TREATMENT ALGORITHM FOR IRON DEFICIENCY IN HEART FAILURE

VERSION:Oktober 2015

REFERENCES:McMurray JJ et al. European Heart Journal 2012;33:1787-847. McMurray JJ et al. Eur J Heart Fail. 2012;14:803-69.Anker SD et al. Eur J Heart Fail. 2009;11:1084–91.Ponikowski P et al. European Heart Journal 2015 Mar 14;36(11):657-68.McDonagh T et al. Eur J Heart Fail. 2015 Mar;17(3):248-62.

Iron deficiency is common in HF, it can lead to anaemia and/or skeletal muscle dysfunction, and has been associated with a worse prognosis. I.V. iron has been studied in patients with HFrEF and iron deficiency both with and without anaemia. More specifically, I.V. ferric carboxymaltose has been shown to improve self-reported patient global assessment, NYHA class, and exercise capacity.Treatment was also associated with a significant reduction in hospitalizations for worsening HF in the Confirm HF trial. However, no I.V. iron trial was powered to determine the impact on major outcomes, or to evaluate separately the effects in anaemic and non-anaemic patients.Finally, the effect of treating iron deficiency in HFpEF and the long-term safety of iron therapy in either HFrEF or HFpEF is unknown.

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DIAGNOSIS AND TREATMENT OF IRON DEFICIENCY IN CHRONIC HEART FAILURE

Determine cause of anaemia*

and treat accordingly

CHRONIC HEART FAILURE(NYHA II-IV)

IRON DEFICIENCY

ferritin <100 ng/mL or

ferritin 100-299 ng/mL and TSAT** <20%

YESYES NONO

YES NOAnaemiaMale Hb <13 g/dL

Female Hb <12 g/dL

AnaemiaMale Hb <13 g/dL

Female Hb <12 g/dL

Determine cause of anaemia*

and treat accordingly No treatment

Ferric carboxymaltose***

as 500-1000 mg single doses to correct iron deficiency

Check ferritin/TSAT** at next scheduled visit (preferable 1-3 months)

Ferric carboxymaltose as 500 mg to maintain ferritin/TSAT** on target

Check ferritin/TSAT** if change in clinical picture orHb decrease or 1-2 times per year

* * Causes of anaemia: • Occult bleeding e.g. GI, malignancies • Renal e.g. erythropoietin • Other deficiencies e.g. Vitamin B12, folic acid • Other haemoglobinopathies e.g. thalassaemia, sickle cell anaemia • ...

** TSAT: transferrin saturation

*** See Summary of Product Characteristics