deferoxamine
Iron-chelating agent· Brands: DesferalIMIVSC
Mechanism of action
Deferoxamine chelates ferric iron to form ferrioxamine, a stable water-soluble complex that is excreted renally. It also chelates aluminium, but does not affect iron bound to transferrin or haemoglobin.
Pharmacokinetics
Deferoxamine is poorly absorbed from the gastrointestinal tract, so for systemic effects it is given parenterally. It is extensively metabolised in the liver to inactive metabolites. The drug and its iron complex are excreted primarily in the urine. The half-life of deferoxamine is about 1 hour, but the ferrioxamine complex persists longer.
Indications & dosing
Acute iron poisoning (severe)
Infuse at 15 mg/kg/hour. Maximum daily dose 6 g.
- adult · IV: 15 mg/kg/hour continuous infusion · Infuse at 15 mg/kg/hour. Maximum daily dose 6 g.
Chronic iron overload (e.g. thalassemia, sickle cell disease)
Subcutaneous infusion over 8-12 hours. Adjust based on serum ferritin.
- adult · SC: 20–40 mg/kg/day daily · Subcutaneous infusion over 8-12 hours. Adjust based on serum ferritin.
Aluminium toxicity (e.g. in chronic kidney disease)
Administer as slow IV infusion. Regimens vary; consult local formulary.
- adult · IV: 5–20 mg/kg once weekly · Administer as slow IV infusion. Regimens vary; consult local formulary.
Contraindications & precautions
- Hypersensitivity to deferoxamine or any component of the formulation · Rarely reported, but can cause severe reactions.
- Severe renal impairment or anuria · Excreted mainly by the kidneys; accumulation of the drug and complex may occur.
- Pregnancy (unless the potential benefit outweighs the risk) · Animal data show adverse effects; use only if clearly needed.
- Monitor blood pressure and pulse during intravenous infusion; slow the infusion rate if hypotension occurs.
- Perform baseline and regular ophthalmological and audiological assessments in patients on long-term therapy.
- Use with caution in renal impairment; reduce the dose and monitor closely because accumulation of the iron-chelator complex occurs in renal failure.
- Resuscitation facilities should be available when the drug is administered intravenously, because of the risk of anaphylaxis.
- Do not use concurrently with prochlorperazine; this combination may cause loss of consciousness.
- Ensure adequate hydration and urine output during treatment to minimise the risk of nephrotoxicity from the iron-chelator complex.
Adverse effects
- Injection site reactions (pain, erythema, swelling)
- Flushing and urticaria
- Nausea, vomiting, and gastrointestinal upset
- Hypotension, especially with rapid intravenous infusionserious
- Visual and auditory disturbances (optic neuropathy, hearing loss, tinnitus)serious
- Anaphylactic reactionsserious
- Severe infections, including Yersinia enterocolitica septicaemiaserious
- Acute respiratory distress syndrome (ARDS)serious
Renal & hepatic adjustment
- eGFR 0+: Renal impairment: dose reduction or extended dosing interval may be necessary. Monitor for signs of accumulation and toxicity.
Monitoring, pregnancy & toxicity
- Serum ferritin · Every 3-12 months depending on clinical need
- Serum iron and transferrin saturation · Baseline and periodically during treatment
- Renal function (serum creatinine, urea) · Baseline and at regular intervals
- Auditory function (audiometry) · Annually
- Ophthalmological examination (fundoscopy) · Annually
- Urine iron excretion · When monitoring chelation efficacy
- Pregnancy: Deferoxamine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In acute iron poisoning, it is life-saving and should not be withheld. For chronic iron overload, consider alternative chelation if possible.
- Toxicity: Hypotension and anaphylactic reactions · Stop infusion, give IV fluids, and treat anaphylaxis with adrenaline and supportive care.
- Toxicity: Pulmonary toxicity (acute respiratory distress syndrome) · Discontinue the drug and provide intensive supportive care.
- Toxicity: Visual and auditory disturbances (retinopathy, optic neuritis, ototoxicity) · Stop treatment and refer for specialist assessment; consider alternative chelation.
- Toxicity: Renal impairment and acidosis in overdose · Discontinue the drug, monitor renal function and acid-base balance, and provide supportive care. Haemodialysis may enhance elimination.
Clinical notes
Used for acute iron poisoning, especially with severe symptoms or high serum iron levels, and for chronic iron overload such as in thalassaemia. Rapid IV infusion can cause hypotension; allergic reactions and ototoxicity may occur. Urine may become reddish-brown, indicating iron excretion. Doses are individualised; chelation therapy requires careful monitoring.
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BNF; local formulary