Parenteral iron test doses and hot flushes on tamoxifen

Which IV iron products require administration of a test dose before the infusion?

Many IV iron replacement products are currently available, including iron dextran (Dexferrum, Infed), iron sucrose (Venofer), ferric gluconate (Ferrlecit), and ferumoxytol (Faraheme). The oldest of these products, iron dextran, has been associated with an elevated risk of anaphylactic-type reactions during infusion. A boxed warning on iron dextran products states that test doses should be used prior to administering the full infusion.

Test doses are not mandated for other iron products. Some patient characteristics may increase the risk of an anaphylactic-type reaction, including a history of reactions to other iron products, current use of an ACE inhibitor (eg, lisinopril [Zestril, Prinivil, generics], ramipril [Altace, generics], etc), or multiple drug allergies. Patients with these risk factors should receive test doses prior to use of any IV iron product. Note that some patients who tolerate the test dose may still develop an anaphylactic-type reaction. Parenteral iron products should be administered in a facility with adequate staff and resources to manage these potentially fatal reactions.

What medications can be used to treat hot flushes in premenopausal women receiving tamoxifen for breast cancer?

Tamoxifen (Nolvadex, generics), which blocks the effects of estrogen on breast and other tissue, is often used in the adjuvant treatment of hormone receptor-positive breast cancer in premenopausal women. Hot flushes are a frequent side effect. While women without breast cancer can use estrogen or progesterone to manage their hot flushes, these hormones are not used in cancer patients because of the risk that they will stimulate hormone-positive breast cancers. Studies in this population have found that estrogen and progesterone use more than doubles the risk of recurrence. Therefore, other medications are used to manage hot flushes whenever possible.

No treatment option controls hot flushes in every woman. Therefore, nurses should encourage patients to communicate with their oncologist if their current hot flush medication is not working. Some antidepressants, specifically the selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine) and serotonin and norepinephrine receptor inhibitors (SNRIs) (eg, venlafaxine [Effexor, generics]), are effective in managing hot flushes in many women. Studies of venlafaxine, fluoxetine, and citalopram (Celexa, generics) have reported fewer hot flushes in women taking these medications. Women receiving tamoxifen should not take paroxetine (Paxil, Pexeva) because it interferes with the metabolism of tamoxifen to its active form. Other antidepressants produce this effect to a lesser degree, and venlafaxine does not seem to interfere at all.

Gabapentin (Gabarone, Gralise, Neurontin, generics) and clonidine (Catapres, generics) have also been studied in the treatment of hot flushes. While both these medications are effective in some women, clonidine is not often used because of side effects, including drowsiness, dizziness, and dry mouth.

In addition to lifestyle modifications, such as dressing in layers and avoiding spicy foods, some vitamins and herbs have been purported to manage hot flushes. However, a randomized trial of vitamin E showed that it was no better than placebo in controlling hot flushes. Black cohosh, phytoestrogens, and other herbs have weak estrogenic properties and should not be used in women with a history of breast cancer. Women who wish to use herbal therapy for managing hot flushes should discuss the possible effects with their oncologist. ONA