16 June 2020

What’s driving rise in IV iron therapy?

General Practice Women

Intravenous iron therapy among women of reproductive age has increased five-fold since 2013, driving concern it is being used inappropriately, according to research in the MJA.

The study, which analysed PBS dispensing data for more than 190,000 women aged 18 to 44, found claims for intravenous iron grew from 17,920 in 2013 to 97,040 in 2017.

Most iron preparations were prescribed by GPs (43%), with fewer prescribed by specialists (21%) and other medical practitioners (20%).

“The rapid growth raises concerns about whether it [the therapy] is being employed appropriately and cost-effectively, given the potential harms and the lack of strong evidence for its value for improving quality of life and reproductive health outcomes,” the authors said.

And while the reasons for the rise in the use of intravenous iron were unclear, it could be attributable to increased awareness of patient blood management guidelines, the ease of treatment, and perception the side-effects were more favourable than oral iron therapy, the authors said.

The study fails to mention, however, how one type of iron, ferric carboxymaltose, was only made available for delivery in general practice from 2014, despite being used in more than 70% of all infusions.

Associate Professor Jennifer Hunter, GP and adjunct at Western Sydney University’s NICM Health Research Institute, told The Medical Republic that prior to the availability of ferric carboxymaltose, the only available iron infusions were polymoltose and sucrose.

Both of these infusions had a higher rate of anaphylaxis, which is why patients had to be referred to a hospital setting to receive the therapy intravenously.

In the primary care setting, polymoltose and sucrose were administered intramuscularly, but the procedure came with the significant risk of staining at the injection site.

“The medico-legal risk of permanent skin staining meant that intramuscular delivery before 2014 was a big problem for GPs, some were even sued for not providing sufficient informed consent about the risks of staining,” Professor Hunter said.

And even those patients who were referred to tertiary care for the intravenous infusion of polymoltose and sucrose experienced side-effects such as aches, pains and fatigue.

“The newer type of infusion since 2014, ferric carboxymoltose, has a lower risk of anaphylaxis making it appropriate to be delivered in the primary care setting, without the same staining risk of the two intramuscular iron types, which is one reason why there may have been a rapid uptake,” Professor Hunter said.

“There may have also been women prior to 2014 who would have benefitted from intravenous iron infusions but weren’t using them because they had to be delivered in a hospital setting, and coordinating that therapy is more difficult.”

Professor Hunter said intravenous iron therapy provided more options for women when oral supplements were ineffective or not tolerated. She noted that compared with some of the more expensive oral formulas, gastrointestinal side-effects were more commonly experienced with the oral iron compounds available on the PBS.

“If a patient is very symptomatic it takes up to three months to get their iron stores back to normal on oral tablets, but it’s much faster with a one-off infusion of intravenous iron,” she said.

MJA 2020, June 8 (online)

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Peter Bradley
Peter Bradley
3 months 8 days ago
Call me a cynic if you wish, but as the incidence of severe iron deficient anaemia in our society is quite rare, and I never had a case in 45 years that I felt justified IV iron, I find the increase in IV iron infusions is probably more driven by money and convenience. On the one hand, only a basic consult item for prescribing iron orally, whereas an infusion has the perverse incentive of a separate item which is quite generous. Compounded on the other by collusion by the patient, who just wants a quick fix, without having to take… Read more »
Dr Daniel Byrne
Dr Daniel Byrne
3 months 8 days ago

Transfer of care from hospitals to general practice is good care. I fail to see the problem here?