Ferric Carboxymaltose

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# Overview
Ferric Carboxymaltose is an iron supplement that is FDA approved for the treatment of iron deficiency anemia in adult patients.   Common adverse reactions include nausea, hypertension, flushing, hypophosphatemia, and dizziness.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

# Indications
- Injectafer is indicated for the treatment of iron deficiency anemia in adult patients:
- Who have intolerance to oral iron or have had unsatisfactory response to oral iron;
- Who have non-dialysis dependent chronic kidney disease.

# Dosage
- For patients weighing 50 kg (110 lb) or more:  Give Injectafer in two doses separated by at least 7 days.  Give each dose as 750 mg for a total cumulative dose not to exceed 1500 mg of iron per course.
- For patients weighing less than 50 kg (110 lb):  Give Injectafer in two doses separated by at least 7 days. Give each dose as 15 mg/kg body weight for a total cumulative dose not to exceed 1500 mg of iron per course.
- The dosage of Injectafer is expressed in mg of elemental iron. Each mL of Injectafer contains 50 mg of elemental iron.  Injectafer treatment may be repeated if iron deficiency anemia reoccurs.
- Administer Injectafer intravenously, either as an undiluted slow intravenous push or by infusion.  When administering as a slow intravenous push, give at the rate of approximately 100 mg (2 mL) per minute.  When administered via infusion, dilute up to 750 mg of iron in no more than 250 mL of sterile 0.9% sodium chloride injection, USP, such that the concentration of the infusion is not less than 2 mg of iron per mL and administer over at least 15 minutes.
- When added to an infusion bag containing 0.9% sodium chloride injection, USP, at concentrations ranging from 2 mg to 4 mg of iron per mL, Injectafer solution is physically and chemically stable for 72 hours when stored at room temperature.  To maintain stability, do not dilute to concentrations less than 2 mg iron/mL.
- Inspect parenteral drug products visually for the absence of particulate matter and discoloration prior to administration.  The product contains no preservatives. Each vial of Injectafer is intended for single-use only. Any unused drug remaining after injection must be discarded.
- Avoid extravasation of Injectafer since brown discoloration of the extravasation site may be long lasting.  Monitor for extravasation.  If extravasation occurs, discontinue the Injectafer administration at that site.

# DOSAGE FORMS AND STRENGTHS
- 750 mg iron/15 mL single-use vial

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Ferric Carboxymaltose in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Ferric Carboxymaltose in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Ferric Carboxymaltose in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Ferric Carboxymaltose in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Ferric Carboxymaltose in pediatric patients.

# Contraindications
- Hypersensitivity to Injectafer or any of its components.

# Warnings
Hypersensitivity Reactions
- Serious hypersensitivity reactions, including anaphylactic-type reactions, some of which have been life-threatening and fatal, have been reported in patients receiving Injectafer. Patients may present with shock, clinically significant hypotension, loss of consciousness, and/or collapse. Monitor patients for signs and symptoms of hypersensitivity during and after Injectafer administration for at least 30 minutes and until clinically stable following completion of the infusion. Only administer Injectafer when personnel and therapies are immediately available for the treatment of serious hypersensitivity reactions.In clinical trials, serious anaphylactic/anaphylactoid reactions were reported in 0.1% (2/1775) of subjects receiving Injectafer. Other serious or severe adverse reactions potentially associated with hypersensitivity which included, but not limited to, pruritus, rash, urticaria, wheezing, or hypotension were reported in 1.5% (26/1775) of these subjects.
Hypertension
- In clinical studies, hypertension was reported in 3.8% (67/1,775) of subjects in clinical trials 1 and 2. Transient elevations in systolic blood pressure, sometimes occurring with facial flushing, dizziness, or nausea were observed in 6% (106/1,775) of subjects in these two clinical trials. These elevations generally occurred immediately after dosing and resolved within 30 minutes.   Monitor patients for signs and symptoms of hypertension following each Injectafer administration.
Laboratory Test Alterations
- In the 24 hours following administration of Injectafer, laboratory assays may overestimate serum iron and transferrin bound iron by also measuring the iron in Injectafer.

# Adverse Reactions

## Clinical Trials Experience
- The following adverse reactions are discussed in greater detail in other sections of the labeling:
- Hypersensitivity Reactions
- Hypertension
- Laboratory Test Alterations
Adverse Reactions in Clinical Trials
- Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed cannot be directly compared to rates in other clinical trials and may not reflect the rates observed in clinical practice.
- In two randomized clinical studies, a total of 1,775 patients were exposed to Injectafer 15 mg/kg body weight up to a maximum single dose of 750 mg of iron on two occasions separated by at least 7 days up to a cumulative dose of 1500 mg of iron.
- Adverse reactions reported by  1% of treated patients are shown in the following table.
- Other adverse reactions reported by  0.5% of treated patients include abdominal pain, diarrhea, gamma glutamyl transferase increased, injection site pain/irritation, rash, paraesthesia, sneezing. Transient decreases in laboratory blood phosphorus levels (< 2 mg/dL) have been observed in 27% (440/1638) patients in clinical trials.

## Postmarketing Experience
Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. The following serious adverse reactions have been most commonly reported from the post-marketing spontaneous reports with Injectafer:  urticaria, dyspnea, pruritis, tachycardia, erythema, pyrexia, chest discomfort, chills, angioedema, back pain, arthralgia, and syncope. One case of hypophosphatemic osteomalacia was reported in a subject who received 500 mg of Injectafer every 2 weeks for a total of 16 weeks.  Partial recovery followed discontinuation of Injectafer.

# Drug Interactions
- Formal drug interaction studies have not been performed with Injectafer.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): 
Pregnancy Category C
Risk Summary
- Adequate and well controlled studies in pregnant women have not been conducted.    However, animal reproduction studies have been conducted with ferric carboxymaltose. In these studies, administration of ferric carboxymaltose to rabbits during the period of organogenesis caused fetal malformations and increased implantation loss at maternally toxic doses of approximately 12% to 23% of the human weekly dose of 750 mg (based on body surface area).  The incidence of major malformations in human pregnancies has not been established for Injectafer. However, all pregnancies, regardless of exposure to any drug, has a background rate of 2 to 4% for major malformations, and 15 to 20% for pregnancy loss. Injectafer should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Animal Data
- Administration of ferric carboxymaltose to rats as a one-hour intravenous infusion up to 30 mg/kg/day iron on gestation days 6 to 17 did not result in adverse embryofetal findings.  This daily dose in rats is approximately 40% of the human weekly dose of 750 mg based on body surface area.  In rabbits, ferric carboxymaltose was administered as a one-hour infusion on gestation days 6 to 19 at iron doses of 4.5, 9, 13.5, and 18 mg/kg/day.  Malformations were seen starting at the daily dose of 9 mg/kg (23% of the human weekly dose of 750 mg).  Spontaneous abortions occurred starting at the daily iron dose of 4.5 mg/kg (12% of the human weekly dose based on body surface area).  Pre-implantation loss was at the highest dose.  Adverse embryofetal effects were observed in the presence of maternal toxicity.
- A pre- and post-natal development study was conducted in rats at intravenous doses up to 18 mg/kg/day of iron (approximately 23% of the weekly human dose of 750 mg on a body surface area basis).  There were no adverse effects on survival of offspring, their behavior, sexual maturation or reproductive parameters.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Ferric Carboxymaltose in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Ferric Carboxymaltose during labor and delivery.

### Nursing Mothers
- A study to determine iron concentrations in breast milk after administration of Injectafer (n=11) or oral ferrous sulfate (n=14) was conducted in 25 lactating women with postpartum iron deficiency anemia.  Mean breast milk iron levels were higher in lactating women receiving Injectafer than in lactating women receiving oral ferrous sulfate.

### Pediatric Use
- Safety and effectiveness have not been established in pediatric patients.

### Geriatic Use
- Of the 1775 subjects in clinical studies of Injectafer, 50% were 65 years and over, while 25% were 75 years and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

### Gender
There is no FDA guidance on the use of Ferric Carboxymaltose with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Ferric Carboxymaltose with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Ferric Carboxymaltose in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Ferric Carboxymaltose in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Ferric Carboxymaltose in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Ferric Carboxymaltose in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Intravenous

### Monitoring
There is limited information regarding Monitoring of Ferric Carboxymaltose in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of Ferric Carboxymaltose in the drug label.

# Overdosage
- Excessive dosages of Injectafer may lead to accumulation of iron in storage sites potentially leading to hemosiderosis. A patient who received Injectafer 18,000 mg over 6 months developed hemosiderosis with multiple joint disorder, walking disability and asthenia. Hypophosphatemic osteomalacia was reported in a patient who received Injectafer 4000 mg over 4 months. Partial recovery followed discontinuation of Injectafer.

# Pharmacology
There is limited information regarding Ferric Carboxymaltose Pharmacology in the drug label.

## Mechanism of Action
- Ferric carboxymaltose is a colloidal iron (III) hydroxide in complex with carboxymaltose, a carbohydrate polymer that releases iron.

## Structure
- Ferric carboxymaltose, an iron replacement product, is an iron carbohydrate complex with the chemical name of polynuclear iron (III) hydroxide 4(R)-(poly-(14)-O--D-glucopyranosyl)-oxy-2(R),3(S),5(R),6-tetrahydroxy-hexanoate. It has a relative molecular weight of approximately 150,000 Da corresponding to the following empirical formula:
- n k,
- where n  103, m  8, l  11, and k  4
(l represents the mean branching degree of the ligand).
- The chemical structure is presented below:
- Injectafer (ferric carboxymaltose injection) is a dark brown, sterile, aqueous, isotonic colloidal solution for intravenous injection. Each mL contains 50 mg iron as ferric carboxymaltose in water for injection.  Injectafer is available in 15 mL single-use vials.  Sodium hydroxide and/or hydrochloric acid may have been added to adjust the pH to 5.0-7.0.
- Vial closure is not made with natural rubber latex.

## Pharmacodynamics
- Using positron emission tomography (PET) it was demonstrated that red cell uptake of 59Fe and 52Fe from Injectafer ranged from 61% to 99%. In patients with iron deficiency, red cell uptake of radio-labeled iron ranged from 91% to 99% at 24 days after Injectafer dose. In patients with renal anemia red cell uptake of radio-labeled iron ranged from 61% to 84% after 24 days Injectafer dose.

## Pharmacokinetics
- After administration of a single dose of Injectafer of 100 to 1000 mg of iron in iron deficient patients, maximum iron levels of 37 g/mL to 333 g/mL were obtained respectively after 15 minutes to 1.21 hours post dose. The volume of distribution was estimated to be 3 L.
- The iron injected or infused was rapidly cleared from the plasma, the terminal half-life ranged from 7 to 12 hours. Renal elimination of iron was negligible.

## Nonclinical Toxicology
Carcinogenesis and Mutagenesis and Impairment of Fertility
- Carcinogenicity studies have not been performed with ferric carboxymaltose.
- Ferric carboxymaltose was not genotoxic in the following genetic toxicology studies: in vitro microbial mutagenesis (Ames) assay, in vitro chromosome aberration test in human lymphocytes, in vitro mammalian cell mutation assay in mouse lymphoma L5178Y/TK+/- cells, in vivo mouse micronucleus test at single intravenous doses up to 500 mg/kg.
- In a combined male and female fertility study, ferric carboxymaltose was administered intravenously over one hour to male and female rats at iron doses of up to 30 mg/kg.  Animals were dosed 3 times per week (on Days 0, 3, and 7).  There was no effect on mating function, fertility or early embryonic development. The dose of 30 mg/kg in animals is approximately 40% of the human dose of 750 mg based on body surface area.

# Clinical Studies
- The safety and efficacy of Injectafer for treatment of iron deficiency anemia were evaluated in two randomized, open-label, controlled clinical trials (Trial 1 and Trial 2). In these two trials, Injectafer was administered at a dose of 15 mg/kg body weight up to a maximum single dose of 750 mg of iron on two occasions separated by at least 7 days up to a cumulative dose of 1500 mg of iron.
Trial 1: Iron Deficiency Anemia in Patients Who Are Intolerant to Oral Iron or Have Had Unsatisfactory Response to Oral Iron
- Trial 1 was a randomized, open-label, controlled clinical study in patients with iron deficiency anemia who had an unsatisfactory response to oral iron (Cohort 1) or who were intolerant to oral iron (Cohort 2) during the 14 day oral iron run-in period. Inclusion criteria prior to randomization included hemoglobin (Hb) <12 g/dL, ferritin  100 ng/mL or ferritin  300 ng/mL when transferrin saturation (TSAT)  30%. Cohort 1 subjects were randomized to Injectafer or oral iron for 14 more days.  Cohort 2 subjects were randomized to Injectafer or another IV iron per standard of care . The mean age of study patients was 43 years (range, 18 to 94); 94% were female; 42% were Caucasian, 32% were African American, 24% were Hispanic, and 2% were other races. The primary etiologies of iron deficiency anemia were heavy uterine bleeding (47%) and gastrointestinal disorders (17%).
- Table 2 shows the baseline and the change in hemoglobin from baseline to highest value between baseline and Day 35 or time of intervention.
Trial 2: Iron Deficiency Anemia in Patients with Non-Dialysis Dependent Chronic Kidney Disease
- Trial 2 was a randomized, open-label, controlled clinical study in patients with non-dialysis dependent chronic kidney disease. Inclusion criteria included hemoglobin (Hb)  11.5 g/dL, ferritin  100 ng/mL or ferritin  300 ng/mL when transferrin saturation (TSAT)  30%.  Study patients were randomized to either Injectafer or Venofer. The mean age of study patients was 67 years (range, 19 to 96); 64% were female; 54% were Caucasian, 26% were African American, 18% Hispanics, and 2% were other races.
- Table 3 shows the baseline and the change in hemoglobin from baseline to highest value between baseline and Day 56 or time of intervention.
- Increases from baseline in mean ferritin (734.7  337.8 ng/mL), and transferrin saturation (30  17%) were observed at Day 56 in Injectafer-treated patients.

# How Supplied
- NDC 0517-0650-01           750 mg iron/15 mL Single-Use Vial        Individually boxed
- NDC 0517-0650-02           750 mg iron/15 mL Single-Use Vial        Packages of 2

## Storage
- Store at 20C to 25C (68F to 77F); excursions permitted to 15C to 30C (59F to 86F).Do not freeze.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
Question patients regarding any prior history of reactions to parenteral iron products.
- Advise patients of the risks associated with Injectafer.
- Advise patients to report any signs and symptoms of hypersensitivity that may develop during and following Injectafer administration, such as rash, itching, dizziness, lightheadedness, swelling and breathing problems .

# Precautions with Alcohol
- Alcohol-Ferric Carboxymaltose interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- INJECTAFER

# Look-Alike Drug Names
- A  B

# Drug Shortage Status

# Price