement activation-related pseudo-allergy. However, though exceedingly rare (<1:250,000 administrations), they should not be ignored, and intravenous iron should be administered only at facilities where staff is trained to evaluate and manage these reactions. As preventive measures, prior to the infusion, staff should inform all patients about infusion reactions and identify those patients with increased risk of hypersensitivity or contraindications for intravenous iron. Infusion should be started at a low rate for a few minutes. In the event of a reaction, the very first intervention should be the immediate cessation of the infusion, followed by evaluation of severity and treatment. An algorithm to scale the intensity of treatment to the clinical picture and/or response to therapy is presented.
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Ramasawmy R, Rogers T, Alcantar MA, McGuirt DR, Khan JM, Kellman P, Xue H, Faranesh AZ, Campbell-Washburn AE, Lederman RJ, Herzka DA. Blood volume measurement using cardiovascular magnetic resonance and ferumoxytol: preclinical validation. J Cardiovasc Magn Reson 2018; 20:62. [PMID: 30201013 PMCID: PMC6131893 DOI: 10.1186/s12968-018-0486-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/20/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The hallmark of heart failure is increased blood volume. Quantitative blood volume measures are not conveniently available and are not tested in heart failure management. We assess ferumoxytol, a marketed parenteral iron supplement having a long intravascular half-life, to measure the blood volume with cardiovascular magnetic resonance (CMR). METHODS Swine were administered 0.7 mg/kg ferumoxytol and blood pool T1 was measured repeatedly for an hour to characterize contrast agent extraction and subsequent effect on Vblood estimates. We compared CMR blood volume with a standard carbon monoxide rebreathing method. We then evaluated three abbreviated acquisition protocols for bias and precision. RESULTS Mean plasma volume estimated by ferumoxytol was 61.9 ± 4.3 ml/kg. After adjustment for hematocrit the resultant mean blood volume was 88.1 ± 9.4 ml/kg, which agreed with carbon monoxide measures (91.1 ± 18.9 ml/kg). Repeated measurements yielded a coefficient of variation of 6.9%, and Bland-Altman repeatability coefficient of 14%. The blood volume estimates with abbreviated protocols yielded small biases (mean differences between 0.01-0.06 L) and strong correlations (r2 between 0.97-0.99) to the reference values indicating clinical feasibility. CONCLUSIONS In this swine model, ferumoxytol CMR accurately measures plasma volume, and with correction for hematocrit, blood volume. Abbreviated protocols can be added to diagnostic CMR examination for heart failure within 8 min.
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Affiliation(s)
- Rajiv Ramasawmy
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
| | - Toby Rogers
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
| | - Miguel A. Alcantar
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
| | - Delaney R. McGuirt
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
| | - Jaffar M. Khan
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
| | - Peter Kellman
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
| | - Hui Xue
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
| | - Anthony Z. Faranesh
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
| | - Adrienne E. Campbell-Washburn
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
| | - Robert J. Lederman
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
| | - Daniel A. Herzka
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Building 10, Room 2C713, 10 Center Drive, Bethesda, MD 20892 USA
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Boucher AA, Pfeiffer A, Bedel A, Young J, McGann PT. Utilization trends and safety of intravenous iron replacement in pediatric specialty care: A large retrospective cohort study. Pediatr Blood Cancer 2018; 65:e26995. [PMID: 29369486 DOI: 10.1002/pbc.26995] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 12/19/2017] [Accepted: 01/02/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Iron deficiency is a common and clinically diverse hematologic disorder in childhood for which oral iron is often an infeasible or ineffective treatment option. Intravenous (IV) iron can be an efficient and highly successful means of iron replacement but its use has not been well-characterized on a large scale in pediatrics. PROCEDURE All IV iron doses administered to patients for iron replacement therapy at a tertiary pediatric hospital from January 2010 through October 2016 were evaluated. Analyses included patient demographics, underlying medical conditions, and detailed information for each dose. Individual chart review was performed to identify infusion-related reactions. Nephrology patients as well as those patients 21 years or older at the time of the first infusion were excluded. RESULTS A total of 1,088 doses of IV iron administered to 194 patients met inclusion criteria. A wide variety of specialties prescribed IV iron, with gastroenterology, hematology, and hospital medicine being the highest users in this cohort. A majority of patients (68%) required multiple infusions and dosing was highly variable, ranging from 1.3-1,030 mg per infusion. Premedication use was infrequent (10.3% of doses) and no severe infusion-associated reactions occurred. CONCLUSIONS IV iron is commonly prescribed by certain pediatric specialties but there is little standardization in the indications, formulations, or dosing. These data suggest that IV iron should be considered a safe alternative for iron deficiency treatment in pediatrics when oral iron is either unsuccessful or contraindicated.
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Affiliation(s)
- Alexander A Boucher
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amanda Pfeiffer
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashley Bedel
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer Young
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patrick T McGann
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Current misconceptions in diagnosis and management of iron deficiency. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 15:422-437. [PMID: 28880842 DOI: 10.2450/2017.0113-17] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 06/30/2017] [Indexed: 12/15/2022]
Abstract
The prevention and treatment of iron deficiency is a major public health goal. Challenges in the treatment of iron deficiency include finding and addressing the underlying cause and the selection of an iron replacement product which meets the needs of the patient. However, there are a number of non-evidence-based misconceptions regarding the diagnosis and management of iron deficiency, with or without anaemia, as well as inconsistency of terminology and lack of clear guidance on clinical pathways. In particular, the pathogenesis of iron deficiency is still frequently not addressed and iron not replaced, with indiscriminate red cell transfusion used as a default therapy. In our experience, this imprudent practice continues to be endorsed by non-evidence-based misconceptions. The intent of the authors is to provide a consensus that effectively challenges these misconceptions, and to highlight evidence-based alternatives for appropriate management (referred to as key points). We believe that this approach to the management of iron deficiency may be beneficial for both patients and healthcare systems. We stress that this paper solely presents the Authors' independent opinions. No pharmaceutical company funded or influenced the conception, development or writing of the manuscript.
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Adkinson NF, Strauss WE, Macdougall IC, Bernard KE, Auerbach M, Kaper RF, Chertow GM, Krop JS. Comparative safety of intravenous ferumoxytol versus ferric carboxymaltose in iron deficiency anemia: A randomized trial. Am J Hematol 2018; 93:683-690. [PMID: 29417614 PMCID: PMC5947731 DOI: 10.1002/ajh.25060] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 12/17/2022]
Abstract
Few trials have examined rates of hypersensitivity reactions (HSRs) with intravenous iron formulations used to treat iron deficiency anemia (IDA). This randomized, multicenter, double‐blind clinical trial compared the safety, and efficacy of ferumoxytol versus ferric carboxymaltose (FCM), focusing on rates of HSRs and hypotension as the primary end point. Patients with IDA of any etiology in whom oral iron was unsatisfactory or intolerable received ferumoxytol (n = 997) or FCM (n = 1000) intravenously over ≥15 minutes on days 1 and 8 or 9 for total respective doses of 1.02 g and 1.50 g. Composite incidences of moderate‐to‐severe HSRs, including anaphylaxis, or moderate‐to‐severe hypotension from baseline to week 5 (primary safety end point) were 0.6% and 0.7% in the ferumoxytol and FCM groups, respectively, with ferumoxytol noninferior to FCM. No anaphylaxis was reported in either group. The secondary safety end point of incidences of moderate‐to‐severe HSRs, including anaphylaxis, serious cardiovascular events, and death from baseline to week 5 were 1.3% and 2.0% in the ferumoxytol and FCM groups, respectively (noninferiority test P < .0001). Least‐squares mean changes in hemoglobin at week 5 were 1.4 g/dL and 1.6 g/dL in the ferumoxytol and FCM groups, respectively (noninferiority test P < .0001). Incidence of hypophosphatemia was 0.4% for ferumoxytol and 38.7% for FCM.
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Affiliation(s)
| | | | | | | | - Michael Auerbach
- Auerbach Hematology and Oncology; Baltimore Maryland
- Georgetown University School of Medicine; DC Washington
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Khalafallah AA, Hyppa A, Chuang A, Hanna F, Wilson E, Kwok C, Yan C, Gray Z, Mathew R, Falloon P, Dennis A, Pavlov T, Allen JC. A Prospective Randomised Controlled Trial of a Single Intravenous Infusion of Ferric Carboxymaltose vs Single Intravenous Iron Polymaltose or Daily Oral Ferrous Sulphate in the Treatment of Iron Deficiency Anaemia in Pregnancy. Semin Hematol 2018; 55:223-234. [PMID: 30502851 DOI: 10.1053/j.seminhematol.2018.04.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/11/2018] [Indexed: 11/11/2022]
Abstract
Iron deficiency anaemia (IDA) is the most common nutritional deficiency affecting pregnant women worldwide. This study aims to compare the efficacy and safety of a newly available intravenous (IV) iron preparation, ferric carboxymaltose (FCM), against IV iron polymaltose (IPM), and standard oral iron (ferrous sulphate) for the treatment of IDA in pregnancy. This is an open-labelled prospective randomised controlled trial (RCT) with intention-to-treat analysis conducted at a primary health care facility with a single tertiary referral centre in Launceston. Tasmania, Australia. A 3-arm randomised controlled trial was conducted comparing a single IV infusion of 1000mg of FCM (n = 83 patients) over 15 minutes against a single IV infusion of 1000mg of IPM (n = 82) over 2 hours against 325mg daily oral ferrous sulphate (n = 81) until delivery, for the treatment of IDA in pregnancy. A total of 246 consecutive pregnant women were recruited between September 2013 and July 2014. The median age was 28 years, with a median and mean gestation of 27 weeks. The median serum ferritin was 9µg/L, with a mean of 13µg/L. The mean haemoglobin (Hb) was 114g/L. The primary outcome was the change in ferritin and Hb levels at 4 weeks after intervention. Secondary outcomes included ferritin and Hb improvements at predelivery, safety, tolerability, quality of life (QoL), cost utility, and fetal outcomes. The mean Hb level differences between the baseline intervention time point and 4 weeks thereafter were significantly higher in the FCM versus the oral group by 4.35g/L (95% CI: 1.64-7.05; P = 0.0006) and in the IPM vs the oral group by 4.08g/L (95% CI: 1.57-6.60; P = 0.0005), but not different between the FCM and IPM groups (0.26g/L; 95% CI: -2.59 to 3.11; P = 0.9740). The mean ferritin level differences were significantly higher at 4 weeks in the FCM vs oral iron group by 166µg/L (95% CI: 138-194; P < 0.0001) and in the IPM vs oral iron group by 145µg/L (95% CI: 109-1180, P < 0.0001), but not between the 2 IV groups (21.5µg/L; 95% CI: -23.9 to 66.9; P = 0.4989). Administration of IV FCM during pregnancy was safe and better tolerated than IV IPM or oral iron. Compliance to oral iron was the lowest amongst treatment groups with one-third of the patients missing doses of daily iron tablets. Significant improvement in overall QoL scores was observed in both IV iron supplement groups by achieving normal ferritin following effective and prompt repletion of iron stores, compared to the oral iron group (P = 0.04, 95% CI: 21.3, 1.8). The overall cost utility of IV FCM and IV IPM appear to be similar to oral iron. There were no differences in the fetal outcomes between the 3 trial arms. In conclusion, this study demonstrates that a single IV iron infusion is an effective and safe option for treatment of IDA during pregnancy. FCM was more convenient than other treatments. Rapid parenteral iron repletion can improve iron stores, Hb levels and QoL in pregnant women, with ongoing benefits until delivery. Integration of IV iron for IDA in pregnancy can potentially improve pregnancy outcomes for the mother. Update of guidelines to integrate the use of new IV iron preparations in pregnancy is warranted.
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Affiliation(s)
- Alhossain A Khalafallah
- Menzies Institute for Medical Research, University of Tasmania, Launceston, Tasmania, Australia; Department of Haematology, Launceston General Hospital, Launceston, Tasmania, Australia.
| | - Annemarie Hyppa
- Department of Haematology, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Anthony Chuang
- Department of Obstetrics and Gynaecology, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Fayez Hanna
- Faculty of Health Sciences, University of Tasmania, Launceston, Tasmania, Australia
| | - Emily Wilson
- Department of Obstetrics and Gynaecology, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Christine Kwok
- Department of Obstetrics and Gynaecology, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Carl Yan
- Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Zara Gray
- Department of Obstetrics and Gynaecology, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Ronnie Mathew
- Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Peter Falloon
- Pharmacy Department, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Amanda Dennis
- Department of Obstetrics and Gynaecology, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Toly Pavlov
- Department of Obstetrics and Gynaecology, Launceston General Hospital, Launceston, Tasmania, Australia
| | - John Carson Allen
- Duke-NUS Medical School Singapore, Centre for Quantitative Medicine, Office of Clinical Sciences, The Academia, Singapore, Singapore
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Nielsen OH, Soendergaard C, Vikner ME, Weiss G. Rational Management of Iron-Deficiency Anaemia in Inflammatory Bowel Disease. Nutrients 2018; 10:nu10010082. [PMID: 29342861 PMCID: PMC5793310 DOI: 10.3390/nu10010082] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/09/2018] [Accepted: 01/11/2018] [Indexed: 02/06/2023] Open
Abstract
Anaemia is the most frequent, though often neglected, comorbidity of inflammatory bowel disease (IBD). Here we want to briefly present (1) the burden of anaemia in IBD, (2) its pathophysiology, which mostly arises from bleeding-associated iron deficiency, followed by (3) diagnostic evaluation of anaemia, (4) a balanced overview of the different modes of iron replacement therapy, (5) evidence for their therapeutic efficacy and subsequently, (6) an updated recommendation for the practical management of anaemia in IBD. Following the introduction of various intravenous iron preparations over the last decade, questions persist about when to use these preparations as opposed to traditional and other novel oral iron therapeutic agents. At present, oral iron therapy is generally preferred for patients with quiescent IBD and mild iron-deficiency anaemia. However, in patients with flaring IBD that hampers intestinal iron absorption and in those with inadequate responses to or side effects with oral preparations, intravenous iron supplementation is the therapy of choice, although information on the efficacy of intravenous iron in patients with active IBD and anaemia is scare. Importantly, anaemia in IBD is often multifactorial and a careful diagnostic workup is mandatory for optimized treatment. Nevertheless, limited information is available on optimal therapeutic start and end points for treatment of anaemia. Of note, neither oral nor intravenous therapies seem to exacerbate the clinical course of IBD. However, additional prospective studies are still warranted to determine the optimal therapy in complex conditions such as IBD.
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Affiliation(s)
- Ole Haagen Nielsen
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, DK-2730, Denmark.
| | - Christoffer Soendergaard
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, DK-2730, Denmark.
| | - Malene Elbaek Vikner
- Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, DK-2730, Denmark.
| | - Günter Weiss
- Department of Internal Medicine II, Medical University Hospital of Innsbruck, Innsbruck, A-6020, Austria.
- Christian Doppler Laboratory for Iron Metabolism and Anemia Research, University of Innsbruck, Innsbruck, A-6020, Austria..
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Abstract
OBJECTIVE To consider the key implications of iron deficiency for biochemical and physiological functions beyond erythropoiesis. METHODS PubMed was searched for relevant journal articles published up to August 2017. RESULTS Anemia is the most well-recognized consequence of persisting iron deficiency, but various other unfavorable consequences can develop either before or concurrently with anemia. Mitochondrial function can be profoundly disturbed since iron is a cofactor for heme-containing enzymes and non-heme iron-containing enzymes in the mitochondrial electron transport chain. Biosynthesis of heme and iron-sulfur clusters in the mitochondria is inhibited, disrupting synthesis of compounds such as hemoglobin, myoglobin, cytochromes and nitric oxide synthase. The physiological consequences include fatigue, lethargy, and dyspnea; conversely, iron repletion in iron-deficient individuals has been shown to improve exercise capacity. The myocardium, with its high energy demands, is particularly at risk from the effects of iron deficiency. Randomized trials have found striking improvements in disease severity in anemic but also non-anemic chronic heart failure patients with iron deficiency after iron therapy. In vitro and pre-clinical studies have demonstrated that iron is required by numerous enzymes involved in DNA replication and repair, and for normal cell cycle regulation. Iron is also critical for immune cell growth, proliferation, and differentiation, and for specific cell-mediated effector pathways. Observational studies have shown that iron-deficient individuals have defective immune function, particularly T-cell immunity, but more evidence is required. Pre-clinical models have demonstrated abnormal myelogenesis, brain cell metabolism, neurotransmission, and hippocampal formation in iron-deficient neonates and young animals. In humans, iron deficiency anemia is associated with poorer cognitive and motor skills. However, the impact of iron deficiency without anemia is less clear. CONCLUSION The widespread cellular and physiological effects of iron deficiency highlight the need for early detection and treatment of iron deficiency, both to ameliorate these non-erythropoietic effects, and to avoid progression to iron deficiency anemia.
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Affiliation(s)
| | - Ali T Taher
- b American University of Beirut Medical Center , Beirut , Lebanon
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Allen RP, Picchietti DL, Auerbach M, Cho YW, Connor JR, Earley CJ, Garcia-Borreguero D, Kotagal S, Manconi M, Ondo W, Ulfberg J, Winkelman JW. Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease in adults and children: an IRLSSG task force report. Sleep Med 2017; 41:27-44. [PMID: 29425576 DOI: 10.1016/j.sleep.2017.11.1126] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 11/09/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Brain iron deficiency has been implicated in the pathophysiology of RLS, and current RLS treatment guidelines recommend iron treatment when peripheral iron levels are low. In order to assess the evidence on the oral and intravenous (IV) iron treatment of RLS and periodic limb movement disorder (PLMD) in adults and children, the International Restless Legs Syndrome Study Group (IRLSSG) formed a task force to review these studies and provide evidence-based and consensus guidelines for the iron treatment of RLS in adults, and RLS and PLMD in children. METHODS A literature search was performed to identify papers appearing in MEDLINE from its inception to July 2016. The following inclusion criteria were used: human research on the treatment of RLS or periodic limb movements (PLM) with iron, sample size of at least five, and published in English. Two task force members independently evaluated each paper and classified the quality of evidence provided. RESULTS A total of 299 papers were identified, of these 31 papers met the inclusion criteria. Four studies in adults were given a Class I rating (one for IV iron sucrose, and three for IV ferric carboxymaltose); only Class IV studies have evaluated iron treatment in children. Ferric carboxymaltose (1000 mg) is effective for treating moderate to severe RLS in those with serum ferritin <300 μg/l and could be used as first-line treatment for RLS in adults. Oral iron (65 mg elemental iron) is possibly effective for treating RLS in those with serum ferritin ≤75 μg/l. There is insufficient evidence to make conclusions on the efficacy of oral iron or IV iron in children. CONCLUSIONS Consensus recommendations based on clinical practice are presented, including when to use oral iron or IV iron, and recommendations on repeated iron treatments. New iron treatment algorithms, based on evidence and consensus opinion have been developed.
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Affiliation(s)
- Richard P Allen
- Department of Neurology, Johns Hopkins University, Hopkins Bayview Medical Center, Baltimore, MD, USA.
| | - Daniel L Picchietti
- University of Illinois College of Medicine at Urbana-Champaign and Carle Foundation Hospital, Urbana, IL, USA
| | - Michael Auerbach
- Department of Medicine, Georgetown University, Washington DC, USA
| | - Yong Won Cho
- Department of Neurology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - James R Connor
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey PA, USA
| | - Christopher J Earley
- Department of Neurology, Johns Hopkins University, Hopkins Bayview Medical Center, Baltimore, MD, USA
| | | | - Suresh Kotagal
- Department of Neurology and the Center for Sleep Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano, Lugano, Switzerland
| | - William Ondo
- Methodist Neurological Institute, Weill Cornell Medical School Houston, TX, USA
| | - Jan Ulfberg
- Sleep Disorders Department, Capio Health Center, Örebro, Sweden
| | - John W Winkelman
- Departments of Psychiatry and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Chapman E, Leal D, Alvarez L, Duarte M, García E. Two case reports of desensitization in patients with hypersensitivity to iron. World Allergy Organ J 2017; 10:38. [PMID: 29075363 PMCID: PMC5635505 DOI: 10.1186/s40413-017-0166-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Iron deficiency anemia is a disease that can significantly compromise a patient's quality of life. Desensitization is a safe and effective treatment option for iron-deficient anemic patients who require intravenous iron despite their hypersensitivity to iron. This report describes a safe desensitization protocol for patients with iron hypersensitivity who require iron treatment for their clinical improvement. CASE PRESENTATION Two patients of 20 and 46-year-old diagnosed with secondary iron deficiency anemia hipermenorreas and a clinical history of fail treatment with oral iron, who presented a reaction of the anaphylactic type while they receive iron parenteral sucrose. Therefore, the patients were treated with the desensitization protocol applied for patients with hypersensitivity to iron. CONCLUSION Iron deficiency anemia is a disease that can significantly compromise the quality of life of patients. The desensitization protocol for patients with hypersensitivity to iron is a safe and effective treatment option for patients with a history of allergy to intravenous iron. This case report shows the usefulness to use the desensitization protocol for patients with hypersensitivity to iron.
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Affiliation(s)
- Edgardo Chapman
- Fundación Santa Fe de Bogota, Carrera 7 N 117–15, Bogotá, Colombia
| | - Drixie Leal
- Fundación Santa Fe de Bogota, Carrera 7 N 117–15, Bogotá, Colombia
| | - Leidy Alvarez
- University of Cartagena, Cra. 6 #36, Cartagena, Bolívar, Colombia
| | - Mónica Duarte
- Fundación Santa Fe de Bogota, Carrera 7 N 117–15, Bogotá, Colombia
| | - Elizabeth García
- Fundación Santa Fe de Bogota, Carrera 7 N 117–15, Bogotá, Colombia
- Faculty of Medicine University of the Andes, Carrera 1 No 18 A –, 10 Bogotá, Colombia
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41
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Adkinson NF, Strauss WE, Bernard K, Kaper RF, Macdougall IC, Krop JS. Comparative safety of intravenous Ferumoxytol versus Ferric Carboxymaltose for the Treatment of Iron Deficiency Anemia: rationale and study design of a randomized double-blind study with a focus on acute hypersensitivity reactions. J Blood Med 2017; 8:155-163. [PMID: 29033620 PMCID: PMC5628663 DOI: 10.2147/jbm.s142236] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Intravenous (IV) iron is often used to treat iron deficiency anemia in patients who are unable to tolerate or are inadequately managed with oral iron. However, IV iron treatment has been associated with acute hypersensitivity reactions. The comparative risk of adverse events (AEs) with IV iron preparations has been assessed by a few randomized controlled trials, which are most often limited by small patient numbers, which lack statistical power to identify differences in low-frequency AE such as hypersensitivity reactions. Materials and methods Ferumoxytol versus Ferric Carboxymaltose for the Treatment of Iron Deficiency Anemia (FIRM) is a randomized, double-blind, international, multicenter, Phase III study designed to compare the safety of ferumoxytol and ferric carboxymaltose (FCM). The study includes adults with hemoglobin <12.0 g/dL (females) or <14.0 g/dL (males), transferrin saturation ≤20% or ferritin ≤100 ng/mL within 60 days of dosing, and a history of unsatisfactory or nontolerated oral iron therapy or in whom oral iron therapy is inappropriate. Patients are randomized (1:1) to ferumoxytol 510 mg or FCM 750 mg, each given intravenously on days 1 and 8. Primary end points are the incidence of moderate-to-severe hypersensitivity reactions, including anaphylaxis, and moderate-to-severe hypotension. All potential hypersensitivity and hypotensive reactions will be adjudicated by a blinded, independent Clinical Events Committee. A secondary safety end point is the composite frequency of moderate-to-severe hypersensitivity reactions, including anaphylaxis, serious cardiovascular events, and death. Secondary efficacy end points include mean change in hemoglobin and mean change in hemoglobin per milligram of iron administered from baseline to week 5. Urinary excretion of phosphorus and the occurrence of hypophosphatemia after IV iron administration will be examined as well as the mechanisms of such hypophosphatemia in a substudy. Conclusion FIRM will provide data on the comparative safety of ferumoxytol and FCM, two IV iron preparations with similar dosing schedules, focusing on moderate-to-severe hypersensitivity reactions, including anaphylaxis, and moderate-to-severe hypotension. The study plans to enroll 2000 patients and is expected to complete in 2017.
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Affiliation(s)
- N Franklin Adkinson
- Department of Medicine, Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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42
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Stoumpos S, Hennessy M, Vesey AT, Radjenovic A, Kasthuri R, Kingsmore DB, Mark PB, Roditi G. Ferumoxytol-enhanced magnetic resonance angiography for the assessment of potential kidney transplant recipients. Eur Radiol 2017; 28:115-123. [PMID: 28677065 PMCID: PMC5717122 DOI: 10.1007/s00330-017-4934-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/16/2017] [Accepted: 06/08/2017] [Indexed: 11/13/2022]
Abstract
Objectives Traditional contrast-enhanced methods for scanning blood vessels using magnetic resonance imaging (MRI) or CT carry potential risks for patients with advanced kidney disease. Ferumoxytol is a superparamagnetic iron oxide nanoparticle preparation that has potential as an MRI contrast agent in assessing the vasculature. Methods Twenty patients with advanced kidney disease requiring aorto-iliac vascular imaging as part of pre-operative kidney transplant candidacy assessment underwent ferumoxytol-enhanced magnetic resonance angiography (FeMRA) between December 2015 and August 2016. All scans were performed for clinical indications where standard imaging techniques were deemed potentially harmful or inconclusive. Image quality was evaluated for both arterial and venous compartments. Results First-pass and steady-state FeMRA using incremental doses of up to 4 mg/kg body weight of ferumoxytol as intravenous contrast agent for vascular enhancement was performed. Good arterial and venous enhancements were achieved, and FeMRA was not limited by calcification in assessing the arterial lumen. The scans were diagnostic and all patients completed their studies without adverse events. Conclusions Our preliminary experience supports the feasibility and utility of FeMRA for vascular imaging in patients with advanced kidney disease due for transplant listing, which has the advantages of obtaining both arteriography and venography using a single test without nephrotoxicity. Key Points • Evaluation of vascular disease is important in planning kidney transplantation. • Standard vascular imaging methods are often problematic in kidney disease patients. • FeMRA has the advantage of arteriography and venography in a single test. • FeMRA is safe and non-nephrotoxic. • FeMRA is not limited by arterial calcification.
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Affiliation(s)
- Sokratis Stoumpos
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK. .,Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK.
| | - Martin Hennessy
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alex T Vesey
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Aleksandra Radjenovic
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Ram Kasthuri
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - David B Kingsmore
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Giles Roditi
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
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43
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Varallyay CG, Toth GB, Fu R, Netto JP, Firkins J, Ambady P, Neuwelt EA. What Does the Boxed Warning Tell Us? Safe Practice of Using Ferumoxytol as an MRI Contrast Agent. AJNR Am J Neuroradiol 2017; 38:1297-1302. [PMID: 28495944 PMCID: PMC5509484 DOI: 10.3174/ajnr.a5188] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/17/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Despite the label change and the FDA's boxed warning added to the Feraheme (ferumoxytol) label in March 2015, radiologists have shown increasing interest in using ferumoxytol as an MR imaging contrast agent as a supplement or alternative to gadolinium. The goals of this study were to provide information regarding ferumoxytol safety as an imaging agent in a single center and to assess how the Feraheme label change may affect this potential, currently off-label indication. MATERIALS AND METHODS This retrospective study evaluated the overall frequency of ferumoxytol-related adverse events when used for CNS MR imaging. Patients with various CNS pathologies were enrolled in institutional review board-approved imaging studies. Ferumoxytol was administered as multiple rapid bolus injections. The risk of adverse events was correlated with demographic data/medical history. RESULTS The safety of 671 ferumoxytol-enhanced MR studies in 331 patients was analyzed. No anaphylactic, life-threatening, or fatal (grade 4 or 5) adverse events were recorded. The overall proportion of ferumoxytol-related grade 1-3 adverse events was 10.6% (8.6% occurring within 48 hours), including hypertension (2.38%), nausea (1.64%), diarrhea (1.04%), and headache (1.04%). History of 1 or 2 allergies was associated with an increased risk of adverse events (14.61% versus 7.51% [no history]; P = .007). CONCLUSIONS The frequency of mild ferumoxytol-related adverse events was comparable with literature results, and no serious adverse event was recorded. Although the recommendations in the boxed warning should be followed, serious adverse events appear to be rare, and with proper precautions, ferumoxytol may be a valuable MR imaging agent.
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Affiliation(s)
- C G Varallyay
- From the Departments of Radiology (C.G.V., J.P.N.)
- Neurology (C.G.V., G.B.T., J.P.N., J.F., P.A., E.A.N.)
| | - G B Toth
- Neurology (C.G.V., G.B.T., J.P.N., J.F., P.A., E.A.N.)
| | - R Fu
- Medical Informatics and Clinical Epidemiology (R.F.)
- School of Public Health (R.F.), Oregon Health & Science University, Portland, Oregon
| | - J P Netto
- Neurology (C.G.V., G.B.T., J.P.N., J.F., P.A., E.A.N.)
| | - J Firkins
- Neurology (C.G.V., G.B.T., J.P.N., J.F., P.A., E.A.N.)
| | - P Ambady
- Neurology (C.G.V., G.B.T., J.P.N., J.F., P.A., E.A.N.)
| | - E A Neuwelt
- Neurology (C.G.V., G.B.T., J.P.N., J.F., P.A., E.A.N.)
- Neurosurgery (E.A.N.)
- Portland Veterans Affairs Medical Center (E.A.N.), Portland, Oregon
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44
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Morales Mateluna CA, Scherer Hofmeier K, Bircher AJ. Approach to hypersensitivity reactions from intravenous iron preparations. Allergy 2017; 72:827-830. [PMID: 27977865 DOI: 10.1111/all.13106] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2016] [Indexed: 01/17/2023]
Abstract
Hypersensitivity reactions (HSRs) to intravenous iron preparations (IVIPs) are well known. With newer preparations, HSRs have become rarer; however, severe reactions may still occur. We retrospectively reviewed records of patients evaluated for HSRs to IVIPs, to determine the safety of controlled re-administration (CRA). Allergological work-up included a detailed history, skin prick tests (SPTs) with IVIP, and basophil activation tests (BATs) in some patients. CRA with an IVIP was carried out if indicated. Thirty-one patients with mild to severe reactions were evaluated. SPTs and BATs were negative in all patients tested. Eighteen CRAs in 15 patients were performed. Twelve patients tolerated the procedure, including three with a previous grade IV HSR. Two developed urticaria and one developed urticaria and dyspnea. The pathophysiology of HSRs to IVIPs remains currently unclear. SPTs and BATs provided no additional information. However, in appropriate situations, CRA under surveillance can be safely performed in most patients.
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Affiliation(s)
| | - K. Scherer Hofmeier
- Allergy Unit; Dermatology Clinic; University Hospital Basel; Basel Switzerland
| | - A. J. Bircher
- Allergy Unit; Dermatology Clinic; University Hospital Basel; Basel Switzerland
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45
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Iron nanomedicines induce Toll-like receptor activation, cytokine production and complement activation. Biomaterials 2017; 119:68-77. [DOI: 10.1016/j.biomaterials.2016.11.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 11/03/2016] [Accepted: 11/20/2016] [Indexed: 11/22/2022]
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46
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Management of the Jehovah's Witness in Obstetrics and Gynecology: A Comprehensive Medical, Ethical, and Legal Approach. Obstet Gynecol Surv 2017; 71:488-500. [PMID: 27526872 DOI: 10.1097/ogx.0000000000000343] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patients who refuse blood transfusion. Although there are some reports in the literature about management of Jehovah's Witness patients in obstetrics and gynecology, most of them are case reports, and a comprehensive review about these patients including ethicolegal perspective is lacking. OBJECTIVE This review outlines the medical, ethical, and legal implications of management of Jehovah's Witness patients in obstetrical and gynecological settings. EVIDENCE ACQUISITION A search of published literature using PubMed, Ovid Medline, EMBASE, and Cochrane databases was conducted about physiology of oxygen delivery and response to tissue hypoxia, mortality rates at certain hemoglobin levels, medical management options for anemic patients who refuse blood transfusion, and ethical/legal considerations in Jehovah's Witness patients. RESULTS Early diagnosis of anemia and immediate initiation of therapy are essential in patients who refuse blood transfusion. Medical management options include iron supplementation and erythropoietin. There are also some promising therapies that are in development such as antihepcidin antibodies and hemoglobin-based oxygen carriers. Options to decrease blood loss include antifibrinolytics, desmopressin, recombinant factor VII, and factor concentrates. When surgery is the only option, every effort should be made to pursue minimally invasive approaches. CONCLUSION AND RELEVANCE All obstetricians and gynecologists should be familiar with alternatives and "less invasive" options for patients who refuse blood transfusions.
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47
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How I treat anemia in pregnancy: iron, cobalamin, and folate. Blood 2017; 129:940-949. [DOI: 10.1182/blood-2016-08-672246] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 12/21/2016] [Indexed: 01/28/2023] Open
Abstract
AbstractAnemia of pregnancy, an important risk factor for fetal and maternal morbidity, is considered a global health problem, affecting almost 50% of pregnant women. In this article, diagnosis and management of iron, cobalamin, and folate deficiencies, the most frequent causes of anemia in pregnancy, are discussed. Three clinical cases are considered. Iron deficiency is the most common cause. Laboratory tests defining iron deficiency, the recognition of developmental delays and cognitive abnormalities in iron-deficient neonates, and literature addressing the efficacy and safety of IV iron in pregnancy are reviewed. An algorithm is proposed to help clinicians diagnose and treat iron deficiency, recommending oral iron in the first trimester and IV iron later. Association of folate deficiency with neural tube defects and impact of fortification programs are discussed. With increased obesity and bariatric surgery rates, prevalence of cobalamin deficiency in pregnancy is rising. Low maternal cobalamin may be associated with fetal growth retardation, fetal insulin resistance, and excess adiposity. The importance of treating cobalamin deficiency in pregnancy is considered. A case of malarial anemia emphasizes the complex relationship between iron deficiency, iron treatment, and malaria infection in endemic areas; the heightened impact of combined etiologies on anemia severity is highlighted.
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48
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Wetmore JB, Weinhandl ED, Zhou J, Gilbertson DT. Relative Incidence of Acute Adverse Events with Ferumoxytol Compared to Other Intravenous Iron Compounds: A Matched Cohort Study. PLoS One 2017; 12:e0171098. [PMID: 28135334 PMCID: PMC5279762 DOI: 10.1371/journal.pone.0171098] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 01/16/2017] [Indexed: 01/23/2023] Open
Abstract
Concerns persist about adverse reactions to intravenous (IV) iron. We aimed to determine the relative safety of ferumoxytol compared to other IV iron compounds. This retrospective cohort study with propensity-score matching for patients and drug doses used the Medicare 20% random sample to identify patients (1) without chronic kidney disease (non-CKD) and (2) with non-dialysis-dependent chronic kidney disease (NDD-CKD) who received a first dose of IV iron in 2010–2012. Exposures were ferumoxytol, iron sucrose, sodium ferric gluconate, or iron dextran. Outcomes were hypersensitivity symptoms, anaphylaxis, emergency department (ED) encounters, hospitalizations, and death after acute IV iron exposure. In the primary analysis for reactions on the day of or following exposure, there was no difference in hypersensitivity symptoms (hazard ratio 1.04, 95% confidence interval 0.94–1.16) or hypotension (0.83, 0.52–1.34) between 4289 non-CKD ferumoxytol users and an equal number of users of other compounds; results were similar for 7358 NDD-CKD patients and an equal number of controls. All-cause ED encounters or hospitalizations were less common in both the non-CKD (0.56, 0.45–0.70) and NDD-CKD ferumoxytol-treated patients (0.83, 0.71–0.95). Fewer than 10 deaths occurred in both the non-CKD and NDD-CKD ferumoxytol users and in matched controls; the hazard for death did not differ significantly between ferumoxytol users and controls in the non-CKD patients (2.00, 0.33–11.97) or in the NDD-CKD patients (0.25, 0.04–1.52). Multiple sensitivity analyses showed similar results. Ferumoxytol did not appear to be associated with more adverse reactions than other compounds for the treatment of iron-deficiency anemia in both non-CKD and NDD-CKD patients.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, United States of America
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota, United States of America
- * E-mail:
| | - Eric D. Weinhandl
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, United States of America
| | - Jincheng Zhou
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, United States of America
| | - David T. Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, United States of America
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49
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Powers JM, Shamoun M, McCavit TL, Adix L, Buchanan GR. Intravenous Ferric Carboxymaltose in Children with Iron Deficiency Anemia Who Respond Poorly to Oral Iron. J Pediatr 2017; 180:212-216. [PMID: 27776750 DOI: 10.1016/j.jpeds.2016.09.053] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/28/2016] [Accepted: 09/19/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To assess the benefits and risks of intravenous (IV) ferric carboxymaltose (FCM) in children with iron deficiency anemia (IDA). STUDY DESIGN In a retrospective cohort study of patients seen at our center, we identified all FCM infusions in children with IDA over a 12-month period through a query of pharmacy records. Clinical data, including hematologic response and adverse effects, were extracted from the electronic medical record. RESULTS A total of 116 IV FCM infusions were administered to 72 patients with IDA refractory to oral iron treatment (median age, 13.7 years; range, 9 months to 18 years). Median preinfusion and postinfusion hemoglobin values were 9.1 g/dL and 12.3 g/dL, respectively (at 4-12 weeks after the initial infusion; n = 53). Sixty-five patients (84%) experienced no adverse effects. Minor transient complications were encountered during or immediately after 7 infusions. CONCLUSION FCM administered as a short IV infusion without a test dose proved to be safe and highly effective in a small yet diverse population of infants, children, and adolescents with IDA refractory to oral iron therapy.
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Affiliation(s)
- Jacquelyn M Powers
- Division of Hematology/Oncology, Baylor College of Medicine, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX; Texas Children's Hospital, Houston, TX.
| | - Mark Shamoun
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX; Children's Health, Dallas, TX
| | - Timothy L McCavit
- Division of Hematology/Oncology, Cook Children's Hospital, Fort Worth, TX; Department of Pediatrics, Cook Children's Hospital, Fort Worth, TX
| | | | - George R Buchanan
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX; Children's Health, Dallas, TX; Division of Hematology/Oncology, The University of Texas Southwestern Medical Center, Dallas, TX
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50
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Auerbach M, Deloughery T. Single-dose intravenous iron for iron deficiency: a new paradigm. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:57-66. [PMID: 27913463 PMCID: PMC6142502 DOI: 10.1182/asheducation-2016.1.57] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Iron-deficiency anemia is the most common hematologic problem in the world. Although oral iron is often viewed as front-line therapy, extensive published evidence has accumulated that IV iron is superior, in both efficacy and safety, to oral iron in many clinical situations and should be introduced much sooner in the treatment paradigm of iron-deficient patients. In this chapter, we will review the formulations of IV iron that allow total complete replacement doses in 1 or 2 sessions including practical tips for administration. We realize safety concerns abound and therefore will analyze evidence based overstated concerns regarding serious adverse events highlighting unnecessary interventions for minor, self-limiting infusion reactions, which infrequently occur with intravenous iron administration. Recent data for the use of IV iron in a variety of clinic situations will be reviewed including women with heavy uterine bleeding, pregnancy, bariatric surgery, inflammatory bowel disease, and restless legs syndrome. Briefly discussed is the new frontier of IV iron's use in the prevention of acute (high altitude) mountain sickness. It is clear that in many clinical situations IV iron is a new and improved standard of care offering advantages over oral iron in efficacy, toxicity, and convenience to patients and health care providers.
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Affiliation(s)
- Michael Auerbach
- Private Practice, Baltimore, MD
- Clinical Professor of Medicine, Georgetown University School of Medicine, Washington, DC; and
| | - Thomas Deloughery
- Department of Hematology and Medical Oncology, Division of Laboratory Medicine, and
- Department of Pathology, Oregon Health Sciences University, Portland, OR
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