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Management of the Severely Anemic Jehovah's Witness

TO THE EDITOR: Mann and colleagues [1] describe an intelligent and badly needed approach to the treatment of the anemic Jehovah's Witness. Their recommendations regarding the use of erythropoietin and iron dextran are both accurate and prudent. However, there is an error in their reference to our article [2]: Iron dextran is and has been labeled for intravenous use; such use is restricted (under label) to undiluted, intravenous boluses not to exceed 100 mg. Our study clearly showed the superiority of total dose infusion of iron dextran given in 500 mL of normal saline over the approved (label) method of intravenous iron administration. Mann and coworkers point toward the usefulness of total dose infusion, but their admonition regarding the occurrence of two anaphylactic reactions in our study may create undue alarm. There were two acute reactions: A substance abuser experienced total body pain within seconds of the test dose; this was clearly an anxiety reaction but one that needed to be mentioned for the integrity of the study. A second person had a genuine acute hypersensitivity reaction, with wheezing and tachycardia but without hypotension or shock. This reaction abated within 30 minutes with administration of intravenous methylprednisolone. We have subsequently treated over 200 patients without an acute reaction. Furthermore, the acute reactions occurred with the test dose and do not relate to the method of iron dextran administration. Test doses are recommended with any form of parenteral iron administration, and acute reactions occur equally with intramuscular administration, intravenous bolus administration, and total dose infusion. Our conclusion should therefore be underscored: If parenteral iron is indicated, it should be given as a total dose infusion. We believe clarifying this point solidifies the therapeutic recommendations in this extremely timely and well-written article.