Suboptimal Perioperative IV Iron Dosing Leads to Minimal Hemoglobin Gains

Credit: Marcelo Leal/Unsplash

Administration of ferric carboxymaltose (FCM) was not very effective before elective surgery among patients diagnosed with anemia, with a low percentage of patients achieving response, defined as hemoglobin (Hb) levels of 13 g/dL or higher.¹

This multicenter, retrospective study, conducted in patients aged ≥18 who underwent surgery between January 2017 and December 2018, identified an underdiagnosis of FCM and an inadequate time between the administration of FCM and surgery for most participants.

“It is necessary to develop a protocol for the management of FCM to ensure adequate prescription and include any iron study as a factor in determining who to administer IV iron,” wrote the investigative team, led by Angel Manuel Yuste Gutierrez, department of pharmacy, Guadalajara University Hospital. “The findings suggest that the administration of FCM in clinical practice often falls short of the recommended guidelines, particularly in patients with more severe anemia.”

Preoperative anemia has been linked to complications both before and after surgery, as an autonomous risk for perioperative blood transfusion, morbidity, and mortality.² Numerous guidelines from hematological organizations endorse the use of intravenous iron in the management of perioperative anemia.³

The immediacy of preoperative FCM treatment in patients with anemia can reduce the need for transfusion and the length of hospital stay to benefit surgical outcomes. In this study, Gutierrez and colleagues sought to measure the effectiveness of administering preoperative FCM in anemic patients undergoing elective surgery.¹

Investigators collected data on demographic variables, dose scheme, baseline and perioperative Hb levels, transfusion requirements, and admission days at 3 hospitals in Spain. Response rates and effectiveness of FCM were defined as the proportion of patients with Hb preoperative levels ≥13 g/dL. Patient response was defined as an increase in Hb by ≥1 g/dL.

Overall, 446 of 506 patients treated with FCM were included in the study, including 246 (55.2%) women, with a median age of 69 years. Anemia presence in the study population was 84.3% (n = 376), with greater prevalence in males (93.5%) than in females (76.8%).

The most common procedures were gastrointestinal surgery (39.7%), orthopedic surgery (17%), cardiovascular surgery (15.5%), and excluding gynecological surgery (6.5%). At the time of data collection, the median baseline Hb was 10.5 g/dL.

Upon analysis, 11.6% of patients had preoperative Hb ≥13 g/dL and 52.5% had high-risk bleeding—the overall response rate was 24.9%, with a mean increase in Hb levels of 0.28 g/dL. FCM was administered 5 days before surgery, with 15.3% of patients experiencing more than 4 weeks between FCM administration and surgery.

Gutierrez and colleagues found the median total dose of FCM administered was 1000 mg over 5 days, with no signifiant differences between the 3 hospitals (P >.05). Overall, 280 (62.8%) patients received lower doses.

Further analysis of transfusion requirements found 95 (21.3%) patients required blood transfusion after FCM administration, with a mean of 0.73 units transferred. The mean hospitalization stay was 12 days, calculated from the time of surgery to hospital discharge.

“This under-dosing could have significant implications for patient outcomes, indicating a need for further investigation into the reasons for these discrepancies and potentially a reassessment of clinical practices to ensure that patients receive the appropriate dosage of FCM as per the guidelines,” they added.

References

1. _{Yuste Gutierrez AM, Alonso-Moreno M, Perez Blanco JL, et al. Use and Effectiveness of Carboximaltose Iron in Preoperative Anemia Treatment: A Multicenter and Retrospective Study. J Blood Med. 2024;15:477-486. Published 2024 Nov 16. doi:10.2147/JBM.S460422}
2. _{Muñoz M, Gómez-Ramírez S, Campos A, Ruiz J, Liumbruno GM. Pre-operative anaemia: prevalence, consequences and approaches to management. Blood Transfus. 2015;13(3):370-379. doi:10.2450/2015.0014-15}
3. _{Kotzé A, Harris A, Baker C, et al. British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia [published correction appears in Br J Haematol. 2016 Jan;172(1):148. doi: 10.1111/bjh.13854]. Br J Haematol. 2015;171(3):322-331. doi:10.1111/bjh.13623}