Ferric carboxymaltose/monosodium phosphate
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Hypophosphataemia and other toxicities: case report A 43-year-old woman developed anxiety attack and hypophosphataemia during treatment with ferric carboxymaltose for chronic iron deficiency. Additionally, she developed nausea, painful indigestion, chest discomfort, epigastric discomfort and unspecified indigestion symptoms during treatment with monosodium phosphate for hypophosphataemia [not all routes stated]. The woman presented to the emergency department with symptoms of iron deficiency. She had been receiving oral ferrous sulfate tablet for the chronic iron deficiency, but reported poor adherence to taking ferrous sulfate due to unspecified gastrointestinal side-effects. Her serum ferritin level was found to be low. Therefore, she started receiving IV infusion of ferric carboxymaltose [Ferinject] six days before this presentation. At that time, she was planned to receive ferric carboxymaltose 1000mg dose made up to 270mL with 0.9% sodium chloride solution to run over 30 minutes; however, she tolerated only half of the ferric carboxymaltose infusion (received 519mg only) due to a severe anxiety attack. Blood reports were unremarkable except slight decrease in serum phosphate level to 0.6 mmol/L. Within a week, she developed symptomatic and severe hypophosphataemia following administration of IV ferric carboxymaltose (519mg in total). The woman was reassured and discharged with monosodium phosphate tablets [Sandoz Phosphate; sodium acid phosphate anhydrous]. She again admitted after 3 days due to symptoms of hypophosphatemia including painful legs cramps, fatigue, dizziness and nausea. It was noted that her serum phosphate level was 0.43 mmol/L. She could not tolerate the monosodium phosphate due to severe nausea, severe chest and epigastric discomfort and painful indigestion. Her other blood results were unremarkable with elevated serum ferritin. Urinalysis showed a fractional excretion of phosphate (FEPO4) of 24.2%, confirming severe renal wasting of phosphate in the presence of severe hypophosphataemia. She was hospitalised and started receiving IV infusion of monosodium phosphate [Phosphate Polyfusor] 150mL over 12h (containing 15 mmol of phosphate). Due to recurrent low serum phosphate levels and her symptoms, she needed 15 doses of IV monosodium phosphate over a 4-week hospitalisation. She also received calcitriol, colecalciferol [vitamin D3] and a bespoke syrup monosodium phosphate [sodium dihydrogen phosphate] 15 mmol three times a day along with a phosphate-rich diet. She still developed unspecified indigestion symptoms due to monosodium phosphate syrup. The last monosodium phosphate infusion was given on day 26, and she was discharged on day 30 on calcitriol, colecalciferol, monosodium phosphate syrup and some unspecified effervescent phosphate tablets. Her serum phosphate levels normalised, which remained normal following dose reduction of phosphate supplements. Her repeat serum ferritin level was low, and hence, she was advised to start oral iron tablets. On day 42, she was able to discontinue
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