Dosing and uses of Desferal (deferoxamine)
Adult dosage forms and strengths
powder for injection
- 500mg/vial
- 2g/vial
Acute Iron Poisoning
IM administration is indicated for all patients NOT in shock; administer 1g IM initially and then 500mg Q4hr for 2 doses
Depending upon clinical response, subsequent doses of 500mg Q4-12hr can be administered
Maximum dose: 6g in 24 hours
IV administration should be reserved for patients in a state of cardiovascular collapse or shock; 1g slow IV infusion
Rate of infusion should not exceed 15mg/kg/hr for the first dose; subsequent doses should not be infused at a faster rate than 125mg/hr
Chronic Iron Overload
SC administration: 1-2g (20-40mg/kg/day) SC over 8-24 hours using a small portable pump capable of providing continuous mini-infusion; individualize infusion duration
IV administration in patients with IV access: 40-50mg/kg/day over 8-12 hours for 5-7 days/ week (maximum of < 60mg/kg/day and an IV infusion rate of <15mg/kg/hr)
IM administration: 0.5-1g QD (maximum of 1g QD)
Additional Information
Can be administered prior to or following same day blood transfusion in patients that are poorly compliant; should not be administered concurrently as this can lead to errors in interpretation of ADRs
Pediatric dosage forms and strengths
powder for injection
- 500mg/vial
- 2g/vial
Acute Iron Poisoning
<3 years: Safety and effectiveness has not been established
≥3 years: Administer 1g IM initially and then 500mg Q4hr for 2 doses for all patients not in shock
Depending upon clinical response, subsequent doses of 500mg Q4-12hr can be administered; maximum dose: 6g in 24 hours
IV administration should be reserved for patients in a state of cardiovascular collapse or shock; 1g slow IV infusion
Rate of infusion should not exceed 15mg/kg/hr for the first dose; subsequent doses should not be infused at a faster rate than 125mg/hr
20 mg/kg IM (for all patients not in shock) or IV (only if patient in cardiovascular collapse/shock); then, 10 mg/kg IM/IV q4hr x2; then, depending on clinical circumstance, may administer addtional doses of 10 mg/kg IM/IV q4-12hr PRn
IV infusion rate: Initial 1 g at 15 mg/kg/hr, all subsequent doses no more than 125 mg/hr
No more than 6 g/day (IM/IV), but in severe cases should continue infusion up to 24 hours
Chronic Iron Overload
<3 years: Safety and effectiveness has not been established
≥3 years: 0.5-1g IM QD (maximum of 1g QD)
SC administration: 1-2g (20-40mg/kg/day) SC over 8-24 hours using a small portable pump capable of providing continuous mini-infusion; individualize infusion duration
IV administration in patients with IV access: 40-50mg/kg/day over 8-12 hours for 5-7 days/ week (maximum of < 60mg/kg/day and an IV infusion rate of <15mg/kg/hr)
Additional Information
Can be administered prior to or following same day blood transfusion in patients that are poorly compliant; should not be administered concurrently as this can lead to errors in interpretation of ADRs
Desferal (deferoxamine) adverse (side) effects
Frequency not defined
Injection site reactions (eg, localized irritation, induration, infiltration, pain, erythema, wheal formation, eschar, burning, swelling, pruritus, crust, vesicles, local edema); these may be associated with systemic allergic reactions
Systemic reactions (eg, abdominal pain, arthralgia, asthma, fever, headache, myalgia, nausea, vomiting)
Cardiovascular reactions (eg, hypotension with too rapid IV infusion, tachycardia, shock)
Hypersensitivity reactions (eg, anaphylactic reaction with or without shock, angioedema, generalized rash, urticaria)
Digestive reactions (eg, abdominal discomfort, diarrhea, nausea, vomiting)
Hematologic reactions (eg, blood dyscrasia including thrombocytopenia and leucopenia)
Hepatic reactions (eg, increased transaminases, hepatic dysfunction)
Musculoskeletal reactions (eg, muscle spasms, growth retardation and bone changes including metaphyseal dysplasia are common in doses ≥ 60 mg/kg, especially those who begin iron chelation in the first three years of life; reduced risk if doses are kept to ≤ 40 mg/kg)
Nervous System reactions (eg, neurological disturbances including dizziness, peripheral sensory, motor, or mixed neuropathy, paresthesias, seizures; exacerbation or precipitation of aluminum-related dialysis encephalopathy)
Special Senses reactions (eg, high-frequency sensorineural hearing loss and/or tinnitus are uncommon if dosage guidelines are not exceeded and if dose is reduced when ferritin levels decline; visual disturbances inlcuding decreased acuity, blurred vision, loss of vision, dyschromatopsia, night blindness, visual field defects, scotoma, retinopathy (pigmentary degeneration), optic neuritis, and cataracts are rare if dosage guidelines are not exceeded)
Respiratory reactions (eg, acute respiratory distress syndrome with dyspnea, cyanosis, and/or interstitial infiltrates)
Very rare generalized rash
Urogenital reactions including dysuria, acute renal failure, increased serum creatinine and renal tubular disorders
Postmarketing Reports
Renal dysfunction, including renal failure; monitor patients for changes in renal function (eg, increased serum creatinine)
Warnings
Contraindications
Known hypersensitivity to deferoxamine or any of its components
Patients with severe renal disease or anuria
Cautions
Administration by rapid IV injection may cause flushing of the skin, urticaria, hypotension, and shock; administer IM or by slow SC or IV infusion
Rare fatal cases of mucormycosis have been reported; if any signs and symptoms occur, discontinue treatment and conduct mycological tests immediately
Severe chronic iron overload may precipitate reversible cardiac function impairment if high doses of Vitamin C (> 500 mg QD in adults) are given concomitantly; do not administer Vitamin C to HF patients; wait > 1 month after treatment to begin supplemental Vitamin C therapy; administer vitamin C only if the patient is receiving Desferal regularly, ideally soon after setting up the infusion pump; do not exceed a daily vitamin C dose of 200 mg in adults, given in divided doses; monitor cardiac function closely during such combined therapy
Dialysis patients with aluminum-related encephalopathy may experience neurological dysfunction (seizures), possibly due to an acute increase in circulating aluminum;onset of dialysis dementia may be precipitated; treatment in the presence of aluminum overload may result in decreased serum calcium and aggravation of hyperparathyroidism
Monitor for changes in renal function
Not a substitute for standard measures generally used in iron toxicity (eg, induced emesis, gastric lavage)
Iron overload increases susceptibility of patients to Yersinia enterocolitica and Yersinia pseudotuberculosis infections; treatment may therefpre enhance patient's susceptibility
Monitor pediatric patients for body weight and growth every 3 months
Pregnancy and lactation
Pregnancy category: C
Lactation: Unknown if excreted in breast milk, use caution
Pregnancy categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA: Information not available.
Pharmacology of Desferal (deferoxamine)
Mechanism of action
Desferal chelates iron by forming a stable complex that prevents the iron from entering into further chemical reactions; also chelates iron readily from ferritin and hemosiderin but not readily from transferrin; does not combine with the iron from cytochromes and hemoglobin; chelate is readily soluble and is renally excreted
Pharmacokinetics
Metabolism: Principally by plasma enzymes; pathways not yet defined
Excretion: Primarily urine; partly excreted in feces
Additional Information
100mg of deferoxamine binds to about 10mg of iron and 4.1mg of aluminum
End points of treatment are clinical improvement, resolution of anion gap and acidosis, return of urine color to baseline, serum iron level ≤ 100 mcg/dL
Vin Rose urine, or a change in urine color from baseline, indicates presence of deferoxamine-iron chelate; may not always be present, so cannot be used to rule out significant iron ingestion; patient should be advised to obtain baseline urine for visual comparison and keep at bedside
Administration
Reconstitution
Preparation for IM administration: 500mg with 2mL SWI/ 2g with 8mL SWI (final concentration after reconstitution for both: 213mg/mL)
Preparation for IV administration: 500mg with 5mL SWI/ 2g with 20mL SWI (final concentration after reconstitution for both: 95mg/mL)
Preparation for SC administration: 500mg with 5mL SWI/ 2g with 20mL SWI (final concentration after reconstitution for both: 95mg/mL)
Use immediately; ≤ 3hours of reconstitution
When reconstitution is carried under aseptic conditions, may store ≤ 24 hr at 25°C; do not refrigerate; do not reconstitute with other solvents or under different conditions due to risk of precipitation
