Iron Deficiency Treatment and Monitoring

1. Commonly used oral iron preparations include: ferrous gluconate, ferrous fumarate, and ferrous sulfate. One preparation is not preferred over another; patient tolerance should be the guide. (Refer Appendix B).
2. The usual adult dose is 180 mg of elemental iron/day in divided doses.¹⁴ Therapeutic doses can range from 100 to 200 mg of elemental iron/day, depending on severity of symptoms, ferritin levels, age of the patient, and gastrointestinal side effects.
3. Iron intolerance is very common;
   1. Oral iron preparations may cause nausea, vomiting, dyspepsia, constipation, diarrhea or dark stools.
   2. Strategies to minimize these effects include: start at a lower dose and increase gradually over 4 to 5 days; giving divided doses or the lowest effective dose, or taking supplements with meals (note: iron absorption is enhanced if supplements are taken on an empty stomach; however, it may not be tolerated).
   3. Although sustained release iron preparations tend towards less gastrointestinal side effects, they may not be as effective as standard film coated products due to reduced/poor iron absorption.¹⁵
4. Iron absorption can be decreased by various medications and supplements; space administration apart by at least 2 hours. (Refer to Appendix B)
5. Iron absorption from pharmaceutical preparations can be enhanced by taking them on an empty stomach (at least 1.5 to 2 hours after a meal), with acidic juices or vitamin C, and not with other multivitamin, calcium, or antacid tablets.
6. Iron replacement therapy may begin as soon as iron deficiency is detected; however, it is essential to determine and correct the underlying causes of iron deficiency (see Appendix B and Table 1).¹
7. Oral iron therapy in iron deficient anemia will increase hemoglobin by 10-20 g/L in 2 to 4 weeks. Order a Hematology Profile initially at 2 to 4 weeks to monitor response to replacement regime.
8. Anemia will correct within 2 to 4 months if appropriate iron dosages are administered and underlying cause of iron deficiency is corrected.
9. Continue iron therapy an additional 4 to 6 months (adults) after the hemoglobin normalizes to replenish the iron stores.¹⁶ The frequency of subsequent monitoring depends upon the severity of the anemia, the underlying cause of the iron deficiency, and the clinical impact upon the patient.
10. If the patient's clinical status is compromised by moderate to severe anemia, consider admission to an acute care facility and blood transfusion. Once the patient is stable, iron replacement can be commenced.
11. Oral iron replacement is preferred to intravenous (IV) therapy. It is safer, more cost-effective, and convenient when compared to IV therapy.¹⁷ However, intravenous therapy may be substituted when there is: inadequate iron absorption, continued blood loss, noncompliance or intolerance to oral iron therapy. Internal medicine/hematologist consultation is recommended.¹³ (Refer Appendix B)
12. Complete or partial failure of monitored iron therapy trial (in compliant patients) may be due to insufficient absorption or ongoing loss (e.g. hemorrhage) or both. It should be investigated appropriately. Intravenous iron preparations may be considered in these patients.
13. Intramuscular (IM) iron therapy is not recommended except in institutions with facility for treating anaphylactic reactions.¹⁸ Additional risks of IM iron therapy include unpredictable absorption and local complications (e.g. pain, staining of the skin, sarcoma formation).¹⁹

^Source: 
Nadeem Zia, B.Pharm, RPh,

OpenDoor Team, www.OpenDoor.cc

Consulting Pharmacist, Vancouver, BC Canada

LinkedIn: http://ca.linkedin.com/in/NadeemPharmacist

Google + : google.com/+NadeemZiaRPh

Vancouver, British Columbia, Canada

^{Reference: http://www.bcguidelines.ca/guideline_iron_deficiency.html}

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