Absolute iron deficiency: ferritin <15 µg/L (diagnostic) or <30 µg/L (supportive), and/or TSAT <20% - particularly if symptomatic or Hb is low.
Heart failure–related iron deficiency (guideline definition): ferritin <100 µg/L OR ferritin 100–299 µg/L with TSAT <20% (iron deficiency may be present even if Hb is normal).
Inflammation / functional iron deficiency (e.g. CKD, CHF, IBD): ferritin may be normal or high but TSAT low due to hepcidin-mediated iron sequestration → oral iron often ineffective; IV iron bypasses absorption.
Oral iron failure or intolerance (GI side effects, poor adherence, malabsorption, or inadequate Hb/ferritin response).
Need for rapid repletion (e.g. symptomatic anaemia, ongoing blood loss, peri-operative optimisation, PBM pathways).
Chronic kidney disease: IV iron commonly preferred in dialysis; in non-dialysis CKD the route is individualised based on severity, response to oral iron, access, and timeframe.

🫀 Heart Failure – Practical “UK-style” Trigger

📌 Consider IV iron in chronic HFrEF when iron deficiency is present (check ferritin + TSAT), regardless of whether anaemia is present.
🎯 Evidence strongest for improvement in symptoms, exercise tolerance, and quality of life; effects on hospital admissions vary between trials.

💉 Common IV Iron Options (UK practice)

Formulation	Typical approach	Infusion time	Hypersensitivity risk	Notes
Ferric carboxymaltose (FCM) Ferinject	🔹 Large single doses (per weight/label)	⏳ ~15–30 min	🟢 Very low	⭐ Widely used; higher hypophosphataemia risk than some alternatives.
Ferric derisomaltose (FDI) Monofer / Monoferric	🔹 High total dose in one visit (per weight/label)	⏳ ~30–60 min	🟢 Very low	✅ Convenient “one-and-done”; hypophosphataemia can still occur but is generally lower than with FCM.
Iron sucrose Venofer	🔸 Smaller doses → multiple visits	⏳ ~30–60 min	🟢 Low	🏥 Common in renal units; less convenient for large deficits.

🚫 Avoid high–molecular-weight iron dextran due to historically higher anaphylaxis risk (largely obsolete in UK practice).

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Intravenous Iron Replacement

🩸In UK guidance (NICE NG24 / BSH-aligned practice), red cell transfusion is generally reserved for:

🩸 IV Iron Is Preferred or Recommended

🫀 Heart Failure – Practical “UK-style” Trigger

💉 Common IV Iron Options (UK practice)

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