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Iron Deficiency in Heart Failure – the Relevance for the Patient Proceedings of a satellite symposium held at the ESC Congress 2014 on 1 September 2014 in Barcelona This symposium was organised and fully financed by Vifor Pharma Katrina Mountfort, Medical Writer, Radcliffe Cardiology Vifor Pharma funded the author to attend the symposium and develop this manuscript accordingly

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Proceedings of Symposium organised and fully financed by Vifor Pharma

Iron Deficiency in Heart Failure – the Relevance for the Patient Katrina Mountfort M e d i c a l Wr i t e r Pr ocee di ngs of a Sa tellite Sy mposium Held a t t h e E S C Co n g r e s s 2 0 1 4 , 1 S e p t e m b e r 2 0 1 4 , B a r c e l o n a , Sp ain Re vi ew ed for a c c ura c y by : Josep C omin- Co l e t , 1 Ca r o l y n S P L a m , 2 P i o t r P o n i k o w s k i 3 a n d S t e f a n A n k e r 4 1. Department of Cardiology, Hospital del Mar, Barcelona, Spain; 2. Women’s Heart Health Clinic; National University Heart Centre; Yong Loo Lin School of Medicine; Asia Pacific Association of Women’s Cardiovascular Disease, Singapore; 3. Department of Heart Diseases Clinical Military Hospital, Medical University, Wroclaw, Poland; 4. Department of Cardiology, Charité Campus Virchow-Klinikum, Berlin, Germany

T his sy mposium wa s org a n i s e d a n d f u l l y f i n a n c e d b y V i f o r Ph a r m a

Editorial Process Radcliffe Cardiology (RC) approached Vifor Pharmaceuticals Ltd (Vifor) to develop a proceedings article summarising presentations from their industry-supported symposium that took place at the European Society of Cardiology Meeting in Barcelona on September 1 2014. Vifor provided funding to RC for a medical writer to attend the sponsored session and develop a manuscript accordingly. This draft was reviewed for scientific accuracy by each of the session chairmen and presenters; and two blinded peer reviewers with suggested amends incorporated. On approval by all reviewing parties, the symposium was submitted to Radcliffe Cardiology and accepted for publication in Cardiac Failure Review (CFR).

Abstract A satellite symposium at the 2014 European Society of Cardiology (ESC) congress discussed the importance of iron deficiency (ID) in heart failure (HF). ID is the main cause of anaemia and is observed in almost 50 % of HF patients in Europe and up to 80 % of patients in Asia. ID is an independent factor associated with reduced exercise capacity, reduced quality of life (QoL) and poor outcomes in HF. The importance of ID in HF is reflected in the fact that the current ESC Guidelines for HF recognise ID as a co-morbidity in HF for the first time, and recommend routine diagnosis and monitoring for ID based on iron parameters. Intravenous (i.v) administration of ferric carboxymaltose (FCM) was considered as a possible treatment option according to the findings of the Ferric Carboxymaltose Assessment in Patients With IRon Deficiency and Chronic Heart Failure (FAIR-HF) clinical study, which showed that treatment with FCM in HF patients with ID improves symptoms, exercise capacity and QoL. These findings were confirmed by the recent Ferric CarboxymaltOse evaluatioN on perFormance in patients with IRon deficiency in coMbination with chronic Heart Failure (CONFIRM-HF) study, which demonstrated that, in symptomatic patients with chronic HF and ID treatment with i.v. FCM over one year resulted in sustainable improvements in exercise capacity, symptoms and QoL, and was associated with a reduced risk of hospitalisations due to worsening HF.

Keywords Ferric carboxymaltose, heart failure, iron deficiency Disclosure: Josep Comin-Colet has received consulting fees from Vifor Pharma and was a member of the FAIR-HF and CONFIRM-HF steering committees. Stefan Anker has received honoraria for consultancy, lectures, clinical trial committee work and/or trial adjudication work as well as he received research grants from Vifor Pharma. Carolyn SP Lam has received unrestricted research grants and honoraria from Vifor Pharma. Piotr Ponikowski has received honoraria from Vifor Pharma as a member of the FAIR-HF and CONFIRM-HF steering committees; consultancy and speakers bureau from Vifor Pharma and Amgen Inc; and a research grant from Vifor Pharma. Received: 8 September 2014 Accepted: 13 November 2014 Citation: Cardiac Failure Review, 2015;1(1): Epub ahead of print

Support: Support is indicated in the editorial process box above.

A satellite symposium, sponsored by Vifor Pharma and chaired by Josep Comin-Colet, Barcelona, Spain and Stefan Anker, Berlin, Germany was held at the European Society of Cardiology (ESC) congress in Barcelona on the 1st September 2014. Its objectives were to raise awareness on the epidemiology, aetiology and pathophysiology of iron deficiency (ID) in heart failure (HF), to raise awareness of the

clinical impact of ID on patient outcomes and quality of life (QoL) in HF; to discuss the latest guidelines for chronic HF in the context of ID; to present data from the Ferric CarboxymaltOse evaluatioN on perFormance in patients with IRon deficiency in coMbination with chronic Heart Failure (CONFIRM-HF) clinical trial; and to share diagnostic and treatment algorithms based on clinical evidence.

Iron Deficiency in Heart Failure – the Relevance for the Patient

Impact of Iron Deficiency in Heart Failure J o s e p Co m i n - Co l e t Department of Cardiology, Hospital del Mar, Barcelona, Spain

In 2012, the ESC Guidelines for the diagnosis and treatment of acute and chronic HF recognised ID as a co-morbidity in HF for the first time and recommended diagnosis of ID based on iron parameters in all patients suspected of having HF.2,7 Furthermore, the guidelines now detail the mechanism of action of iron in muscle function (and therefore the explanation for deficiency-related pathology and onset of symptoms in HF independent of the pro-erythropoietic function of iron); the need for routine monitoring for ID; and the beneficial effects on symptoms,

Figure 1: Prevalence of Iron Deficiency in Chronic Heart Failure 70 60

Percent (%)

HF has a significant impact on QoL that is worse than the impact of other chronic diseases, particularly in terms of physical function.1 HF is characterised by exercise intolerance, fatigue and dyspnoea, and is classified according to severity in New York Heart Association (NYHA) classes I–IV, where Class I is no limitation of physical activity and Class IV is the inability to undertake any physical activity without discomfort.2 An emerging problem in HF is ID. ID is prevalent among patients with HF; in a recent international pooled cohort study (n=1,506), ID (defined as serum ferritin <100 µg/L or <299 µg/L if transferrin saturation [TSAT] <20 %) was found in 50 % of the total patient population. ID is the commonest cause of anaemia, but even in the absence of anaemia, ID was present in 45.6 % of patients (see Figure 1).3 Disease severity, assessed by NYHA class and N-terminal of pro-brain natriuretic peptide (NT-proBNP) levels, proved to be powerful and independent predictors of a disordered iron status. Furthermore, ID has been found to be an independent factor associated with reduced exercise capacity,4 reduced QoL5,6 and poor outcome.3

n=1,506 61.2 %

50 %

45.6 %

40 30 20 10 0

Anaemic

Non-anaemic

Whole population

Source: Klip et al., 2013. 3

physical performance and QoL of treating ID with intravenous (i.v) ferric carboxymaltose (FCM). Based on the findings of the Ferric Carboxymaltose Assessment in Patients With IRon Deficiency and Chronic Heart Failure (FAIR-HF) study, which found that treatment with i.v. FCM in iron deficient patients with chronic HF improves symptoms, exercise capacity and QoL irrespective of whether anaemia was present or not. FCM is now considered as a possible treatment option in the current ESC Guidelines for HF.2,7,8 In conclusion, ID is a significant burden in HF and merits further investigation. n

Iron Deficiency, a Common Neglected Burden in Heart Failure Ca r o l y n S P L a m Director, Women’s Heart Health Clinic; Consultant, National University Heart Centre; Associate Professor, Yong Loo Lin School of Medicine; Chair, Asia Pacific Association of Women’s Cardiovascular Disease, Singapore

Dr Carolyn Lam began by discussing data from the recent prevalence study of ID in HF,3 for which the study cohort was from European countries only. A study of ID in Asian patients with HF (n=751) found a higher prevalence of ID (61 %).8 The prevalence was particularly high in women (71 % versus 59 % in men) and in South Asian Indian populations (a prevalence of 82 %).8 South Asians tend to be vegetarian and also drink black tea, which has been shown to decrease iron absorption by 80 % when taken with food.9 Genetic factors are also important in determining ID; a number of studies have investigated TMPRSS6, which encodes a transmembrane serine protease produced by the liver that regulates the expression of the systemic iron-regulatory hormone hepcidin. Germline mutations in TMPRSS6 have been found in extended families where more than one member had ID.10 Variants in TMPRSS6 have also been found to be risk factors for ID and iron deficiency anaemia (IDA) in 2,139 unrelated elderly Chinese women.11 In order to evaluate the impact of ID in HF, it is important to understand iron metabolism. Dietary iron is utilised not only in circulating erythrocytes, but also in muscle myoglobin and other

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iron containing enzymes.12 Patients with HF may be iron deficient as a result of reduced iron storage (absolute ID), which may be caused by malnutrition, malabsorption and gastrointestinal (GI) oedema and blood losses (due to use of anticoagulants, non-steroidal anti-inflammatory drugs [NSAIDs] and loss of mucosal integrity).13 Another important cause of ID in HF is impaired iron mobilisation (functional ID), resulting from the inflammatory processes that characterise chronic HF. Activation of pro-inflammatory cytokines such as interleukin-6 (IL-6), interleukin-1 (IL-1) and tumour necrosis factor alpha (TNF-α) causes overexpression of hepcidin by the liver. This blocks the intestinal absorption of iron and diverts iron from the circulation into the reticuloendothelial system (RES), causing reticuloendothelial block, as well as blunting responses to erythropoietin (EPO) and causing apoptosis of erythroid progenitors.13–15 At the cellular level, ID reduces the delivery of oxygen to the mitochondria but also directly decreases the activity of key enzymes of the citric acid cycle and of the respiratory chain of the mitochondria, resulting in reduced oxygen utilisation (which is, in the clinical setting, observed as reduced peak oxygen consumption [pVO2]).16 ID reduces work capacity and energy efficiency in HF17,18 and iron status correlates to NYHA status.3 The fact that ID but not anaemia

Proceedings of Symposium organised and fully financed by Vifor Pharma Figure 2: Association Between Iron Deficiency and Mortality in Heart Failure n=1,506 100 HR (95 % CI) for all-cause mortality

p=0.001 Cumulative survival (%)

80 60 40 20 0

*p<0.01

Time in study (years) Patients without iron deficiency

p<0.001

†

† 2

No ID No Anaemia

No ID Anaemia

ID No Anaemia

ID Anaemia

Patients with iron deficiency

CI = confidence interval; HR = hazard ratio; ID = iron deficiency. Source: Klip et al., 2013.3

Figure 3: Suggested Algorithm for Diagnosis of Iron Deficiency in Heart Failure Chronic HF (NYHA II–IV)

Anaemia Male Hb <13 g/dL Female Hb <12 g/dL No Consider ID treatment

Patients with concurrent ID and anaemia had the poorest prognosis regardless of EF.

ID: Ferritin <100 ng/mL or Ferritin 100–299 ng/mL when TSAT <20 %

Yes

Anaemia Male Hb <13 g/dL Female Hb <12 g/dL Yes

Yes

Exclude other causes for anaemia depending on clinical status: • Occult bleeding (e.g. Gl, malignancies) • Renal insufficiency (erythropoietin) • Other deficiencies (e.g. Vit B12, folic acid) • Other haemoglobinopathies (e.g. thalassaemia, sickle cell anaemia)

No No treatment

GI = gastrointestinal; Hb = haemoglobin; HF = heart failure; ID = iron deficiency; NYHA = New York Heart Association; TSAT = transferrin saturation; Vit = vitamin.

is associated with reduced exercise capacity in HF4 can be explained by the non-haematopoietic effects of iron, including its role in mitochondrial function in cells with high energy requirements, such as cardiomyocytes and skeletal myocytes. In patients with chronic HF, ID but not anaemia has also been associated with reduced QoL (assessed using the Minnesota Living with Heart Failure [MLWHF] questionnaire), mostly due to physical factors.5,6 Furthermore, ID is a stronger negative prognostic indicator for all-cause mortality than anaemia (see Figure

2).3 A recent study in Singapore assessed the impact of ID in Asian patients with HF. Functional ID was found in the majority (64 %) of patients with HF. Patients with ID were more symptomatic with higher NYHA class and MLWHF score, regardless of ejection fraction (EF).19

In the 2012 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, the ESC recommended ID testing in HF patients based on the assessments of ferritin and TSAT.2,7 This raises the question of which iron indices are the most useful. Two are currently used: ferritin (a measure of stored iron) and TSAT (a measure of circulating iron for functional utilisation). However, ferritin is also an acute phase protein and can be falsely elevated if inflammation or subclinical infection is present, but a low ferritin level is a clear indication of ID (absolute). If ferritin is increased TSAT (<20 %) can be used for the diagnosis of ID (functional). The only limitation of TSAT is the circadian differences since the calculated value is dependent on the serum iron. Due to their intrinsic limitations, the combination of thresholds of these two parameters is suggested, as for the FAIR-HF study (ferritin <100 ng/mL or ferritin 100–300 ng/mL if TSAT <20 %). The ideal marker would probably be the soluble transferrin receptor (sTfR); however, this is not widely available or used in clinical practice.13 Based on the ESC recommendations and data from the FAIR-HF clinical trial, a suggested algorithm for diagnosis on ID in HF is proposed (see Figure 3). Recommendations worldwide are being changed to incorporate the need to assess and treat ID in patients with chronic HF.20 In conclusion, ID is present in half of all HF patients in Europe and in up to 80 % of Asian patients. While it is the main cause of anaemia in HF, ID occurs in over 45 % of non-anaemic patients and is independently associated with reduced exercise capacity, reduced QoL and poor outcomes. n

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Iron Deficiency in Heart Failure – the Relevance for the Patient

CONFIRM-HF – Targeting for Improvement in Exercise Capacity in Heart Failure Piotr Ponikowski Department of Heart Diseases, Clinical Military Hospital, Medical University, Wroclaw, Poland

Another option for correcting ID is iron therapy, which may be administered by oral or i.v. routes. There is no evidence for the clinical benefits of oral iron supplementation – studies comparing oral iron with ESA in patients with HF and anaemia found no clinically meaningful benefits associated with such combination.25–29 A recent pilot study (n=18) suggested that i.v. and not oral iron improves exercise capacity in HF patients.30 Early clinical studies have also demonstrated the efficacy of i.v. therapy but were either single-arm, open-label studies with a short-term follow-up or small sample size.31–34 A larger, randomised, double-blind, placebo-controlled trial was therefore needed. Therefore, the FAIR-HF (n=459) trial was performed and showed that treatment of HF patients with i.v FCM in patients with chronic HF and ID, with or without anaemia, improved symptoms, exercise capacity and Qol at six months, including significant improvements in self-reported patient global assessment (PGA), NYHA functional class, six-minute walk test (6MWT), Kansas City Cardiomyopathy Questionnaire (KCCQ) overall score and EQ-5D visual analogue scale (VAS) score.22 Improvements were seen from week 4 onwards irrespective of whether or not the patients were anaemic. In order to broaden the evidence in support to treat ID with i.v. iron in HF, it was necessary to replicate these findings in a further study, and also to evaluate different, more robust and objective endpoints, including safety endpoints as well as a longer follow-up. In addition, the FAIR-HF study employed repeated 200 mg doses, therefore an evaluation of higher single-dose (up to 1,000 mg) was needed. To address these questions, the CONFIRM-HF clinical trial was designed.

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Figure 4: The CONFIRM-HF Study – Change in Six-minute Walking Test Distance at 24 Weeks 30 LSM change in 6MWT distance from baseline (m)

p=0.002 20 10 0 -10 -20 -30

Week 24 FCM (N=150)

Placebo (N=151)

FCM = ferric carboxymaltose; LSM = least square mean; 6MWT = six-minute walk test. Source: Ponikowski et al., 2014. 35

Figure 5: The CONFIRM-HF Study – First Hospitalisation Due to Worsening Heart Failure 30 Hospitalisation rate (per 100 subjects)

ID is a frequent co-morbidity in stable HF and in patients admitted to hospital due to HF worsening.3,6,21,22 Its association with impaired exercise capacity, poor QoL and increased mortality, irrespective of anaemia,3–5 make it an attractive therapeutic target – a hypothesis that has recently been tested in clinical studies.22 Several options are available for the correction of ID. Blood transfusion is generally not recommended since it is associated with high mortality and a lengthy stay in hospital;23 its use should be reserved for life-threatening emergency situations. Erythropoiesis-stimulating agents (ESA) are used mainly to correct anaemia. In the Reduction of Events with Darbepoetin alfa in Heart Failure (RED-HF) study, a randomised, double-blind trial on anaemic patients with chronic HF (n=2,278), correcting anaemia with darbepoetin alpha did not lead to improvement in survival nor clinically meaningful change in QoL.24 Furthermore, patients treated with darbepoetin alpha had an increased risk for thromboembolic adverse effects.24 One potential explanation of the neutral treatment effects on the outcomes could be due to the fact that ESA therapy can further exacerbate ID by stimulating the production of red blood cells, which requires a large amount of iron. Therefore, there could be a subpopulation of patients included in the RED-HF study with underlying untreated ID based on the current definition of ID in the ESC Guidelines for HF. Post hoc subanalysis investigating the association between ID and the outcomes in the RED-HF trial is undergoing.

Log-rank test, p=0.009

20 10

180

270

360

Time (days) FCM FCM = ferric carboxymaltose. Source: Ponikowski et al., 2014.

Placebo 35

CONFIRM-HF was a multicentre, randomised (1:1) double-blind, placebo-controlled trial of stable, ambulatory HF patients.35 The main inclusion criteria were: • NYHA class II/II with left ventricle ejection fraction (LVEF) ≤45 %; • Brain natriuretic peptide (BNP) >100 pg/mL or the prohormone NT-proBNP >400 pg/mL; • ID, defined as serum ferritin <100 ng/mL or 100–300 ng/mL if TSAT <20 %; and • haemoglobin (Hb) <15 g/dL and no lower Hb cut-off level. Patients who needed a blood transfusion were excluded from the study. The methodology involved blinded and unblinded personnel and

Proceedings of Symposium organised and fully financed by Vifor Pharma Figure 6: Suggested Treatment Algorithm for Iron Deficiency in Heart Failure, Based on Evidence from Clinical Trials Evidence-based in FAIR-HF

ID Treatment

FCM: Weekly 200 mg single doses to correct ID according Ganzoni formula Check ferritin/TSAT within next scheduled visit (preferable 1–3 months)

FCM: 4-weekly 200 mg single doses for maintenance

Evidence-based in CONFIRM-HF Being assessed in EFFECT-HF

FCM: 500–1,000 mg single doses to correct ID (SmPC) Check ferritin/TSAT within next scheduled visit (preferable 1–3 months)

FCM: 500 mg to maintain ferritin/TSAT on target Check ferritin/TSAT if change in clinical picture or Hb decrease or 1–2 x/year

CONFIRM-HF = Ferric carboxymaltOse evaluatioN on perFormance in patients with IRon deficiency in coMbination with chronic Heart Failure; EFFECT-HF = EFfect of Ferric carboxymaltose on Exercise Capacity in PaTients with iron deficiency and chronic Heart Failure; FAIR-HF = Ferric Carboxymaltose Assessment in Patients With IRon Deficiency and Chronic Heart Failure; FCM = ferric carboxymaltose; haemoglobin = Hb; ID = iron deficiency; smPC = summary of product characteristics; TSAT = transferrin saturation.

the usage of curtains and black syringes for injections, to mask the brownish colour of FCM. Treatment involved a correction phase (given as 1–2 i.v. injections of 500–1,000 iron as single dose treatment (500 mg) continued (at weeks 12, 24 and 36) if ID was not corrected. The primary endpoint was the change in 6MWT distance from baseline to Week 24. Key secondary endpoints included the 6MWT distance at Week 6, 12, 36 and 52; PGA score, NYHA class, KCCQ, EQ-5D and fatigue score at Week 6, 12, 24, 36 and 52. Outcome-related secondary endpoints included hospitalisation rate (all hospitalisation, for any cardiovascular [CV] reason, due to worsening HF); time to first hospitalisation (all

hospitalisation, for any CV reason and due to worsening HF); and time to death (any death, death for any CV reason and due to worsening HF).35 At Week 24, there was an increase in 6MWT distance by 18 ± 8 m in the FCM group, whereas in the placebo group 6MWT distance decreased by 16 ± 8 m (both least squares mean + standard error [SE]). It resulted in a significant increase in 6MWT distance at Week 24 in FCM by 33 ± 11 m (least squares mean ± SE) compared with placebo (p=0.002, see Figure 4), a treatment effect that had only previously been seen for cardiac resynchronisation therapy. In all subgroups examined, including those patients with and without anaemia, the treatment effect was preserved. The improvement in exercise capacity was striking in that it was reported not only at 24 weeks, but also at 36 and 52 weeks, with a sustained improvement in fatigue score also observed. Throughout the study, improvements in other secondary endpoints in patients treated with FCM were detected with statistical significance observed from Week 24 onwards. Treatment with FCM was associated with a significant reduction in the risk of hospitalisations for worsening HF (hazard ratio [95 % confidence interval]: 0.39 [0.19–0.82], p=0.009; see Figure 5). The number of deaths (FCM: 12, placebo: 14 deaths) and the incidence of adverse events were comparable between both groups.35 In conclusion, the CONFIRM-HF trial demonstrated that in symptomatic patients with chronic HF and ID treatment with i.v. FCM over one year resulted in sustainable improvements in exercise capacity, symptoms and QoL and may be associated with a reduced risk of hospitalisations due to worsening HF. Further studies are planned and ongoing, including a meta-analysis, the EFfect of Ferric carboxymaltose on Exercise Capacity in PaTients with iron deficiency and chronic Heart Failure (EFFECT-HF), iron in Congestive Heart Failure (iCHF)36 and the Ferric Carboxymaltose Assessment in Patients With IRon Deficiency and Chronic Heart Failure with preserved ejection fraction (FAIR-HFpEF) studies.37 Based on current data, a suggested treatment algorithm has been proposed (see Figure 6). n

Summary and Take-home Messages ID remains under-recognised among cardiologists – an audience survey revealed that a significant minority regularly monitor ID in their HF patients. The take-home messages of the symposium were the following: • ID is the main cause of anaemia, but also highly prevalent in non-anaemic patients; it is observed in almost 50 % of HF patients in Europe and the prevalence is even higher in Asia. • ID but not anaemia is associated with: - reduced exercise capacity; - reduced QoL; and

- poor outcome • Treatment with FCM in iron deficient chronic HF patients (FAIRHF/CONFIRM-HF studies) improves: - symptoms; - exercise capacity; and - QoL. These results were seen in both anaemic and non-anaemic patients, and the risk of hospitalisation due to worsening HF may be reduced. • The ESC Guidelines have given a Class I recommendation for ID testing in all HF patients. n

The link for the webcast of the presentations is now available: http://congress365.escardio.org/Session/14186#.VFukzrFbDIW The CONFIRM-HF results were also discussed at the Expert on the Spot session and webcast is also available by this link: http://congress365.escardio.org/Session/14134#.VFulWLFbDIV

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Iron Deficiency in Heart Failure – the Relevance for the Patient

3. 4. 5.

9. 10. 11. 12. 13.

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Ferinject®

(ferric carboxymaltose)

Prescribing Information - UK For full prescribing information refer to the Summary of Product Characteristics (SmPC) Active ingredient: Ferric carboxymaltose (50mg/mL) Presentation: Solution for injection/infusion. Available as a 2mL vial (as 100mg of iron), 10mL vial (as 500mg of iron) and 20mL vial (as 1000mg of iron). Indication: Treatment of iron deficiency when oral iron preparations are ineffective or cannot be used. The diagnosis must be based on laboratory tests. Dosage and Administration: The cumulative dose for repletion of iron using Ferinject is determined based on the patient’s body weight and haemoglobin level and must not be exceeded. The table in the SmPC should be used to determine the cumulative iron dose. Intravenous injection: A maximum single dose of up to15mg/ kg bodyweight. For doses <200mg there is no prescribed administration time. For doses >200mg to ≤500mg, Ferinject should be administered at a rate of 100mg/min. For doses >500mg Ferinject should be administered over 15mins. Intravenous drip: A maximum single dose of up to 20mg/kg bodyweight. Ferinject must be diluted in 0.9% m/V NaCl. Do not administer 1000mg of iron (20ml) more than once a week. Contraindications: Hypersensitivity to Ferinject or any of its excipients. Known serious hypersensitivity to other parenteral iron products. Anaemia not attributed to iron deficiency. Iron overload or disturbances in utilisation of iron. Special warnings and precautions: Parenterally administered iron preparations can cause potentially fatal anaphylactic/ anaphylactoid reactions. The risk is enhanced for patients with known allergies, a history of severe asthma, eczema or other atopic allergy, and in patients with immune or inflammatory conditions. Ferinject should only be administered in the presence of staff trained to manage anaphylactic reactions where full resuscitation facilities are available (including 1:1000 adrenaline

solution). Each patient should be observed for 30 minutes following administration. If hypersensitivity reactions or signs of intolerance occur during administration, the treatment must be stopped immediately. In patients with liver dysfunction, parenteral iron should only be administered after careful risk/benefit assessment. Careful monitoring of iron status is recommended to avoid iron overload. There is no safety data on the use of single doses of more than 200mg iron in haemodialysis-dependant chronic kidney disease patients. Parenteral iron must be used with caution in case of acute or chronic infection, asthma, eczema or atopic allergies. It is recommended that treatment with Ferinject is stopped in patients with ongoing bacteraemia. In patients with chronic infection a benefit/risk evaluation has to be performed. Caution should be exercised to avoid paravenous leakage when administering Ferinject. Special populations: The use of Ferinject has not been studied in children. A careful risk/benefit evaluation is required before use during pregnancy. Ferinject should not be used during pregnancy unless clearly necessary. Undesirable effects: Common (≥1/100 to <1/10): Headache, dizziness, hypertension, nausea, injection site reaction, alanine aminotransferase increased, hypophosphataemia. Please consult the SmPC in relation to other undesirable effects. Legal category: POM Price: pack of 5 x 2ml = £95.50; pack of 5 x 10ml = £477.50 pack of 1 x 20ml = £181.45 MA Number: 15240/0002 Date of Authorisation: 19.07.2007 MA Holder: Vifor France S.A. 7-13 Boulevard Paul-Emile victor, 92200 Neuilly-sur-Seine, France. Further details available from : Vifor Pharma UK Limited, The Old Stables, Bagshot Park, Bagshot, Surrey GU19 5PJ T: +44 1276 853 600 F: +44 1276 452 341 medicalInfo_UK@viforpharma.com Ferinject® is a registered trademark Date of revision: 10/13

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Vifor Pharma UK Ltd. Tel: +44 1276 853633

U K /F E R /1 5 /0 1 0 5 D ec ember 2014