March 2023

In This Issue

• Spotlight on Ferric Derisomaltose
• ACC- Ambulatory Care Centre: Infusion/Treatment Clinic
• Newsboard
  • ORBCoN Fall (MHP) Symposium
• Upcoming Events
  • Register: CBS/ORBCoN Technical Dry Workshop
  • Register: 18th Annual Transfusion Medicine Webconference
  • Register: Transfusionists Talk: Transfusion Made Bloody Easy
  • UofT TM Rounds

Did you know?

Spotlight on Ferric Derisomaltose

Alanna Howell, RN
ONTraC Program Manager

The Global Health Burden 2019 Study estimated that there were 1.8 billion cases of anemia in the world and anemia accounted for 50.3 million years lived with disablility.¹ Iron deficiency is known to be the most common type of anemia.
For several decades intravenous (IV) iron  has been used as a successful treatment modality for iron deficiency and iron deficiency anemia (IDA). It is an option when oral iron is not effective or poorly tolerated or when there is a need to correct anemia rapidly. IV iron is used in various hospital specialty groups including cardiac, oncology, gastroenterology, gynecology and obstetrics. The use of IV iron has expanded in recent years and is now a part of perioperative patient blood management programs.
Earlier IV iron formulations were associated with serious reactions caused by a rapid iron release. In recent years newer formulations have come on the markets which are deemed to be safer. They contain carbohydrate cores which bind elemental iron more tightly resulting in a slower, controlled release and fewer reactions.² One of these newer formulations is ferric derisomaltose (Monoferric®) which was formerly known as iron isomaltoside 1000.  It is a third – generation IV iron compound. It allows for high dose infusion of up to 20 mg/kg or maximum of 1,500 mg administered as an infusion over 30 minutes or more in one visit versus multiple visits.  First introduced in Europe in 2009, it was approved by Health Canada in 2018.  The table below lists the indications and methods of administration for ferric derisomaltose in Canada.³ 

Ferric derisomaltose has shown good efficacy and safety in clinical trials. PROPOSE (N=351), FERWON-Nephro (N=1538), PROVIDE (N=511) and FERWON – IDA (N=1512) compared iron isomaltoside 1000 to iron sucrose in patients with IDA. All of these trials showed iron isomaltoside 1000 to be non-inferior to iron sucrose in raising and/or maintaining hemoglobin levels.^,4,5,6

The recommended total dose is typically between 1000 mg and 1500 mg. The dose may be calculated using the Ganzoni formula or by using a simplified table that can be found within the product monograph. The cost of ferric derisomaltose is $45 per mL leading to a drug cost of $450 for a 1000 mg course of therapy, comparable to a three dose course of Venofer, an iron sucrose. The list below shows various ways the cost of the drug may be covered for patients in the province of Ontario.

• Self pay
• Private Insurance – DIN #02477777
• Limited Use (LU) benefit funded through the Ontario Drug Benefit program The LU criteria is shown in the table below7:

• Canada Veterans Affairs formulary coverage as a standard benefit
• Government of Canada Non-Insured Health Benefit (NIHB) program as an open benefit

The use of ferric derisomaltose is becoming more popular. It provides a complete or near-complete replacement in a single infusion and is generally well tolerated. This results in improved convenience for the patient, shorter chair times, reduced number of infusions needed and a faster correction of anemia.

References

1. Safiri S, Kolahi AA, Noori M, Nejadghaderi SA, Karamzad N, Bragazzi NL, Sullman MJM, Abdollahi M, Collins GS, Kaufman JS, Grieger JA. Burden of anemia and its underlying causes in 204 countries and territories, 1990-2019: results from the Global Burden of Disease Study 2019. J Hematol Oncol. 2021 Nov 4;14(1):185. doi: 10.1186/s13045-021-01202-2.
2. Auerbach M, Macdougall IC. Safety of intravenous iron formulations: facts and folklore. Blood Transfus. 2014 Jul;12(3):296-300. doi: 10.2450/2014.0094-14..
3. Monoferric (ferric derisomaltose) Canadian Product Monograph Pharmacosmos A/S  Nov 2022.
4. Derwman, R. et al. A randomized trial of iron isomaltoside versus iron sucrose in patients with iron anemia. AmJHematol.92, 286-291 (2017)
5. Auerbach M. et al. A prospective, multi-center, randomized comparison of iron isomaltoside 1000 versus iron sucrose in patients with iron deficiency anemia; the FERWON-IDA trial. Am J. Hematol. 94, 1007 -1014 (2019)
6. CADTH Clinical Review Report: Iron Isomaltoside 1000 ( Monoferric): Pharmacosmos A/S): Indication: For the treatment of iron deficiency anemia in adult patients who have intolerance or unresponsiveness to oral iron therapy (May 2020)
7. Ontario Drug Benefit Formulary /Comparative Drug Benefit.  Available online at https://www.formulary.health.gov.on.ca/formulary/

ACC- Ambulatory Care Centre: Infusion/Treatment Clinic

Leslie Chambers, RN BScN, Patient Care Manager Operating Room, Day Surgery, Chemotherapy and Specialist Clinics, St. Joseph’s General Hospital Elliot Lake

The pandemic brought many opportunities and changes to our care delivery model. Some issues which we faced were quite challenging, and others encouraged us to seek solutions and alternatives to continue provision of care to our patients.
At St. Joseph’s General Hospital Elliot Lake (SJGHEL) patients requiring infusion therapy were historically seen and treated in our Emergency Department (ED). With pandemic protocols, overcapacity, and ED pressures the ED was no longer the appropriate location for these scheduled outpatients to attend. Conversely our Day Surgery Department experienced a decrease in patients due to Ministry enforced reductions and ramp downs of surgical procedures, leaving us with staff available to provide this service.
We developed a pilot project to treat infusion patients on our day surgery unit. Our patient population included those receiving non urgent, Remicade, Simponi, Entyvio, IVIG, iron  infusions and blood transfusions. We were fortunate at the onset to utilize staff that had been accommodated to work outside of acute care areas. We were able to offer this service 5 days per week. 
As Surgical recovery regained increasing activity, we were committed to continuing this care delivery model as the feedback from the Emergency Department and the patients was overwhelmingly positive.  Our evaluation demonstrated improved appointment coordination, significant decrease in cancellations due to other factors (common in the ED), as well as the utilization of order sets for iron, blood components and products. The improved coordination and order set implementation enhanced fiscal accountability ensuring, where appropriate, patient medications were provided through either private insurance or EAP funding models decreasing the cost to the organization. 

The pilot ran for 8 months, due to the demonstrated success we endeavoured to seek additional funding to keep this clinic open 5 days per week. However, due to additional pressures, the organization could not commit to the additional funding. The nursing team advocated and was determined to keep the infusion clinic functioning, citing the clinic had improved our patient experience. As a team we evaluated our volumes and the hours of work per treatment were calculated for workload and feasibility evaluation. We developed a plan using Day Surgery Nursing resources currently in place to ensure that we could continue this service 3 days per week, Tuesday through Thursday. Two part time RNs committed to oversee the bookings and coordinate resources, which included occasional time shifting of hours to allow for working patients to attend appointments at non traditional times after 4 PM.  
This 3-day model of care has been successfully delivering care to patients for 6 months. We have worked collaboratively with our laboratory department to add services such as therapeutic phlebotomy and fluid replacement patients. The infusion clinic has also addressed a lack of service for outpatient oncology patients that are non emergent but require urgent transfusion in a safer environment than an overcrowded ED. We have achieved our goals of improving the patient experience, inspiring employees to be engaged in quality care delivery improvement and demonstrating leadership in our commitment to patient care.

Upcoming Events

CBS/ORBCoN Technical Dry Workshop

18th Annual TM Webconference

Transfusionists Talk: Transfusion Made Bloody Easy

UofT TM Rounds

March 23, 2023 @12pm-1pm

Virtual – Whole Blood Debate by Dr. Nick Crombie, Dr. Mark Yazer and Dr. Jeannie Callum – moderator