Is Triferic a replacement for IV iron?

Triferic is a replacement for IV iron as an iron maintenance therapy. Triferic is the only FDA approved drug indicated to replace iron at every dialysis treatment and maintain hemoglobin in adult CKD-HD patients. Triferic delivers iron to hemodialysis patients at every treatment, replacing the iron they lose during dialysis, and it should be used in place of IV iron for iron maintenance therapy for all patients. IV iron should be given sparingly and only according to the approved FDA label for iron deficiency anemia, when patients experience an excessive blood loss leading to a ferritin < 200 µg/L.

How much iron does each dialysis patient receive from Triferic?

Each patient receives approximately 5-7 mg of iron over the course of their dialysis treatment, which is the average amount of iron lost during each dialysis. So, all patients receive the same dose. There is no need to adjust this iron dose. Final concentration of Triferic iron (III) in the final hemodialysate is 2 µM (110 mcg/L).

What is the unique mechanism-of-action of Triferic?

Triferic is special because once it enters the blood it binds iron immediately and completely to transferrin (iron carrier protein) and is transported directly to red blood cell precursors for hemoglobin synthesis.  There is no non-transferrin bound iron present. Triferic works similar to how we get our iron from food to maintain hemoglobin. Triferic is completely different than IV iron, which is designed to travel to the patient’s liver, where it becomes trapped and can cause iron overload and toxicity linked to cardiovascular disease.

Should all my hemodialysis patients receive Triferic?

Yes, because all patients lose 5-7 mg iron over the course of their dialysis treatment, and just like calcium, magnesium and potassium is replaced every dialysis treatment to maintain homeostasis, iron needs to be replaced with every treatment to maintain ideal iron balance, which is essential for effective erythropoiesis. Triferic is a water-soluble low molecular weight iron complex administered in a very small dose every dialysis treatment via dialysate. Keep in mind that Triferic is not an IV iron product.  A typical, weekly 100 mg IV iron dose is given to the patent quickly over about 8-10 minutes, compared to a 5-7 mg dose of Triferic given over 4 hours; and to give an equivalent (to IV iron) 100 mg dose of Triferic it would take 20 administrations, occurring over 7 weeks.

Should patients with high ferritin values receive Triferic?

Yes. Patients can stay on Triferic regardless of ferritin value, unless the patient has underlying bacteremia, fungemia or sepsis.  Ferritin levels in patients on Triferic will decrease over time. Triferic does not increase iron stores or inflammation because it donates its iron immediately and completely to transferrin, enabling it to be transported directly to the bone marrow for hemoglobin incorporation. Triferic is not processed in the macrophages and it is not metabolized in the liver so it bypasses the hepcidin induced block present in hemodialysis patients. This unique mode-of-action is what enables Triferic to overcome high ferritin and associated toxicity and infections, and Functional Iron Deficiency (FID) which is a serious issue that plagues hemodialysis patients receiving IV iron.

What should our IV iron protocol change to once patients are receiving Triferic?

Once patients are receiving Triferic it is important that your IV iron protocol is changed.

Administer IV iron (500 mg in divided doses) only if serum iron parameters are:

  • Ferritin < 100 ng/mL provided TSAT < 40%
  • Ferritin < 200 ng/mL provided TSAT < 30%
  • Ferritin     200 – 800 ng/mL provided TSAT < 20%

Note:

  • Hgb and ESA dose should be considered as key indicators to determine whether to start IV iron
  • The decision to initiate IV iron requires (2) consecutive confirmatory TSAT values
  • TSAT should be checked monthly and ferritin every (3) months
  • Based on NICE guidelines for IV iron use in CKD-HD patients

This recommended protocol is based on the PRIME clinical study where patients received IV iron according to the above parameters (Read More). Clinical judgment should always guide patient therapy.

Do I need to do any extra cleaning or sanitization of my bicarbonate loop distribution system once using Triferic?

There is no need for any extra cleaning or sanitization of your bicarbonate loop when using Triferic. Triferic is not an elemental iron. Triferic is comprised of iron tightly bound/complexed to pyrophosphate and citrate, making it a highly soluble and stable iron salt. Triferic iron does not oxidize to rust and does not stick to plastic surfaces. Triferic iron does not leave any residue in the bicarbonate tank or central feed loop. Triferic has been administered in over 30 separate bicarbonate loop systems to approximately 3,100 patients over a combined 191 months (16 years) without any change in cleaning protocol and without any incident of bacterial presence. If a biofilm is already present in your water system, bicarb mixer or loop distribution system then you may see discoloration, and you will need to eliminate the biofilm to remove the discoloration.

Are there patients to whom Triferic should not be given?

Physicians should consider withholding all iron therapy for patients with underlying bacteremia, fungemia or sepsis syndrome, otherwise Triferic can continue to be given regardless of ferritin level as long as pre-dialysis TSAT does not exceed 45-50% and there is no clinical evidence of hemochromatosis or iron overload.

Do I need to change or recalibrate any equipment to use Triferic?

There is no need for any changes to your current equipment. Triferic is compatible with all brands of dialysis machines, dialyzers, dialysate concentrates and any configuration central feed system.

Do I need to do any extra cleaning or sanitization of my bicarbonate loop distribution system once using Triferic?

There is no need for any extra cleaning or sanitization of your bicarbonate loop when using Triferic. Triferic is not an elemental iron. Triferic is comprised of iron tightly bound/complexed to pyrophosphate and citrate, making it a highly soluble and stable iron salt. Triferic iron does not oxidize to rust and does not stick to plastic surfaces. Triferic iron does not leave any residue in the bicarbonate tank or central feed loop. Triferic has been administered in over 30 bicarbonate loop systems to approximately 3,100 patients comprising 7.7 million patient treatments over a combined 191 months (16 years) without any change in cleaning protocol and without any incident of bacterial presence. If a biofilm is already present in your water system, bicarb mixer or loop distribution system then you may see discoloration, and you will need to eliminate the biofilm to remove the discoloration.

Do I need to perform extra labs or monitoring with my patients on Triferic?

Regular labs and monitoring as practiced currently in dialysis practice are sufficient, and no additional testing is recommended. Only pre-dialysis blood samples should be used for monitoring iron status.

What are the effects of Triferic on phosphorus and citrate levels?

Triferic has no significant effect on the diffusive transport of these anions during hemodialysis and does not affect their plasma concentrations.

What are the effects of Triferic on inflammation and oxidative stress?

In clinical studies, patients who received Triferic had no effect on serum albumin, C-reactive protein (CRP), IL-6, malondialdehyde or F2 isoprostanes. Triferic does not oversaturate iron binding capacity of transferrin and does not increase levels of non-transferrin bound iron during hemodialysis.

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