TRAINING and EDUCATION
You Make the Call
Each month in “You Make the Call,” we’ll pick a challenging clinical question submitted through ASH’s Consult a Colleague
program and post the expert’s response, but we also want to know what you would do. Send in your responses to next month’s
clinical dilemma and see how your answer matches up to the experts’ in the next print issue.
This month, Michael Auerbach, MD, discusses treatment options for a pregnant woman with iron deficiency who has had
bariatric surgery.
Clinical Dilemma:
A pregnant woman who has had bariatric surgery is very iron deficient. We are having difficulty obtaining iron sucrose.
We plan to treat her during the second trimester. Are the other forms of IV iron safe? If so, which ones and at what dose?
Expert Opinion
Consult a Colleague
Through ASH
Michael Auerbach, MD
Private Practice, Baltimore, Maryland
Clinical Professor of Medicine
Georgetown University School of Medicine
Washington, DC
We have treated dozens of bariatric
gravidas with single 1,000 mg infusions
of intravenous iron using low-
molecular-weight iron dextran
(LMW ID). Iron sucrose (IS)
and ferric gluconate (FG) cost
twice as much and require
four to five visits, whereas
LMW ID requires one. Since
there is zero safety or efficacy
advantage with IS or FG, we
never use either formulation.
We administer 1,000 mg
LMW ID in one hour. We
have administered more than
6,000 of these infusions, many
in gravidas (second or third
trimester because there is no safety
data in the first), without a serious
adverse event (SAE). In the 2016 ASH
Education Book, my chapter provides the
rationale for single-dose infusion as well as
supporting references.
We recently published the results of the first U.S.
prospective study on IV iron in gravidas in the American
Journal of Medicine. All patients received 1,000 mg in one
hour. Previously, we published the results of a study of
189 consecutive, non-selected patients who received a
gram of LMW ID in one hour. There were no SAEs in
either study, which is consistent with the world’s literature
on this topic.
Your patient should receive 1,000 mg of LMW ID
in an hour. Alternatively, she can be treated with two
doses of ferric carboxymaltose (FCM) 750 mg on two
consecutive visits. This drug has a safety record in
pregnancy, as does LMW ID. It costs seven times as much
as LMW ID without the safety or efficacy advantage,
Consult a Colleague is a service for ASH
members that helps facilitate the exchange
of information between hematologists
and their peers. ASH members can seek
consultation on clinical cases from qualified
experts in 11 categories:
• Anemias
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström
macroglobulinemia
• Myeloproliferative disorders
• Myelodysplastic syndromes
• Thrombocytopenias
Assigned volunteers (“colleagues”) will
respond to inquiries within two business
days (either by email or phone).
but has the increased convenience of a 15-minute
administration time. A prospective study published in
Obstetric Medicine compared the two, and no difference
was observed. If a mild reaction to LMW ID occurs, FCM
is usually safe and vice versa.
Another alternative is ferumoxytol, which is approved
only for chronic kidney disease. There are no safety data
in pregnancy. Hopefully, a broad approval for this agent,
which is expensive, will occur soon, giving us another
good option.
Next Month’s Clinical Dilemma:
A 73-year-old woman has stage III large B-cell
lymphoma. I did not do a bone marrow biopsy, but she
had a normal LP and normal brain MRI. She has had
two courses of R-CHOP with a great response. However,
she has developed pronounced short-term memory
ASHClinicalNews.org
loss. She can no longer care for herself and does not
remember events from the previous hour. Is this chemo
brain? If so, what regimen would be safe to use?
How would you respond? Email us at
[email protected]. ●
Have a puzzling clinical dilemma?
Submit a question, and read more
about Consult a Colleague volunteers at
hematology.org/Clinicians/Consult.aspx
or scan the QR code.
*If you have a request related to a
hematologic disorder not listed here,
please email your recommendation to
[email protected] so it can be
considered for addition in the future.
DISCLAIMER: ASH does not recommend
or endorse any specific tests, physicians,
products, procedures, or opinions, and
disclaims any representation, warranty, or
guaranty as to the same. Reliance on any
information provided in this article is solely
at your own risk.
ASH Clinical News
47