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Iron/Aluminium Overload in Dialysis Pregnancy: SPC 4.6 Pregnancy: there is a limited amount of data on the use of desferrioxamine in pregnant patients. Studies in animals (rabbits) have shown reproductive toxicity/teratogenicity. The risk to the foetus/mother is unknown. It should be used during pregnancy only if the expected benefits to the mother outweigh the potential risk to the foetus. Breastfeeding: it is not known whether desferrioxamine is excreted into the breast milk; because of the potential for serious adverse drug reactions in breast-fed newborns/infants, a decision should be made whether to abstain from breast-feeding or to abstain from using the medicinal product, taking into account the importance of the medicinal product to the mother. Fertility: in women of child-bearing potential, in each case the benefits for the mother must be weighed against the risks for the child.

Deferoxamine (Iron/Aluminium Overload in Dialysis)

Brand names: Desferal

Deferoxamine (desferrioxamine) is a parenteral iron- and aluminium-chelating agent used in dialysis patients to manage iron or aluminium overload.

Adult dose

Dose: Chronic iron overload (SPC 4.1: transfusional haemosiderosis in patients receiving regular transfusions, e.g. thalassaemia major; primary and secondary haemochromatosis in patients in whom concomitant disorders, e.g. severe anaemia, hypoproteinaemia, renal or cardiac failure, preclude phlebotomy). Product: desferrioxamine mesilate 500 mg powder for solution for injection or infusion (500 mg per vial). Adults and children: use the lowest effective dose; the average daily dose will probably lie between 20 and 60 mg/kg/day. Serum ferritin below 2000 ng/mL: about 25 mg/kg/day; 2000 to 3000 ng/mL: about 35 mg/kg/day; patients with higher serum ferritin may require up to 55 mg/kg/day. To assess chelation, monitor 24 hour urinary iron excretion daily at first; starting with a dose of 500 mg daily, raise the dose until a plateau of iron excretion is reached. ALUMINIUM OVERLOAD IN MAINTENANCE DIALYSIS (licensed in SPC 4.1): no regimen is given here because the aluminium-overload posology was not retrieved - see notes.
Route: Subcutaneous infusion using a portable, light-weight infusion pump (iron overload). Intramuscular injection only when subcutaneous infusion is not feasible.
Frequency: Slow subcutaneous infusion over 8 to 12 hours, normally with the pump 5 to 7 times a week. Infusing the same daily dose over 24 hours may give a further increase in iron excretion.
SCOPE - THIS CARD COVERS THE IRON-OVERLOAD LIMB OF THE PAGE ONLY. The UK SPC (MHRA Products: DESFERRIOXAMINE MESILATE 500 MG powder for solution for injection or infusion, PL245980020, Noridem Enterprises Ltd) licenses, in section 4.1, both 'chronic iron overload' and 'Aluminium overload - in patients on maintenance dialysis for end stage renal failure where preventative measures (e.g. reverse osmosis) have failed and with proven aluminium-related bone disease and/or anaemia, dialysis encephalopathy; and for diagnosis of aluminium overload'. The page's second route (intravenous after dialysis, for aluminium overload) is NOT COVERED: the retrieved section 4.2 contains the acute iron poisoning and chronic iron overload posology and then stops mid-sentence inside the Elderly paragraph ('...(see sections'), so any aluminium-overload sub-section that follows was never retrieved, and nothing has been filled in. The chronic iron overload regimen above is the label's general regimen for 'Adults and children'; it does not give a separate regimen for patients on dialysis. The acute iron poisoning regimen is a different indication and is not reproduced. CEILING NOT STATED AS ONE MAXIMUM: the SPC prints 'Patients with higher serum ferritin may require up to 55 mg/kg/day' and also 'It is inadvisable to regularly exceed an average daily dose of 50 mg/kg/day except when very intensive chelation is needed in patients who have completed growth'; maxDose is therefore left empty. 'Higher doses should only be employed if the benefit for the patient outweighs the risk of unwanted effects.' START AND ADJUSTMENT: therapy should be commenced after the first 10-20 blood transfusions, or when there is evidence from clinical monitoring that chronic iron overload is present (e.g. serum ferritin >1000 ng/mL); the dose and mode of administration should be individually adapted according to the degree of iron overload. 'If ferritin values fall below 1000 ng/mL, the risk of Desferrioxamine Mesilate toxicity increases; it is important to monitor these patients particularly carefully and perhaps to consider lowering the total weekly dose.' Alternatively the mean daily dose may be adjusted so that the therapeutic index (mean daily dose in mg/kg divided by serum ferritin in micro g/L) stays below 0.025; the SPC says this index is not a substitute for careful clinical monitoring. PREPARATION AND ADMINISTRATION (SPC 4.2): the product should preferably be employed as a 10% solution (e.g. dissolve the contents of one 500 mg vial in 5 mL of water for injection); infusion solutions (sodium chloride 0.9%, dextrose 5%, combined, Ringer's lactate) may be used to dilute the 10% solution but should not be used as solvent for the dry substance; only clear pale yellow solutions should be used. 'Desferrioxamine Mesilate is not formulated to support subcutaneous bolus injection', and should not be given subcutaneously in concentrations and/or doses higher than those recommended (local irritation). Dissolved desferrioxamine can also be added to dialysis fluid and given intraperitoneally to patients on CAPD or CCPD, but the retrieved text gives no dose for that route. Intravenous administration should only be by slow infusion (rapid infusion may lead to hypotension and shock). Some sections of the product information we used were incomplete — check the full SPC.

Paediatric dose

Dose: Children, chronic iron overload: the SPC gives one regimen for 'Adults and children' (see adult dose: average daily dose probably 20 to 60 mg/kg/day, lowest effective dose). If chelation is started before 3 years of age, growth must be monitored carefully and the mean daily dose should not exceed 40 mg/kg.
Route: Subcutaneous infusion using a portable pump (intramuscular only when subcutaneous infusion is not feasible)
Frequency: Slow subcutaneous infusion over 8 to 12 hours, normally 5 to 7 times a week, as for adults
SPC 4.4: growth retardation has been associated with inappropriately high doses in patients with low ferritin levels or in young children (under 3 years at commencement of treatment); dose reduction has been found to restore growth rate to pretreatment levels in some cases. Three monthly checks on body weight and height are recommended in children. Growth retardation from desferrioxamine is rare if the dose is kept below 40 mg/kg; if it has been associated with doses above this value, dose reduction may restore growth velocity, but predicted adult height is not attained. No figure is given for neonates and none is written here. The acute iron poisoning and aluminium-overload regimens are not covered (see adult notes). Verify against a children's formulary.

Dose adjustments

Renal

No numeric dose adjustment is printed in the retrieved SPC. SPC 4.4: 'Desferrioxamine Mesilate should be used with caution in patients with renal impairment since the metal complexes are excreted via the kidneys. In these patients, dialysis will increase the elimination of chelated iron and aluminium. Isolated cases of acute renal failure have been reported'; monitoring patients for changes in renal function (e.g. increased serum creatinine) should be considered. 'Patients with renal failure who are receiving maintenance dialysis and have low ferritin levels may be particularly prone to adverse reactions, visual symptoms having been reported after single doses of desferrioxamine.' SPC 4.2 (acute iron poisoning section): the effectiveness of treatment depends on adequate urine output so that the iron complex (ferrioxamine) is excreted; if oliguria or anuria develop, peritoneal dialysis or haemodialysis may become necessary to remove ferrioxamine.

Hepatic

No hepatic dose adjustment is stated in the retrieved SPC text (section 4.2 is cut off at the fetch limit). SPC 4.2 Elderly paragraph (partly retrieved): dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other medicinal product therapy.

Dose independently re-sourced from UK Summary of Product Characteristics (SPC) via MHRA Products — clinician-reviewed. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

  • Hypersensitivity to the active substance, unless the patient can be desensitised (SPC 4.3, the whole of section 4.3)
  • Use with caution in renal impairment, because the metal complexes are excreted via the kidneys (SPC 4.4 - a precaution, not a contraindication)
  • Do not use in combination with prochlorperazine (a phenothiazine derivative): prolonged unconsciousness may result (SPC 4.5)
  • Vitamin C supplements should not be given to patients with cardiac failure (SPC 4.5)

Side effects

  • Common (SPC 4.8): growth retardation and bone disorder (e.g. metaphyseal dysplasia) in chelated patients given doses of 60 mg/kg, especially those who begin iron chelation in the first three years of life; if doses are kept to 40 mg/kg or below, the risk is considerably reduced
  • Injection site (SPC 4.8 special remarks): pain, swelling, infiltration, erythema, pruritus and eschar/crust are very common (the list continues beyond the source-fetch limit)
  • Uncommon: deafness neurosensory, tinnitus (keeping within dose guidelines helps minimise risk of hearing side effects)
  • Rare: loss of vision, scotoma, retinal degeneration, optic neuritis, cataracts, blurred vision, night blindness, visual field defects, chromatopsia, corneal opacity (rare except if high doses are given); mucormycosis; hypotension, tachycardia and shock if precautions for administration are not adhered to
  • Very rare: Yersinia gastroenteritis infections; blood disorders including thrombocytopenia; anaphylactic shock, anaphylactic reactions, angioneurotic oedema; neurological disturbances including dizziness, precipitation or exacerbation of aluminium-related dialysis encephalopathy, peripheral neuropathy, paraesthesia; acute respiratory distress, lung infiltration; diarrhoea; generalised rash
  • Frequency unknown: leukopenia; convulsion; muscle spasms; acute renal failure, renal tubular disorder, blood creatinine increased
  • SPC 4.8 is truncated at the source-fetch limit, so this list is not guaranteed complete

Interactions

  • Vitamin C (oral, up to a maximum of 200 mg daily in divided doses) may enhance excretion of the iron complex; larger doses fail to produce an additional effect; monitoring of cardiac function is indicated during combined therapy; give only if the patient is receiving desferrioxamine regularly and not within the first month of therapy
  • Vitamin C in high doses (more than 500 mg daily) with desferrioxamine in severe chronic iron-storage disease: impairment of cardiac function, reversible when vitamin C was withdrawn; vitamin C supplements should not be given to patients with cardiac failure
  • Prochlorperazine (phenothiazine): should not be used in combination, prolonged unconsciousness may result
  • Gallium-67 imaging results may be distorted because of rapid urinary excretion of desferrioxamine-bound radiolabel; discontinue desferrioxamine 48 hours before scintigraphy
  • Erythropoietin: desferrioxamine will affect aluminium levels and may necessitate some dosage adjustment of erythropoietin if co-prescribed (SPC 4.4)
  • Heparin is pharmaceutically incompatible with desferrioxamine solutions (SPC 4.2)

Monitoring

  • Ophthalmological and audiological tests both before starting therapy and at 3-monthly intervals during treatment, particularly if ferritin levels are low; if disturbances of vision or hearing occur, stop treatment (usually reversible)
  • Serum ferritin; keep the ratio of mean daily dose (mg/kg) divided by serum ferritin (micro g/L) below 0.025, which may reduce the risk of audiometric abnormalities in thalassaemia patients
  • 24 hour urinary iron excretion, daily at first when assessing chelation, then at intervals of a few weeks once the appropriate dose is established
  • Renal function (e.g. serum creatinine) in renal impairment
  • In children: body weight and height every 3 months (growth retardation)
  • Serum calcium: treatment of aluminium overload may result in decreased serum calcium and aggravation of hyperparathyroidism
  • Infection: if fever with pharyngitis, diffuse abdominal pain or enteritis/enterocolitis develops, stop therapy and treat with antibiotics (Yersinia enterocolitica and Y. pseudotuberculosis infections reported); if signs of mucormycosis occur, discontinue, carry out mycological tests and treat immediately
  • Used alone, desferrioxamine may exacerbate neurological impairment (seizures) in patients with aluminium-related encephalopathy; pretreatment with clonazepam has been shown to afford protection
  • Cardiac function during combined therapy with vitamin C
  • This list may be incomplete — check the full SPC.

Clinical monograph

How it works

It binds free iron and aluminium to form stable complexes (ferrioxamine and an aluminium complex) that are removed from the body, including via dialysis.

Prescribing in practice

  • Ocular and auditory toxicity, including retinopathy and hearing loss, can occur, so visual and audiometric assessment is required with prolonged use.
  • Rapid intravenous administration can cause hypotension, and infusions should be given at a controlled rate.
  • It can increase susceptibility to certain infections such as Yersinia and mucormycosis, which should be considered if a patient becomes unwell.

Monitoring

Monitor visual and auditory function on prolonged therapy, along with iron or aluminium indices and for signs of infection.

Counselling the patient

  • Report any change in vision or hearing promptly.
  • Your urine may turn a reddish colour, which is expected as iron is removed.
  • Seek advice early if you develop fever or feel unwell during treatment.

Evidence & guidelines

Deferoxamine is the established chelator for aluminium and iron overload in dialysis populations, guided by monitoring for cumulative toxicity.

Reference: ERA-EDTA Anaemia Guideline; NICE TA386 (Deferasirox); SPC Desferal; Cappellini et al. Blood Transfusion 2014; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Related

Curated clinical cross-links plus same-class fallbacks.

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