Nissenson AR, Swan S, Lambrecht LL, Anderson P, Schweitzer S
Ferric gluconate (Ferrlecit) is safe in hemodialysis patients
who react to iron dextran
Am Soc Nephrol
J Am Soc Nephrol (abstract)
(Sep) 7:1460 1996
Intravenous iron dextran therapy has been associated with allergic
reactions,
believed due to the dextran portion of the molecule. Ferric gluconate, which
has been in use in Europe for many years, may cause less reactions. The
purpose of this study was to rechallenge patients who had experienced
reactions to iron dextran with ferric gluconate.
9 patients who had suffered severe reactions to iron dextran including
anaphylaxis, chest pain, dyspnea or joint pain were treated with 500-1,000
mg
of ferric gluconate over 8 treatments. The ferric gluconate challenge was
tolerated by all patients without incident. The authors concluded that
ferric
gluconate was safe and effective in patients allergic to iron dextran.
Comment: This is an important contribution, suggesting that there is
not
crossover in allergy between iron dextran and ferric gluconate. The
mechanism
of allergy to iron dextran is unclear, but there is degranulation of mast
cells and basophils without the involvement of immune complexes or IgE. Many
reactions occur with a rapidity of onset atypical for anaphylaxis (with
seconds after initiation of the intravenous push). In addition, the symptom
complex is unusual for the typical case of anaphylaxis, especially the
frequent severe back pain. I believe that some reactions to iron dextran may
indeed be true allergic or anaphylactic reactions. The majority, however,
are
likely to represent some other pathogenic process. I would speculate that in
any formulation of intravenous iron, there will be some vials with a greater
amount of free iron. This may account for the unusual reactions seen with
iron dextran. When rechallenged, as we have occasionally done, a different
manufactured lot of the drug is used, and the patient does not react.
Therefore, it is possible that if the patients in this study had been
rechallenged with iron dextran, they may not have reacted either.
Nonetheless, there rarely is an important enough clinical circumstance to
justify rechallenge with intravenous iron. Ferric gluconate probably is safe
in patients who have had adverse reactions to iron dextran.
(Stephen Fishbane, M.D., Winthrop University Hospital, Mineola, NY)
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Am Soc Nephrol
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