What are treatment options for a pregnant woman with iron deficiency who has had bariatric surgery?

Private Practice, Baltimore, Maryland; Clinical Professor of Medicine, Georgetown University School of Medicine, Washington, DC

This month Michael Auerbach, MD, discusses treatment options for a pregnant woman with iron deficiency who has had bariatric surgery.

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CLINICAL DILEMMA

A pregnant woman who has had bariatric surgery is very iron deficient. We are having difficulty obtaining iron sucrose. We plan to treat her during the second trimester. Are the other forms of IV iron safe? If so, which ones and at what dose?

EXPERT OPINION

We have treated dozens of bariatric gravidas with single 1,000 mg infusions of intravenous iron using low-molecular-weight iron dextran (LMW ID). Iron sucrose (IS) and ferric gluconate (FG) cost twice as much and require four to five visits, whereas LMW ID requires one. Since there is zero safety or efficacy advantage with IS or FG, we never use either formulation.

We administer 1,000 mg LMW ID in one hour. We have administered more than 6,000 of these infusions, many in gravidas (second or third trimester because there is no safety data in the first), without a serious adverse event (SAE). In the 2016 ASH Education Book, my chapter provides the rationale for single-dose infusion as well as supporting references.
We recently published the results of the first U.S. prospective study on IV iron in gravidas in the American Journal of Medicine. All patients received 1,000 mg in one hour. Previously, we published the results of a study of 189 consecutive, non-selected patients who received a gram of LMW ID in one hour. There were no SAEs in either study, which is consistent with the world’s literature on this topic.

Your patient should receive 1,000 mg of LMW ID in an hour. Alternatively, she can be treated with two doses of ferric carboxymaltose (FCM) 750 mg on two consecutive visits. This drug has a safety record in pregnancy, as does LMW ID. It costs seven times as much as LMW ID without the safety or efficacy advantage, but has the increased convenience of a 15-minute administration time. A prospective study published in Obstetric Medicine compared the two, and no difference was observed. If a mild reaction to LMW ID occurs, FCM is usually safe and vice versa.

Another alternative is ferumoxytol, which is approved only for chronic kidney disease. There are no safety data in pregnancy. Hopefully, a broad approval for this agent, which is expensive, will occur soon, giving us another good option.

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NEXT MONTH'S CLINICAL DILEMMA

A 73-year-old woman has stage III large B-cell lymphoma. I did not do a bone marrow biopsy, but she had a normal LP and normal brain MRI. She has had two courses of R-CHOP with a great response. However, she has developed pronounced short-term memory loss. She can no longer care for herself and does not remember events from the previous hour. Is this chemo brain? If so, what regimen would be safe to use?

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