A transfusion medicine physician in California states that some US hospitals are allowing simultaneous infusion of deferoxamine (Desferal) and blood through the same double lumen catheter.  He also states that the version of the US product description which he recently read states "Desferal should be administered separately from the blood." (Editor's Note: The Webmaster's Palm Pilot version of the PDR does not comment one way or the other.)  The California colleague adds that a Swiss product description for deferoxamine states "The Desferal solution...may be added to the blood line by means of a "Y" adaptor located near to the venous site of injection".  According to the AABB Technical Manual, "Other solutions intended for intravenous use may be added to blood or components or may come into contact with blood in an administration set only if they have been approved for this use by the Food and Drug Administration, or if there is documentation to show that their addition to blood is safe and efficacious."  The California physician would like comments from the e-Network Forum regarding the Swiss practice and how it might apply in the U.S.?

The following comments have been received.

1. The above query was sent to a transfusion medicine physician In Switzerland, who reports that the normal route for administering Desferal in their practice is subcutaneously employing a pump. Occasionally deferoxamine is administered very slowly intravenously, AFTER the transfusion of a unit of packed cells. Theoretically, it is allowed to administer it simutaneously, using a catheter with a double lumen. In most cases, the catheter is placed in the subclavian vein, where there is sufficient flow. However, the Swiss physician was unable to locate any physician who actually has experience with administering Desferal using a Y-set.

ADDENDA Sept. 8, 2004

2. A colleague in Brazil reports until 3 years ago it was the practice in their regional blood center to administer Desferal plus red cells by Y-line. The objective was to spare the patient a subcutaneous injection. To his knowledge there were no adverse reactions to administering desferal via Y-line along with red cells, but they eventually stopped that practice. Apparently they became concerned that a simultaneous infusion of both the drug and blood might mask or mimic a transfusion reaction, such as an allergic reaction occurring in response to Desferal.

ADDENDA Sept. 9, 2004

3. A colleague in South Africa reports that in a referral hematology clinic, Desferal is given via a Y-line along with the red cell transfusion, with no observed deleterious effects. This approach appears to be out of necessity, as it is also reported that subcutaneous pumps are not available to patients in public sector hospitals.

ADDENDA Sept. 14, 2004

4. A transfusion medicine physician at a university hospital in Lausanne, Switzerland reports they have experience infusing Desferal (in isotonic saline) through Y-tubing along with red blood cells without any particular problems. In their hands this approach appears to be safe and convenient, particularly for older myelodsplastic patients. He reports also using this approach (in addition to standard subcutaneous infusions) in thalassemic patients who are not very compliant.

ADDENDA Aug. 17, 2005

5. A California physician (different than the one who initiated this discussion) reports that the infusion of Desferal has become a controversial issue within his hospital, in that for more than ten years they have practiced the simultaneous administration of the drug with blood without any observed (reported) problems. However, recently their 'Nursing Administration' instructed their staff to discontinue. In addition, the pharmacy also abruptly stopped preparing Desferal for administration with blood products. The reporting physician does NOT think that giving Desferal simultaneously with blood transfusion is a desirable practice. However, he acknowledges that patients like it. He points out that the AABB Technical Manual refers to the Standards for Blood Banks and Transfusion Services (23rd edition: 5.19.10) which states:

Addition of Drugs and Solutions: With the exception of 0.9% sodium chloride (USP), drugs or medications shall not be added to blood or components unless one of the following conditions are met:

1. They have been approved for this use by the FDA.
2. There is documentation available to show that the addition is safe and does not adversely affect the blood or blood component.

He asks how others 'interpret' the AABB Standards as they seem to imply that FDA approval is NOT needed for administration of drugs with blood, so long as the second standard is met. For those who infuse Desferol simultaneously with blood, what documentation is maintained that the practice is safe, and what has been your experience with AABB and FDA inspections?

ADDENDA Apr. 4, 2006

6. Editor's note: Dr. Darlene Powars has approved posting of the attached letter supporting the use of intravenous Desferal given concomitantly with blood. According to Dr. Powars, she and her colleagues would be pleased to have the letter posted for the 'blood bank group'.

ADDENDA Apr. 28, 2006

7. Dr. Joanne Murdock, Consultant in Transfusion Medicine for the Northern Ireland Blood Transfusion Service (attribution used with permission) reports that she is a member of a UK group conducting a systematic review of the literature around co-infusing drugs with blood. As a slightly different take on the deferoxamine/blood debate, she is aware of a research paper (The Effect of Metal Chelators on Lipid Peroxidation in Stored Erythrocytes, Knight et al, Annals of Clinical and Laboratory Science 1992; 22(4) p. 207-213) which showed that in vitro addition of deferoxamine to CPD blood inhibited erythrocyte lipid peroxidation. The authors concluded that addition of iron-binding substances to donor blood may improve viability and longevity during storage and possibly, the first few days post-transfusion. (They also suggested that giving deferoxamine to blood donors pre-donation might improve longevity/viability of red cells during storage!) Dr. Murdock appreciates that mixing stored blood and deferoxamine in vitro is not equivalent to mixing the two during transfusion but this evidence possibly does add some more weight to the argument that it is probably safe (at least from the red cell point of view).

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator