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Fishbane Reaction

     The Fishbane reaction is a benign, self-limited, nonallergic infusion reaction associated with intravenous iron. Clinical features include acute facial flushing, chest or back tightness, myalgia, and arthralgia during infusion, but resolve spontaneously once the infusion is stopped.1-3 The absence of hypotension, bronchospasm, stridor, angioedema, or cyanosis distinguishes it from anaphylaxis.1,2
     The reaction involves transient exposure to labile (free) iron, often associated with rapid infusion, and is grouped under complement activation-related pseudoallergy (CARPA).1, 3-4 Fishbane reactions do not require prior sensitization and may occur with the first exposure; risk may be influenced by the infusion rate.3

Management includes:

  • Stopping the infusion and monitoring the patient. Symptoms typically resolve within minutes without pharmacologic treatment.1-2, 6
  • Do not treat with epinephrine or diphenhydramine. These are ineffective for the Fishbane reaction and may cause adverse effects such as tachycardia or somnolence.1
  • Once symptoms resolve, clinicians can restart the infusion at a slower rate, as CARPA/Fishbane reactions rarely recur. Adequate pre-infusion hydration and compounding in normal saline may help prevent recurrence.1,4,6 


     The 2026 American Academy of Pediatrics clinical report on iron deficiency in infants, children, and adolescents notes that most IV iron adverse effects in children are temporary and minor (nausea, vomiting, abdominal pain, headache, flushing, pruritus, and urticaria), and emphasizes that modern formulations have a substantially improved safety profile.7

References

  1. Auerbach M, DeLoughery TG, Tirnauer JS. Iron deficiency in adults: a review. JAMA. 2025;333(20):1813-1823. doi:10.1001/jama.2025.0452
  2. Jensen MCH, Holm C, Jørgensen KJ, Schroll JB. Treatment for women with postpartum iron deficiency anaemia. Cochrane Database Syst Rev. 2024;12:CD010861. doi:10.1002/14651858.CD010861.pub3. Accessed October 5, 2026.
  3. Boots JMM, Quax RAM. High-dose intravenous iron with either ferric carboxymaltose or ferric derisomaltose: a benefit-risk assessment. Drug Saf. 2022;45:1019-1036. doi:10.1007/s40264-022-01216-w
  4. Van Doren L, Steinheiser M, Boykin K, Taylor KJ, Menendez M, Auerbach M. Expert consensus guidelines: intravenous iron uses, formulations, administration, and management of reactions. Am J Hematol. 2024;99(7):1338-1348. doi:10.1002/ajh.27220
  5. Sinclair RCF, Nadaraja S, Kennedy NA, et al. Real-world experience of intravenous ferric derisomaltose evaluated through safety and efficacy reporting in the UK. Sci Rep. 2022;12:18859. doi:10.1038/s41598-022-23581-3
  6. Kido K, Beavers CJ, Dulnuan K, et al. Management of iron deficiency in heart failure: practical considerations and implementation of evidence-based iron supplementation. JACC Heart Fail. 2024;12(12):1961-1978. doi:10.1016/j.jchf.2024.05.014
  7. Powers JM, Heeney MM, Hord J, et al. Prevention, screening, diagnosis, and treatment of iron deficiency and iron deficiency anemia in infants, children, and adolescents: clinical report. Pediatrics. 2026;158(1):e2026077414. doi:10.1542/peds.2026-077414

These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.