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Key points

  • We recommend to consult your poison centre with the use of this antidote.
  • It is preferable to use deferoxamine to bind free iron within 24 hours of ingestion. If indicated, the antidote should be started as soon as possible.
  • Ensure the patient undergoes adequate intravascular repletion with crystalloids to avoid hypotension.

+ Synonyms and other terms

  • Desferal™
  • Desferrioxamine
  • DFOA
  • Deferoxamine mesylate
  • Desferrioxamine mesylate

+ Indications

  • History of ingestion equal or greater to 40 mg of elemental iron/kg accompanied by abdominal pain, repeated vomiting, profuse diarrhea or lethargy, or
  • In acute iron poisoning if:
    • Serum concentration greater than 90 mcmol/l (500 mcg/dL) or
    • Serum concentration greater than 63 mcmol/l (350 mcg/dL) with cardiovascular symptoms or with lactic acidosis.

+ Dosage

+ Pediatric Dose

  • Continuous IV Infusion:
    • 15 mg/kg/h 
    • Dose can be increased up to 50 mg/kg/h in severe cases of poisoning as long as blood pressure can be maintained.
    • Maximum dose according to manufacturer’s monograph is 80mg/kg/24 h. However, higher doses can be administered after consultation with your poison centre.
    • Do not infuse for longer than 24h unless recommended by your poison centre.
  • IM Route (rarely indicated):
    • 90 mg/kg initially, then 45 mg/kg per dose (max 1 g/dose) every 8 h.

+ Adult Dose

  • Continuous IV Infusion:
    • 15 mg/kg/h 
    • Dose can be increased up to 50mg/kg/h in severe cases of poisoning as long as blood pressure can be maintained.
    • Maximum dose according to manufacturer’s monograph 6 g/24 h. However, higher doses can be administered after a consultation with your poison centre.
    • Do not infuse for longer than 24h unless recommended by your poison centre.
  • IM Route (rarely indicated):
    • 90 mg/kg initially, then 45 mg/kg per dose (max 2 g/dose) every 8 h.

+ Renal Impairment

  • While the manufacturer does not recommend the use of deferoxamine in patients with severe renal impairment or anuria, it may be recommended by your poison centre in certain cases.
  • Some experts recommend lowering the dose by 25 - 50 % if the glomerular filtration rate is between 10 and 50 ml/min.
  • In patients with renal impairment, provide hemodialysis after the chelation therapy.

+ Hepatic Impairment

No data suggests that the dose should be modified for short-term use.

+ Hemodialysis Patient

No data suggests that the dose should be modified for short-term use.

+ Pregnancy

  • The manufacturer of deferoxamine has raised concerns about the use of the drug during pregnancy and reported skeletal abnormalities in rats.
  • No defects have been reported in patients exposed to the drug during the first trimester.
  • Do not hesitate to use deferoxamine during pregnancy if the toxic effects pose a significant risk of morbidity or mortality.
  • No data suggests that the dose should be modified for short-term use.

+ Obese or Overweight Patient

No data suggests that the dose should be modified for short-term use.

+ Adverse effects

  • Hypotension with rapid IV infusion or an infusion rate equal or greater than 50 mg/kg/h.
  • Hives or erythema.
  • If infusion lasts longer than 24 - 48 h: ARDS, increased susceptibility to sepsis (Yersinia enterocolitica).

+ Monitoring

  • Vital signs
  • Urea and creatinine
    • Changes in the colour of urine (pink/orange) containing ferrioxamine (deferoxamine-iron complex) can vary, since it depends on each patient and urinary pH.
  • AST/ALT
  • CBC, INR/PTT
  • Blood gases
  • Serum iron level as recommended by your poison centre.
  • Plain abdominal x-ray (AXR), since tablets with high elemental iron content are radio-opaque.

+ End of treatment

Two conditions are required:

  1. Decontamination is complete
  2. Resolution of iron poisoning symptoms including metabolic acidosis.

Contact your poison centre if deferoxamine is still running after 24h.

+ Special Notes on Administration

Intravenous Route (IV)

  • Direct IV: Not recommended.
  • Continuous IV Infusion
    • Suggested preparation method using a 500 mg vial:
      • 1000 mg (10.6 ml = 2 vials) in 39.4 ml of NS. Final volume = 50 ml. Final concentration = 20 mg/ml
      • 2000 mg (21.2 ml = 4 vials) in 78.8 ml of NS. Final volume = 100 ml. Final concentration = 20 mg/ml.
    • Suggested preparation method using a 2000 mg vial:
      • 2000 mg (21.1 ml = 1 vial) in 78.9 ml of NS. Final volume = 100 ml. Final concentration = 20 mg/ml.
      • 4000 mg (42.2 ml = 2 vials in 207.8 ml of NS. Final volume = 250 ml. Final concentration = 16 mg/ml.

Subcutaneous Route (SC)

  • Not a recommended administration route.

Intramuscular Route (IM)

  • While the antidote is approved for IM administration, this route is rarely recommended given volume to be injected, erratic absorption, reduced efficiency and significant pain at injection site.
  • For dilution to be used by IM route, consult the pharmacist on duty at your health care facility.

Intraosseous Route (IO)

  • No data available.

Reconstitution

  • Use only SWFI to reconstitute the antidote. The use of any other solution could lead to the formation of precipitate. Never administer if the reconstituted solution is cloudy or contains precipitates.
  • For IV administration:
    • 500 mg vial
      • Reconstitute each vial with: 5 ml of SWFI.
      • Final volume: 5.3 ml.
      • Approximate final concentration: 94 mg/ml.
      • Comment: Final solution will be light yellow.
    • 2000 mg vial
      • Reconstitute each vial with: 20 ml of SWFI.
      • Final volume: 21.1 ml.
      • Approximate final concentration: 95 mg/ml.
      • Comment: Final solution will be light yellow.
  • For IM administration:
    • For administration by IM route, consult the pharmacist on duty at your health care facility.

Compatibility

Partial list only. Consult the pharmacist on duty at your health care facility.

  • Compatible solutions: NS, D5W, ½NS, LR.
  • Y-site compatibility: No data available.
  • Y-site incompatibility: No data available.

Stability

  • Solution reconstituted with SWFI will be stable for 24 hours when stored at a room temperature lower than 23°C away from light.
  • The reconstituted solution diluted with a compatible solution will be stable for 24 hours when stored at a room temperature lower than 23°C away from light.

+ Available products

  • Desferal 500 mg/vial, Pd. Inj., Novartis Pharmaceuticals Canada Inc, DIN 01981242
  • Deferoxamine mesylate 500 mg/vial, Pd. Inj., Pfizer Canada ULC, DIN 02241600
  • Deferoxamine mesylate 2 g/vial, Pd. Inj., Pfizer Canada ULC, DIN 02247022

+ Amount required to treat a person weighting 70kg during 24 hours

  • At least 6000 mg.

+ References

Lee Cantrell, F. 2016. “Deferoxamine.” In Critical Care Toxicology, edited by Jeffrey Brent, Keith Burkhart, Paul Dargan, Benjamin Hatten, Bruno Megarbane, and Robert Palmer, 1–7. Springer International Publishing.

Howland, Mary Ann, Deferoxamine, In Goldfrank’s Toxicologic emergencies,Chapter A7, 10th edition, Mc Graw Hill Education, USA 2015, p 623-627


© Centre antipoison du Québec, CIUSSS de la Capitale-Nationale, 2017. The information contained in this site may be cited, provided the source is acknowledged. Any use for commercial or advertising purposes is strictly prohibited.

Last updated : 2021-08-31