IV iron cost-effective treatment for women with iron deficiency anemia and heavy menstrual bleeding: Study

A single dose of intravenous (IV) iron dextran is the cost-effective treatment for women with heavy menstrual bleeding and iron deficiency anemia (IDA), according to new research published in Blood Advances.

“Oral iron is usually given as first-line treatment because on the surface, it appears less expensive and more convenient,” said study author Daniel Wang, a fourth-year medical student at Yale School of Medicine currently pursuing a research year as a recipient of the American Society of Hematology Medical Student Physician-Scientist Award. “However, we found that the preferred first-line treatment for these patients is IV iron as it delivers the highest value for cost and substantially improves quality of life.”

Globally, nearly a third of women experience IDA, a condition in which the body has insufficient iron to produce hemoglobin, the protein in red blood cells that transports oxygen from the lungs to the rest of the body. Individuals with IDA may experience symptoms like extreme fatigue, shortness of breath, chest pain, and worsening of other preexisting conditions. Women with heavy menstrual bleeding – over >80 mL of menstrual blood loss a month or any level of bleeding that significantly impacts day-to-day quality of life – are at especially high risk for developing IDA.

“These patients are often unidentified, underdiagnosed, and living with a chronic negative iron balance,” said Mr. Wang. “Many then become pregnant, which requires even more iron to support mom and baby with important effects on childhood development, so it’s crucial to identify the best intervention for repleting their iron stores.”

In the United States, patients with IDA and heavy menstrual bleeding typically receive oral iron supplementation as first-line treatment because of its availability, ease of administration, and lower upfront cost to insurers. However, oral iron causes notable gastrointestinal side effects and is less efficient for replenishing iron stores as it is not completely absorbed, whereas IV iron is generally well tolerated and 100% absorbed. Despite IV iron’s advantages, women in the U.S. with heavy menstrual bleeding and IDA receive their first IV iron infusion approximately 4.4 years after symptom onset and 1.4 years after IDA diagnosis.

In the current study, the researchers used a model to compare the cost-effectiveness of first-line IV iron dextran, IV iron sucrose, and oral ferrous sulfate for treating IDA in reproductive-age women with heavy menstrual bleeding. They projected outcomes over a menstrual lifetime, beginning at age 18 and continuing through age 51, with model cycles of three months in length. The model used a base case of 120 mL menstrual blood loss per month, and a net monthly iron deficit of 35 mg. Costs and outcomes were assessed from a societal perspective to account for patient-facing opportunity costs such as wages lost to infusion time.

Under the base case assumptions, the researchers projected that first-line treatment with IV iron dextran (one-time dose of 1000 mg), IV iron ferumoxytol (two doses of 510 mg), or IV iron sucrose (five doses of 200 mg) would resolve IDA until about 30 months post-transfusion, when the patient reaccumulated an iron deficit of 1000 mg due to heavy menstrual bleeding.

In contrast, patients receiving first-line treatment with alternate-day dosing of 325 mg oral ferrous sulfate (65 mg of elemental iron with 20.6% absorbed) were projected to return to a 1000 mg iron deficit approximately every 36 months.

To assess cost-effectiveness of each iron supplementation strategy, the researchers determined incremental cost-effectiveness ratio (ICER, the difference in total cost divided by the difference in total quality-adjusted life year) and net monetary benefit (NMB, the product of total quality-adjusted life years and the willingness-to-pay threshold minus total costs).

In the base case scenario, IV iron dextran was the most cost-effective treatment, yielding an ICER of $28,600/QALY and an incremental NMB of $11,500 when compared with oral ferrous sulfate. IV iron dextran remained the cost-effective option in scenarios of 240 mL and 420 mL monthly menstrual blood loss.

The model did have several limitations, including that women were assumed to undergo uniform menstrual loss across their reproductive lifetimes, and that while the analysis compared several iron interventions, it did not include other single-dose IV iron formulations such as ferric derisomaltose or ferric carboxymaltose, nor did it factor in switching between iron supplementation products.

The researchers plan to continue refining the scope and accuracy of their model and provide patient-, clinician-, and administrator-facing versions to help inform treatment decisions at population and individual patient levels – particularly for individuals whose values and preferences align with first-line IV iron.

“One study at a time, we hope to decrease insurance barriers and enhance decision-making and quality of life across the spectrum of a woman’s reproductive life,” said study author George Goshua, MD, MSc, FACP, assistant professor of medicine in the section of medical oncology and hematology at Yale School of Medicine and Yale Cancer Center, and principal investigator at the Goshua Lab, which facilitated this study. “This is a prevalent global issue, and we hope that others around the world can take this model, adapt it to their contexts, and continue building upon it.”

Reference:

Daniel Wang, Manraj Singh Sra, Satoko Ito, Ding Quan Ng, Samira Glaeser-Khan, Daniel Y Wang, Sam Hirniak, Alfred I Lee, Adam Cuker, Cost-Effectiveness of First-Line IV Versus Oral Iron for Iron Deficiency Anemia in Women with Heavy Menstrual Bleeding, Blood Advances, https://doi.org/10.1182/bloodadvances.2025018315