Daniel Wang

IV Iron Dextran is the Most Cost-Effective Treatment for Iron Deficiency Anemia in HMB, With Daniel Wang

First-line treatment with intravenous (IV) iron dextran is the most cost-effective method of managing 

 in women with heavy menstrual bleeding (HMB) at commonly accepted willingness-to-pay thresholds, according to a recent study.

HMB, defined as menstrual blood loss of a sufficient volume to adversely impact a woman’s physical, emotional, social, and/or material quality of life (QoL), is a symptom of the larger issue of abnormal uterine bleeding in nonpregnant, reproductive-age women. Although data from healthcare systems suggest a prevalence of only 3-5%, past population-based studies have suggested that ≤50% of women of reproductive age are affected.

“Conventionally, oral iron is often prescribed first because it’s very cheap,” Daniel Wang, a medical student at Yale School of Medicine and lead investigator of the study, told 

 in an exclusive interview. “However, for women with heavy menstrual bleeding, the volume of iron they’re losing often precludes oral iron alone to sufficiently replete their iron stores, so these women live with a chronic negative iron balance, which leads to severe iron deficiency anemia and really affects their quality of life in a variety of ways.”

Wang and colleagues developed a Markov simulation including patients aged 18-50, comparing the cost-effectiveness of first-line IV iron dextran, IV iron sucrose, and oral ferrous sulfate for IDA treatment in reproductive-age women with HMB. Costs and quality-adjusted life years (QALY) were assessed from a societal perspective, aiming to account for wages lost due to time spent on infusions.

The team assumed that women with HMB and IDA have an iron deficit of 1000 mg, with an average menstrual blood loss of 120 mL/month in the base case. With an estimated iron loss of 0.5 mg/mL of blood with no coexisting gastrointestinal bleeding, Wang and colleagues determined a monthly iron loss of 60 mg. Additionally, the team assumed that dietary iron intake was sufficient to replace iron when menstrual losses were ≤50 mL/month. Thus, with 120 mL average monthly losses, the average patient will have a net monthly deficit of 35 mg.

Ultimately, Wang and colleagues found IV iron dextran to be the most cost-effective treatment, with 19.26 QALYs at $157,500. This was compared to oral ferrous sulfate, which yielded 19.1 QALYs at $152,900. The incremental cost-effectiveness ratio for IV iron dextran was $28,600 per QALY. Treatment with IV ferumoxytol and iron sucrose cost $158,300 and $163,500, respectively, and provided no additional QALY benefits compared to IV iron dextran.

Despite these data, Wang and colleagues noted several limitations to the study’s structure. Notably, the team operated under the assumption that women undergo uniform menstrual loss across the reproductive lifetime after receiving an HMB diagnosis in the base case – this assumption does not account for underlying causes of HMB, such as uterine polyps or leiomyomas, treatments to reduce menstrual volume, or possible pregnancy. Additionally, the study was by nature not capable of addressing all potential alternative oral or IV iron alternatives, which may be suggested based on cost, coverage, and personal preference. Patients may also switch medications during treatment.

“The hope for our findings is that, while oral iron may appear to be cheaper and more cost-effective from a payer standpoint, over the entire reproductive lifespan of a patient with HMB and IDA, IV iron is going to deliver the best value for money for these patients,” Wang told 

. “Our hope is that, for patients for whom this is appropriate first-line therapy, there would not be any insurance-related barriers or stepwise, sequential treatment that they have to go through.”

Editor’s Note: Wang reports support from the American Society of Hematology.

Wang D, Sra MS, Ito S, et al. Cost-effectiveness of first line IV versus oral iron for iron deficiency anemia in women with heavy menstrual bleeding. 

Munro MG, Mast AE, Powers JM, et al. The relationship between heavy menstrual bleeding, iron deficiency, and iron deficiency anemia.

Videos

Wang discusses results from a recent study, comparing multiple forms of intravenous and oral iron supplements in female patients with heavy menstrual bleeding.

Iron deficiency is currently screened at a ferritin threshold of 15 ug/mL, well below an accepted 25 ug/mL threshold.

Daniel Wang: A More Appropriate Ferritin Threshold is Cost-Effective for Iron Deficiency Screening

Screening for iron deficiency (ID) at a ferritin threshold of under 25µg/L is a cost-effective and more accurate identification and treatment strategy for women with ID.

 66th American Society of Hematology (ASH) Annual Meeting and Exposition

, held December 7-10, 2024, in San Diego, California, by Daniel Wang, Yale School of Medicine.

“The current world health organization guidelines have the lower limit of normal for serum ferritin at 15 micrograms per liter, whereas we know from physiological studies… that a more appropriate threshold is probably 25-to-30, maybe even as high as 50 micrograms per liter, so a huge swath of women of reproductive age who are just going undiagnosed and untreated in a lot of cases,” Wang told 

Wang and colleagues found that screening for ID with a ferritin threshold under 25µg/L is the cost-effective strategy in 100% of 10,000 Monte Carlo iterations, accruing $212,000 in costs and generating 24.3 Quality-Adjusted Life Years (QALYs), compared with $211,000 and 23.3 QALYs with a screening threshold of 15 µg/L, or $210,000 and 22.3 QALYs with no screening. Overall, the data show that the incremental cost-effectiveness ratio of 25 µg/L compared to no screening is $940/QALY which is accepted under willingness-to-pay thresholds in the United State.

The investigators also found that treatment with iron dextran (ICER = $1,700/QALY) is also cost-effective in patients with ID. These findings were supported with sensitivity analyses.

“…Cost should not be a barrier for the screening and treatment of these women and at a population level. If we can raise the bar, I really think so, so many people would benefit,” Wang said.

Wang D, Glaeser-Khan S, Wang DY, et al. Sex, Lies, and Iron Deficiency in 2024: Cost-Effectiveness of Screening Ferritin Thresholds for the Treatment of Iron Deficiency in Women of Reproductive Age. Presented at: ASH Annual meeting; December 7-10; San Diego, California. Abstract 277

Daniel Wang

Articles