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Transplant Management of Intravenous Iron Therapy - Adult - Ambulatory [106]

Transplant Management of Intravenous Iron Therapy - Adult - Ambulatory [106] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols

Delegation Protocol Number: 106

Delegation Protocol Title:
Transplant Management of Intravenous Iron Therapy – Adult – Ambulatory

Delegation Protocol Applies To:
University Hospital Transplant Clinic

Target Patient Population:
Adult solid organ transplant recipients with iron deficiency anemia, without chronic kidney disease

Delegation Protocol Champion:
Arjang Djamali, MD, Department of Medicine - Nephrology

Delegation Protocol Reviewers:
Dave Hager, PharmD - Pharmacy Inpatient Services
Jillian Fose, PharmD - Pharmacy Inpatient Services
Kimberly Holdener, PharmD - Pharmacy Inpatient Services

Responsible Departments: Department of Medicine - Nephrology Department
of Pharmacy

Purpose Statement:
This protocol delegates authority from providers in the Transplant Clinic to pharmacists in the Transplant
Clinic to manage intravenous iron therapy including ordering IV iron and laboratory tests.

Who May Carry Out This Delegation Protocol:
Pharmacists in the UWHC Transplant Clinic trained in the use of this protocol

Guidelines for Implementation:
1. The protocol is initiated by a provider order “Note: Pharmacist Management of Anemia per Transplant Clinic
2. Initial Patient Assessment
Upon receipt of the order, the pharmacist will review the patient’s medical record to determine their
eligibility for IV iron therapy. If the patient does not meet the eligibility criteria or has any contraindications
to the use of this protocol the pharmacist will contact the provider for further direction.
2.1. Eligibility criteria:
2.1.1. Patient is iron deficient defined as ferritin value < 100 ng/mL and/or TSAT value < 20%
2.1.2. Patient has anemia defined as hemoglobin <13.6 g/dL (hematocrit <40%) in males or hemoglobin
<11.6 g/dL (hematocrit <34%) in females
2.1.3. Patient has eGFR > 60 mL/min per the Modification of Diet in Renal Disease (MDRD) Study equation
2.1.4. Patient remains anemic without reaching iron study goals after three months of oral iron
supplementation or has tried and failed oral iron therapy. Failure is defined as intolerance
(e.g., nausea, constipation, etc.)
2.2. Contraindications:
2.2.1. Patient is allergic to iron sucrose
2.2.2. Patient has ferritin levels greater than 800ng/mL or TSAT levels greater than 40%.
2.2.3. Patient has a significant active infection (e.g. bacteremia, any infection requiring IV
antibiotics, draining wounds, pneumonia and cellulitis, even if on oral antibiotics). IV iron may
be given in the presence of minor infection (e.g. urinary tract infections requiring short-term (7-
10 days) oral antibiotics).
3. Intravenous iron ordering and monitoring
3.1. The pharmacist will enter an order for iron sucrose, ferritin and TSAT. If the patient does not have an
IV line the pharmacist will also enter an order to insert the IV line and the premedications for needle
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:

3.1.1. The first line option for therapy is IV iron sucrose 500 mg in 250 mL of 0.9% sodium chloride
infused IV over 3 hours, up to two doses.
3.1.2. An alternative regimen of three doses of iron sucrose 300 mg in 250 mL of 0.9% sodium
chloride infused IV over 90 minutes may be ordered if the patient is unable to tolerate the
500 mg dose or based on patient convenience or preference.
3.1.3. IV iron may be given on consecutive days if desired (maximum of 500 mg of iron sucrose per day).
3.1.4. Patients will remain on their oral iron, if receiving at the time of IV iron supplementation
3.2. Iron studies (ferritin, TSAT) will be rechecked between five and thirty days after IV iron administration.
3.3. Patients who remain iron deficient and anemic will receive another cycle of IV iron. If iron stores are
in therapeutic range, the patient will not require further follow-up with the transplant pharmacists.
If the patient remains iron deficient after receiving two cycles of IV iron, the provider will be
4. Upon initiation of the protocol, the pharmacist will write a progress note documenting the indication for IV
iron, hemoglobin or hematocrit, ferritin, and TSAT results. A follow-up note will be created each time iron
studies are re-assessed.

Order Mode: Protocol/Policy, Without Cosign

1. Shepshelovich D, Rozen-Zvi B, Avni T, Gafter U, Gafter-Gvili A. Intravenous Versus Oral Iron
Supplementation for the Treatment of Anemia in CKD: An Updated Systematic Review and Meta-
analysis. American Journal of Kidney Diseases. 2016;68(5):677-690. doi:10.1053/j.ajkd.2016.04.018.
2. Djamali A, Becker YT, Simmons WD, Johnson CA, Premasathian N, Becker BN. Increasing hematocrit
reduces early posttransplant cardiovascular risk in diabetic transplant recipients. Transplantation. Sep
15 2003;76(5):816-82.
3. Khan S, Tighiouart H, Kalra A, Raman G, Rohrer RJ, Pereira BJ. Resource utilization among kidney
transplant recipients. Kidney Int. Aug 2003;64(2):657-664.
4. Molnar MZ, Czira M, Ambrus C, et al. Anemia is associated with mortality in kidney-transplanted patients--
a prospective cohort study. Am J Transplant. Apr 2007;7(4):818-824.
5. Winkelmayer WC, Chandraker A, Alan Brookhart M, Kramar R, Sunder-Plassmann G. A prospective study of
anaemia and long-term outcomes in kidney transplant recipients. Nephrol Dial Transplant. Dec
6. Chandler G, Harchowal J, Macdougall IC. Intravenous iron sucrose: establishing a safe dose. Am J Kidney
Dis. Nov 2001;38(5):988-991.
7. Blaustein DA, Schwenk MH, Chattopadhyay J, et al. The safety and efficacy of an accelerated iron sucrose
dosing regimen in patients with chronic kidney disease. Kidney Int Suppl. Nov 2003(87):S72-77.
8. Blaustein DA SM, Chattopadhyay J, Avram MM, et al. Recent experience with high-dose intravenous iron
administration. Kidney Int. 2006;70:S26-29.
9. Vikrant S. Optimum dosage regimen for iron sucrose. Kidney Int. Vol 72. United States2007:225; author reply

Collateral Documents/Tools: N/A

Approved By:
UW Health Ambulatory Protocol Committee: October 2014; *April 2017
UWHC Pharmacy & Therapeutics Committee: October 2014: *May 2017
UWHC Medical Board: November 2014; *May 2017
UW Health Chief Medical Officer: November 2014; *May 2017

Effective Date: May 2017

Scheduled for Review: May 2020
*Expedited Review Process
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: