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Toxicity, Iron: Treatment & Medication
Updated: Jun 24, 2009
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Treatment
Medical Care
The first step in treating a case of acute iron toxicity is to provide appropriate supportive care, with particular attention paid to fluid balance and cardiovascular stabilization. Initial treatment should also address the issue of preventing further absorption of iron by the GI tract.
- Ipecac-induced emesis is not recommended. This is especially true in iron ingestion. GI distress is an early finding in iron poisoning and is present in all potentially serious ingestions. Ipecac-induced vomiting may cloud the clinical picture.
- Gastric lavage is not recommended because iron tablets are relatively large and become sticky in gastric fluid, making lavage unlikely to be of benefit.
- Whole bowel irrigation has been used to speed the passage of undissolved iron tablets through the GI tract. A polyethylene glycol electrolyte solution (eg, GoLYTELY) may be administered orally or nasogastrically at a rate of 250-500 mL/h for toddlers and preschoolers and 2 L/h for adolescents. Continue irrigation until the repeat radiographic findings are negative or rectal effluent is clear.
- Deferoxamine is the iron-chelating agent of choice. Deferoxamine binds absorbed iron, and the iron-deferoxamine complex is excreted in the urine. Deferoxamine does not bind iron in hemoglobin, myoglobin, or other iron-carrying proteins. Base the indications for using deferoxamine on both clinical and laboratory parameters. Indications for treatment include shock, altered mental status, persistent GI symptoms, metabolic acidosis, pills visible on radiographs, serum iron level greater than 500 µg/dL, or estimated dose greater than 60 mg/kg of elemental iron. Initiate chelation if a serum iron level is not available and symptoms are present.
- The administration of deferoxamine may be intramuscular or intravenous. The intramuscular route is not recommended because it is painful and less iron is excreted compared with the intravenous route. The intravenous route is administered as a continuous infusion. The standard dose is 15 mg/kg/h, with an initial dose administered for 6 hours.
- No clear end point of therapy is noted; however, indications for cessation include significant resolution of shock and acidosis. Deferoxamine, administered 6-12 hours, has been suggested for moderate toxicity. For severe toxicity, administer deferoxamine for 24 hours. Because these end points are arbitrary, observe the patient for the recurrence of toxicity 2-3 hours after the deferoxamine has been stopped.
- Adverse effects from deferoxamine are unusual. Pulmonary toxicity (ie, acute respiratory distress syndrome [ARDS], tachypnea) has been described, especially if patients are treated with deferoxamine for more than 24 hours. Rate-related hypotension can occur. Therefore, monitor the patient while titrating the infusion rate upward to a final rate of 15 mg/kg/h.
Surgical Care
- If retained iron tablets are evident after GI decontamination, consider endoscopy or surgery for their removal.
- Failure to remove the iron can result not only in continued iron absorption and exacerbation of systemic symptoms but also in gastric perforation and severe hemorrhage.
Consultations
- Regional poison control centers may be contacted for assistance in patient management.
- In addition, consult an intensivist for help in managing the moderately to severely ill child.
Medication
Chelation agents
Deferoxamine is a specific iron chelator. In the presence of ferric iron, deferoxamine forms the complex ferrioxamine, which is excreted by the kidneys. This complex imparts a reddish, vin rosé, color to the urine. Deferoxamine does not bind iron that is present in hemoglobin, hemosiderin, or ferritin. Deferoxamine is a parenteral iron chelator. It is administered IV or IM in the management of acute iron toxicity.
Deferoxamine mesylate (Desferal)
Freely soluble in water. Approximately 8 mg of iron is bound by 100 mg of deferoxamine. Most effective when continuously provided to the circulation by infusion. May be administered either by IM injection or by slow IV infusion. Does not effectively chelate other trace metals of nutritional importance. Provided in vials containing 500 mg or 2 g of lyophilized sterile drug. Add 2 mL or 8 mL of sterile water for injection to each vial, bringing the concentration to 250 mg/mL. For IV use, this may be diluted in 0.9% sterile saline, 5% dextrose solution, or Ringer solution.
Adult
1000 mg may be administered IV at a rate not to exceed 15 mg/kg/h; follow with a dose of 500 mg q4h for 2 doses; administer additional IV infusion slowly over 24 h; not to exceed 6 g/24 h
Alternatively, 1000 mg IM, followed by 500 mg 4 and 8 h later; depending on response, 500 mg may be administered q4-12h IM; not to exceed 6 g/24 h; IV route preferred
Pediatric
IV route preferred: 15 mg/kg/h IV; not to exceed 6 g/24 h
Concurrent treatment with prochlorperazine, a phenothiazine derivative, may lead to temporary impairment of consciousness
Documented hypersensitivity; patients who do not have acute iron poisoning; severe renal disease and anuria (dose reduction after the loading dose should be considered in these circumstances)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Acute lung injury has recently been described (these patients received deferoxamine [15 mg/kg] for >24 h), and recent recommendations include higher doses of deferoxamine during the first 24 h and subsequently decreasing the dose of deferoxamine; tachycardia, hypotension, and shock may occur in patients receiving long-term therapy and could add to the cardiovascular collapse due to iron toxicity; GI adverse effects include abdominal discomfort, nausea, vomiting, and diarrhea, which may add to the symptoms of acute iron toxicity; flushing and fever are reported
Deferasirox (Exjade)
Tab for PO susp. PO iron chelation agent demonstrated to reduce liver iron concentration in adults and children who receive repeated RBC transfusions. Binds iron with high affinity in a 2:1 ratio. Approved to treat chronic iron overload due to multiple blood transfusions. Treatment initiation recommended upon evidence of chronic iron overload (ie, transfusion of about 100 mL/kg packed RBCs [about 20 U for 40-kg person] and serum ferritin level consistently >1000 µg/L).
Adult
Initial: 20 mg/kg PO qd on empty stomach 30 min ac
Maintenance: Adjust dose by 5-10 mg/kg/d increments q3-6mo according to serum ferritin level trends; not to exceed 30 mg/kg/d
Note: Dissolve tab completely in water, orange juice, or apple juice, then immediately drink susp; resuspend any remaining residue in small volume of liquid and swallow
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Data limited; do not take with aluminum-containing antacids
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Common adverse effects include diarrhea, nausea, abdominal pain, headache, pyrexia, cough, and rash; may increase serum creatinine and hepatic enzyme levels; decrease dose upon persistent elevation of serum creatinine level; may cause auditory and visual disturbances; slight decreases in serum copper and zinc levels may occur; dissolve tab completely in water, orange juice, or apple juice and drink resulting susp immediately (do not swallow tab whole, do not chew or crush); measure serum ferritin levels monthly and adjust dose q3-6mo based on serum ferritin trends
Whole bowel irrigation agents
Polyethylene glycol is used to increase GI transit time, decreasing absorption. It is not absorbed and is excreted entirely through the GI tract.
Polyethylene glycol (GoLYTELY, NuLytely, Colovage, Colyte)
Laxative with strong electrolyte and osmotic effects that has cathartic actions in GI tract.
Adult
2 L/h NG
Pediatric
Toddlers, preschoolers, children: 250-500 mL/h PO/NG
Adolescents: Administer as in adults
Reduces effectiveness and absorption of oral medications
Documented hypersensitivity; colitis; megacolon; bowel perforation; gastric retention; GI obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in ulcerative colitis and hot loop polypectomy
More on Toxicity, Iron |
| Overview: Toxicity, Iron |
| Differential Diagnoses & Workup: Toxicity, Iron |
 Treatment & Medication: Toxicity, Iron |
| Follow-up: Toxicity, Iron |
| Multimedia: Toxicity, Iron |
| References |
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References
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Further Reading
Keywords
iron toxicity, iron poisoning, ferrous sulfate tablets, ferrous sulfate, ferrous gluconate, ferrous fumarate, ferrous lactate, ferrous chloride, metabolic acidosis, hemorrhagic vomiting, diarrhea, abdominal pain, hepatic failure, pyloric obstruction, hepatic cirrhosis, multivitamin ingestion, treatment, diagnosis
