Understanding and Managing Infusion Reactions and Hypophosphataemia With Intravenous Iron-A Nurses' Consensus Paper

Abstract

Aim: To provide evidence-based guidance on practical aspects and potential safety concerns (infusion reactions and hypophosphataemia) related to the use of intravenous iron from a nursing perspective.

Design: A modified Delphi consensus method.

Methods: Literature searches were conducted and used to support the development of 16 consensus statements. Six nurses with expertise in the field of gastroenterology and experience with the administration of intravenous iron participated in a modified Delphi process to develop a final set of statements.

Results: Overall, 16 statements achieved consensus and covered the practicalities of administration, infusion reactions and hypophosphataemia. Patient preparation is a key step in the administration of intravenous iron, but information should be communicated carefully to prevent undue anxiety. Highlighting the nurse's confidence in the management of any reactions may help to reduce anxiety. The patient should be observed during the first 5-10 min of an infusion to allow prompt management of immediate infusion reactions, although severe hypersensitivity reactions are rare. Nurses should be vigilant for symptoms of hypophosphataemia (such as fatigue, weakness and muscle/bone pain), which can develop following treatment with ferric carboxymaltose, saccharated ferric oxide and iron polymaltose. Serum phosphate levels should be measured in patients receiving ferric carboxymaltose who are at risk of low phosphate.

Impact: Infusion reactions and hypophosphataemia with intravenous iron are documented in the literature, but existing publications do not approach these topics from a nursing perspective. This consensus paper highlights the importance of patient preparation, monitoring and prompt management when administering intravenous iron to ensure patient safety. Considering that nurses have a central role in the administration of intravenous iron, the availability of evidence-based guidance is essential for both nurse confidence and patient safety.

Patient or public contribution: No patient or public contribution was involved in the consensus process.

Keywords: fatigue; hypersensitivity reactions; hypophosphataemia; intravenous iron; nursing; safety.

FIGURE 1

Algorithm for the administration of IV iron and the management of potential infusion reactions. Adapted from Achebe M, DeLoughery TG. 2020. Transfusion. 60, no. 6: 1154–1159. https://doi.org/10.1111/trf.15837, licensed under CC‐BY‐NC (https://creativecommons.org/licenses/by‐nc/4.0/), which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. IV = intravenous.

FIGURE 2

Symptoms and complications of hypophosphataemia following IV iron treatment. Figure developed based on Bishay et al. (2017); Zoller et al. (2017); Bartko et al. (2018); Burckhardt (2018); Klein et al. (2018); Tournis et al. (2018); Urbina et al. (2018); Fang et al. (2019); Callejas‐Moraga et al. (2020); Madero Velázquez et al. (2022); Schaefer, Tobiasch, et al. (2022); Vilaca et al. (2022); Strubbe et al. (2025); von Brackel et al. (2025).