Iron chelator (parenteral)
Pregnancy: Use only if essential — limited data; potential fetal effects from severe iron deficit in mother. Specialist haematology / obstetric input. Uncontrolled iron overload itself is harmful.
Desferrioxamine mesilate
Brand names: Desferal
Adult dose
Dose: Acute iron overdose: 15 mg/kg/h IV infusion (max 80 mg/kg/24 hr); continue until urine no longer 'vin rosé' colour AND serum iron <60 µmol/L AND clinical recovery. Chronic transfusional iron overload (e.g., thalassaemia, MDS): 20–60 mg/kg SC infusion over 8–12 hr (overnight via portable pump), 5–7 nights per week. Aluminium overload (dialysis patients): 5 mg/kg IV at end of dialysis weekly.
Route: IV / SC infusion / IM
Frequency: Continuous (acute) or 5–7 nights/week (chronic)
Max: 80 mg/kg/24 hr (acute); 60 mg/kg/day (chronic)
Slow SC infusion (8–12 hr overnight) is the standard chronic regimen — adherence is the major challenge. Burden of nightly infusions has driven uptake of oral chelators (deferasirox, deferiprone).
Paediatric dose
Dose: 20 mg/kg
Route: SC / IV infusion
Frequency: Overnight 8–12 hr, 5–7 nights/week
Max: 60 mg/kg/day chronic; lower in young children to limit growth retardation
Same dosing as adults by weight. Children <3 yrs: ≤40 mg/kg/day to minimise bone growth toxicity.
Dose adjustments
Renal
Caution; iron-desferrioxamine complex (ferrioxamine) is renally excreted — accumulates in renal failure. Dialysis-removable.
Hepatic
Caution.
Paediatric weight-based calculator
Same dosing as adults by weight. Children <3 yrs: ≤40 mg/kg/day to minimise bone growth toxicity.
Clinical pearls
- Reddish-brown ('vin rosé', 'rust') urine on initiation = diagnostic of iron-desferrioxamine excretion. Useful marker that chelation is working in acute toxicity.
- Acute iron overdose: severe systemic toxicity at >60 mg/kg ingested elemental iron. Indications for IV desferrioxamine: serum iron >90 µmol/L, OR clinical features (shock, acidosis, persistent vomiting, GI bleed, altered consciousness), OR >60 mg/kg ingested.
- Chronic transfusional iron overload (thalassaemia major, MDS, refractory aplastic anaemia): start chelation when serum ferritin >1000 µg/L OR after 20 transfusions OR liver iron concentration >7 mg/g dry weight.
- Adherence to nightly SC infusions is the major limitation — oral chelators (deferasirox 20–40 mg/kg OD; deferiprone 75–99 mg/kg/day TDS) increasingly preferred. Combination therapy used in cardiac iron loading.
- Yersinia enterocolitica sepsis: ALWAYS suspect in chelator users with febrile diarrhoea (yersinia uses ferrioxamine as siderophore). Stop chelator and treat with ciprofloxacin.
- Annual audiometry and ophthalmology mandatory — toxicity is dose-related and partially reversible if caught early.
Contraindications
- Severe renal failure (relative — accumulation; use only if essential, increase dialysis)
- Hypersensitivity to desferrioxamine
Side effects
- Local injection-site reactions (very common): erythema, induration, pain, pruritus (SC)
- Anaphylactoid reactions on rapid IV (slow infusion essential)
- Hypotension if rapid IV
- Auditory toxicity (high-frequency hearing loss, tinnitus) — annual audiometry
- Visual toxicity (cataracts, optic neuritis, pigmentary retinopathy) — annual ophthalmology
- Bone growth retardation in young children (skeletal abnormalities)
- ↑ susceptibility to Yersinia, Klebsiella, mucormycosis (these organisms use iron-desferrioxamine complex as siderophore)
- Reddish-brown urine (ferrioxamine — diagnostic of binding occurring)
- GI upset, fever
- ARDS (rare, with continuous IV >24 hr at high dose)
Interactions
- Vitamin C (>500 mg/day): increases mobilisable iron pool — useful adjunct for chelation efficacy BUT can precipitate cardiac dysfunction in severe iron overload. Specialist titration.
- Prochlorperazine: severe loss of consciousness reported — avoid
- Gallium-67 imaging: avoid 48 hours before — false-negative scans
Monitoring
- Serum ferritin every 3 months (chronic chelation; target <1000 µg/L)
- Liver iron concentration (FerriScan MRI) annually
- Cardiac T2* MRI annually (target >20 ms)
- Annual audiometry, ophthalmology
- U&Es, LFTs, FBC every 3 months
- Growth (height, weight) in children every 3 months
Reference: BNFc; BNF 90; BNF for Children 2024; SmPC Desferal; UK Thalassaemia Society Standards 2016; Cappellini et al. Guidelines for the Management of Transfusion Dependent Thalassaemia 2014; TOXBASE Iron Overdose. Verify against your local formulary and the latest BNF before prescribing.
Related
Curated clinical cross-links plus same-class fallbacks.
Calculators
Pathways
Same specialty