382 An Unusual Reaction to Intravenous Iron Sucrose

BACKGROUND: Intravenous (IV) iron dextran, the original parenteral iron formulation, is associated with a high incidence of non-IgE mediated hypersensitivity. Newer formulations of IV iron therapies include low molecular weight iron sucrose (IS) and sodium ferric gluconate complex (SFGC) without dextran, reducing severe adverse reactions by 93%. A case of a rare reaction to IV IS associated with generalized skin pruritus and difficulty in breathing is reported. METHODS: A 62-year-old Caucasian male with multiple gastric surgeries, secondary to recurrent gastric ulcers and gastric outlet obstruction, presented with severe iron deficiency anemia (IDA) requiring IV iron therapy. RESULTS: Chronic malnutrition and malabsorption, associated with difficulty in tolerating oral and jejunostomy tube (J-tube) feedings, resulted in a two month 30 pound weight loss. Oral iron supplementation via a J-tube did not improve the IDA. Prior administrations of IV iron dextran resulted in flushing, generalized urticaria and angioedema associated with pruritus of the face and extremities within ten minutes of infusion. The allergy/immunology service was consulted. Premedication with IV diphenhydramine, 50 mg, prednisone via J-tube, 32 mg, and IV ranitidine, 50 mg, was followed with slow administration of a test dose of IS, 25 mg, at 1.6 mg/min. Within 30 minutes of the IV IS infusion, symptoms of nausea, flushing, and generalized pruritus, and difficulty in breathing were noted. The infusion was stopped and treatment with IV methyprednisolone, 125 mg, resulted in resolution of the reaction over several hours. No eosinophilia or elevated liver transaminases occurred. Subsequently, the infusion was reattempted: pre-medications consisted of IV methylprednisolone, 60 mg, IV diphenhydramine, 50 mg, and IV ranitidine, 50 mg, 75 minutes prior to the infusion of IS, 275 mg, 1.5 mg/min. Treatment was tolerated without adverse effects. CONCLUSIONS: A rare systemic reaction to IV IS is reported. Pretreatment with methylprednisolone, diphenhydramine and ranitidine 75 minutes before IS infusion was successful.