Pharmacists Help Patients With HFrEF Manage and Navigate Their Iron Deficiency Therapies

Pharmacists have a crucial role when treating patients with heart failure with reduced ejection fraction (HFrEF) and anemia, according to moderators of a Pharmacy Times Clinical Forum discussion held in Tampa, Florida. This is especially notable in the transitions of care setting, noted the panelists, because pharmacists are often focused on preventing readmissions and iron deficiency to mitigate or prevent any readmissions in patients with HFrEF.

Iron deficiency in HFrEF is diagnosed by ordering and interpreting laboratory tests, such as serum ferritin, transferrin saturation, and hemoglobin levels. Once the condition is diagnosed, pharmacists are able to recommend and manage the appropriate treatment options—whether oral or IV iron supplementation—and monitor patients for their response to treatment and make adjustments to therapies as needed.

A deptiction of health care professionals collaborating to examine a heart. Image Credit: © Frogella.stock - stock.adobe.com

When it comes to screening, pharmacists can help patients identify symptoms and risk factors, such as fatigue, shortness of breath, and reduced exercise tolerance. They can also review patients' medication lists for drugs that may contribute to iron deficiency—such as proton pump inhibitors and aspirin—while also keeping an eye on any potential drug-drug interactions.

The Clinical Forum participants also discussed the importance of pharmacists in optimizing IV iron therapy. They highlighted the need for pharmacists to be involved in the selection of the most appropriate IV iron product, the calculation of the correct dose, and the monitoring of patients for adverse effects. Additionally, pharmacists can play a role in developing and implementing protocols for the use of IV iron in patients with HFrEF. As an example, Natalie Verbosky, PharmD, an inpatient pharmacist in the Cardiac Intensive Care Unit (ICU) at James A. Haley Veteran’s Hospital, noted that pharmacists and other health care professionals may tend to gravitate to ferric carboxymaltose (Injectafer; Daiichi Sankyo) when prescribing treatment for anemia in HFrEF.

Ferric carboxymaltose is administered in 2 dose administrations of 750 mg, separated by at least 7 days, 100% of which is delivered into the patient’s bloodstream. Ferric carboxymaltose is also available as a single-dose 100 mg iron/2 mL vial. Each infusion is administered over a 15-minute duration (at least), with a slow IV push over 7.5 minutes. Ferric carboxymaltose can restore up to 1500 mg in 1 course of therapy.¹

However, Verbosky noted that treatment with ferric carboxymaltose is not always an option for patients due to its cost and the challenges associated with obtaining insurance coverage for the therapy; for these reasons, ferric carboxymaltose is not widely implemented. Kevin Astle, PharmD, BCPS, BCACP, AAHIVP, CDCES, an associate professor and ambulatory care team specialist at the University of South Florida, echoed this and explained that in the outpatient setting, patients will need to try oral iron therapy prior to receiving approval for injectable therapies.

“[In the outpatient setting,] one of the more challenging things to navigate is the insurance approvals… Even if you have a severe iron deficiency/anemia patient, this still require patients to try and fail an oral iron first, which is very difficult,” said Astle. “For those patients [who] can't tolerate it no matter what they do, and it gets very difficult even with the new dosing…[pharmacists] have to wait a couple months, repeat those iron studies, and then prove [or] show that it didn't improve hemoglobin and patients are still symptomatic before you can start looking down the path of IV iron.”

Placement of a catheter in a patient's arm for IV administration. Image Credit: © Nekrasov - stock.adobe.com

One of the moderators, Amanda Martinez, PharmD, BCACP, CPh, a transitions of care pharmacotherapy specialist at Tampa General Hospital, explained that pharmacists, particularly in the transitions of care setting, will need to ensure patients complete their treatment. However, communication across departments can be difficult, according to Martinez. In her practice, she explained that there are private cardiologists and specialists that work with patients, and oftentimes, information does not get properly relayed between each department and each care team member, which can cause confusion or discrepancies.

“Sometimes, [patients] don't finish the dosing [when they are] inpatient… They still need dosing outpatient, and we don't have a good care coordination for that. We will look at it as transitions of care pharmacists to say, ‘They started [patients] on IV iron, but do they need another dose outpatient,’ and we need to follow up with the labs to see if it did replete the iron stores [and assess whether] they need more. So, I'll say there's not a good process that we have, and it's hard,” said Martinez during the Clinical Forum.

Pharmacists are also poised to help address barriers that patients may be facing, regardless of the setting. Patients who are struggling to adhere with their complex treatments—particularly in outpatient settings—can receive guidance from pharmacists. In instances where patients are having difficulty with their specialists or providers, pharmacists can help advocate for them to ensure patients are receiving optimal care and overcoming barriers as they arise, because they are often the most accessible health care professional. Therefore, their ability to help patients navigate the challenging treatment landscape is significant and essential.

REFERENCE

INJECTAFER (ferric carboxymaltose injection) HCP | IDA & ID in HF Treatment. Accessed February 27, 2025. https://injectaferhcp.com