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    "textoCompleto" => "<p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#58;</span></p><p class="elsevierStylePara">&#160;The replacement of iron is necessary in patients on haemodialysis due to the chronic blood loss that occurs when this technique is employed&#46;<span class="elsevierStyleSup">1</span> The intravenous administration of iron is not&#44; however&#44; free from adverse effects&#46; Amongst these&#44; we distinguish certain predictable reactions &#40;an undesired consequence of the pharmacological actions of iron&#44; such as side effects&#41; from unpredictable reactions &#40;in subjects with sensitivity of the immune system or susceptible to reactions such as hypersensitive and anaphylactoid reactions&#41;&#46;<span class="elsevierStyleSup">2</span> The latter are less common and more serious&#44; and may require suspension of the drug&#46; We describe the case of an adverse reaction to the intravenous administration of iron that manifested as a burning sensation of the tongue&#44; an inadequately defined sensation of peribuccal hyperaesthesia and generalised pruritus&#46;</p><p class="elsevierStylePara">The patient is a 42-year-old woman who began a haemodialysis programme by right jugular tunnelled catheter following bilateral nephrectomy due to hypernephroma&#46; In the postoperative period&#44; the patient required a transfusion of 2 units of packed red blood cells&#46; Ten days later a test showed&#58; haemoglobin&#58; 9&#46;6g&#47;dl&#44; haematocrit 28&#46;4&#44; mean corpuscular volume&#58; 87&#46;1fl&#59; iron&#58; 56&#181;g&#47;dl&#44; ferritin 233ng&#47;ml&#59; transferrin saturation index&#58; 18&#37;&#59; folic acid&#58; 22ng&#47;ml vitamin B<span class="elsevierStyleInf">12</span>&#58; 921pg&#47;ml&#59; C-reactive protein&#58; &#60;5mg&#47;l&#59; Kt&#47;V&#58; 1&#46;7&#46; She was treated with omeprazole&#44; vitamin B complex&#44; folic acid and 30&#181;g of darbepoetin weekly&#46; 100mg of iron sucrose &#40;Venofer<span class="elsevierStyleSup">&#174;</span>&#41; was administered intravenously an hour after haemodialysis&#46; 15 minutes after starting infusion&#44; the patient complained of generalised pruritus&#44; a burning sensation of the tongue and peribuccal hyperaesthesia&#46; Physical examination&#58; blood pressure 100&#47;60mmHg&#44; heart and lung auscultation normal&#44; no lesions of the skin&#46; Iron administration was discontinued and the symptoms gradually disappeared&#46; In the following attempt&#44; the patient was premedicated with dexchlorpheniramine and paracetamol&#46; The reaction was identical and also it occurred with ferric carboxymaltose &#40;Ferinject<span class="elsevierStyleSup">&#174;</span>&#41;&#46; The Allergology Service was consulted&#58; the patch test was negative for both iron preparations&#59; the episode was compatible with the side effect&#46; Clinical manifestations reappeared in a weaker form with the successive administrations of iron without major implications&#46;</p><p class="elsevierStylePara">The rate of adverse effects associated with the administration of various preparations of intravenous iron &#40;high and low molecular weight iron dextran&#44; ferrous gluconate&#44; iron sucrose&#41; is approximately 38 per million&#46;<span class="elsevierStyleSup">3</span> The pruritus associated with ferric carboxymaltose is described as isolated and infrequent &#40;1&#47;100-1000 of patients&#41;&#59;<span class="elsevierStyleSup">4</span> it seems to be present upon the first administrations and subsequently dissapears&#46;<span class="elsevierStyleSup">5</span> The symptoms described by the patient as a burning sensation of the tongue and peribuccal hyperaesthesia&#44; although subject to subjective assessments&#44; did not correspond to the neurological disorders commonly described as paraesthesia or taste disorders<span class="elsevierStyleSup">4</span>&#46; The clinical profile that our patient presented seemed to signal an anaphylactoid reaction which was not confirmed&#46; Generally speaking&#44; reactions secondary to intravenous iron have been attributed to rapid infusion with an oversaturation of transferrin and the release of free iron&#44; which is responsible for toxicity and vasomotor reactions&#46;<span class="elsevierStyleSup">6</span> This limited the total dose of iron administered and the rate of infusion in older formulations&#46; Although ferric carboxymaltose is in this sense better tolerated&#44; there are few studies comparing it to the rest of the formulacions&#46;<span class="elsevierStyleSup">7</span> Furthermore&#44; the potential development of severe&#44; even fatal adverse effects remains a source of concern&#46; Many of these reactions have been associated with high molecular weight iron dextran preparations and seem to have an immunological base<span class="elsevierStyleSup">1&#44;7</span>&#46; However&#44; controlled clinical trials for different intravenous iron preparations are limited by design to detect rare adverse effects as they are conducted in a small number of patients over short follow-up periods&#46;<span class="elsevierStyleSup">1&#44;2</span></p><p class="elsevierStylePara"><br></br> Given the manifestation of infrequent side effects&#44; it is vitally important that the intensity and seriousness of the reaction be established since this may require the permanent suspension of the drug&#44; with the resulting limitation of the therapeutic arsenal available&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p>"
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Adverse reaction to intravenous iron: hypersensitivity or secondary side effect?
Reacción adversa por la administración intravenosa de hierro: ¿hipersensibilidad o efecto secundario?
Ana E. Sirvent-Pedreñoa, Ricardo Enríquez-Ascarzaa, M. Dolores Redondo-Pachóna, Isabel Millán-del Vallea, César González-Martineza, Francisco Amorós-Amorósa
a Servicio de Nefrología, Hospital General Universitario de Elche, Elche, Alicante,
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was administered intravenously an hour after haemodialysis&#46; 15 minutes after starting infusion&#44; the patient complained of generalised pruritus&#44; a burning sensation of the tongue and peribuccal hyperaesthesia&#46; Physical examination&#58; blood pressure 100&#47;60mmHg&#44; heart and lung auscultation normal&#44; no lesions of the skin&#46; Iron administration was discontinued and the symptoms gradually disappeared&#46; In the following attempt&#44; the patient was premedicated with dexchlorpheniramine and paracetamol&#46; The reaction was identical and also it occurred with ferric carboxymaltose &#40;Ferinject<span class="elsevierStyleSup">&#174;</span>&#41;&#46; The Allergology Service was consulted&#58; the patch test was negative for both iron preparations&#59; the episode was compatible with the side effect&#46; Clinical manifestations reappeared in a weaker form with the successive administrations of iron without major implications&#46;</p><p class="elsevierStylePara">The rate of adverse effects associated with the administration of various preparations of intravenous iron &#40;high and low molecular weight iron dextran&#44; ferrous gluconate&#44; iron sucrose&#41; is approximately 38 per million&#46;<span class="elsevierStyleSup">3</span> The pruritus associated with ferric carboxymaltose is described as isolated and infrequent &#40;1&#47;100-1000 of patients&#41;&#59;<span class="elsevierStyleSup">4</span> it seems to be present upon the first administrations and subsequently dissapears&#46;<span class="elsevierStyleSup">5</span> The symptoms described by the patient as a burning sensation of the tongue and peribuccal hyperaesthesia&#44; although subject to subjective assessments&#44; did not correspond to the neurological disorders commonly described as paraesthesia or taste disorders<span class="elsevierStyleSup">4</span>&#46; The clinical profile that our patient presented seemed to signal an anaphylactoid reaction which was not confirmed&#46; Generally speaking&#44; reactions secondary to intravenous iron have been attributed to rapid infusion with an oversaturation of transferrin and the release of free iron&#44; which is responsible for toxicity and vasomotor reactions&#46;<span class="elsevierStyleSup">6</span> This limited the total dose of iron administered and the rate of infusion in older formulations&#46; Although ferric carboxymaltose is in this sense better tolerated&#44; there are few studies comparing it to the rest of the formulacions&#46;<span class="elsevierStyleSup">7</span> Furthermore&#44; the potential development of severe&#44; even fatal adverse effects remains a source of concern&#46; Many of these reactions have been associated with high molecular weight iron dextran preparations and seem to have an immunological base<span class="elsevierStyleSup">1&#44;7</span>&#46; However&#44; controlled clinical trials for different intravenous iron preparations are limited by design to detect rare adverse effects as they are conducted in a small number of patients over short follow-up periods&#46;<span class="elsevierStyleSup">1&#44;2</span></p><p class="elsevierStylePara"><br></br> Given the manifestation of infrequent side effects&#44; 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