IV iron dextran found cost-effective as first-line treatment for IDA in heavy menstrual bleeding

A single dose of intravenous (IV) iron dextran may represent the most cost-effective first-line treatment for iron deficiency anemia (IDA) among reproductive-age women with heavy menstrual bleeding, according to a new analysis published in Blood Advances.^1,2

IDA affects nearly one-third of women globally and is particularly prevalent among those with heavy menstrual bleeding, a condition defined as menstrual blood loss exceeding 80 mL per month or bleeding that significantly disrupts daily functioning. In the United States, oral iron supplementation is typically recommended as initial therapy because of its low upfront cost and ease of administration. However, oral formulations are often associated with gastrointestinal adverse effects and incomplete absorption, which can limit adherence and delay effective iron repletion.

“Oral iron is usually given as first-line treatment because on the surface, it appears less expensive and more convenient,” said study author Daniel Wang, a fourth-year medical student at Yale School of Medicine and recipient of the American Society of Hematology Medical Student Physician-Scientist Award. “However, we found that the preferred first-line treatment for these patients is IV iron as it delivers the highest value for cost and substantially improves quality of life.”

Modeling cost-effectiveness over the reproductive lifespan

To compare iron replacement strategies, investigators developed a Markov simulation model that followed a cohort of women with IDA and heavy menstrual bleeding from age 18 through menopause at age 51. The analysis compared first-line treatment with IV iron dextran, IV iron sucrose, IV ferumoxytol, and alternate-day oral ferrous sulfate. Outcomes were assessed over three-month cycles from a societal perspective, incorporating both direct medical costs and indirect costs such as wages lost during infusion visits.

The base-case model assumed an average menstrual blood loss of 120 mL per month and a net iron deficit of 35 mg monthly. Under these conditions, IV iron dextran was projected to resolve IDA for approximately 30 months following a single 1000-mg infusion. By comparison, patients receiving oral ferrous sulfate were projected to return to a clinically significant iron deficit approximately every 36 months, reflecting slower iron repletion and ongoing losses.

To assess value, investigators calculated incremental cost-effectiveness ratios (ICERs) and net monetary benefit (NMB), using quality-adjusted life years (QALYs) as the primary effectiveness outcome.

IV iron dextran associated with favorable economic outcomes

In the base-case analysis, IV iron dextran yielded 19.26 QALYs at a lifetime cost of $157,500, compared with 19.10 QALYs at $152,900 for oral ferrous sulfate. This translated to an ICER of $28,600 per QALY gained, a value below commonly accepted U.S. willingness-to-pay thresholds. IV iron dextran also demonstrated a higher incremental net monetary benefit than oral iron.

The cost-effectiveness of IV iron dextran was preserved in sensitivity analyses simulating heavier menstrual bleeding. At monthly blood losses of 240 mL and 420 mL, IV iron dextran remained the most cost-effective strategy, with ICERs of $22,500 per QALY and $10,100 per QALY, respectively.

Although IV iron sucrose and IV ferumoxytol achieved similar QALY gains, both were associated with higher total costs due to the need for multiple infusions, reducing their comparative value in the model.

Clinical and public health implications

Despite evidence supporting IV iron’s effectiveness, treatment delays remain common. In the U.S., women with IDA and heavy menstrual bleeding receive their first IV iron infusion an average of 4.4 years after symptom onset and 1.4 years after formal diagnosis.

“These patients are often unidentified, underdiagnosed, and living with a chronic negative iron balance,” Wang said. “Many then become pregnant, which requires even more iron to support mom and baby with important effects on childhood development, so it’s crucial to identify the best intervention for repleting their iron stores.”

The authors noted that oral iron intolerance, incomplete absorption, and adherence challenges may contribute to prolonged symptoms and reduced quality of life. In contrast, IV iron formulations are fully absorbed and generally well tolerated, although they carry a small risk of infusion reactions.

Study limitations and future directions

The investigators acknowledged several limitations, including assumptions of uniform menstrual blood loss across the reproductive lifespan and exclusion of some single-dose IV iron formulations, such as ferric derisomaltose and ferric carboxymaltose. The model also did not account for switching between iron therapies or for potential reductions in bleeding following treatment of underlying gynecologic conditions.

The research team plans to further refine the model and develop patient-, clinician-, and administrator-facing tools to support shared decision-making.

“One study at a time, we hope to decrease insurance barriers and enhance decision-making and quality of life across the spectrum of a woman’s reproductive life,” said senior author George Goshua, MD, MSc, FACP, assistant professor of medicine at Yale School of Medicine and Yale Cancer Center. “This is a prevalent global issue, and we hope that others around the world can take this model, adapt it to their contexts, and continue building upon it.”

References

1. 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. Blood Advances. Published online January 8, 2026. doi:https://doi.org/10.1182/bloodadvances.2025018315
2. American Society of Hematology. IV iron is the cost-effective treatment for women with iron deficiency anemia and heavy menstrual bleeding. EurekAlert! Published January 8, 2026. Accessed January 9, 2026. https://www.eurekalert.org/news-releases/1111829