NO IRON? KNOW YOUR IRON!

Iron deficiency is the most common nutritional deficiency globally, affecting ~1 in 3 women (consistently shown in global and local data). Unfortunately, it is usually only detected when patients develop anaemia which often occurs a few years later. Symptoms of iron deficiency include fatigue, hair loss, brain fog, poor immune function (i.e. more prone to common cold/flu), cold intolerance and much more.

Difference between iron deficiency and anaemia

Iron deficiency and anaemia are often confused – or considered the same disease. Anaemia is detected by looking at haemoglobin (Hb) with a routine blood test. Iron deficiency is the most common cause of anaemia but not the only cause. More importantly, iron deficiency generally occurs years before anaemia so early detection and treatment can avoid anaemia completely.

How to diagnose iron deficiency

Iron deficiency can be diagnosed with a simple blood test that measures patient’s serum ferritin. Knowing your iron levels early may avoid the need for blood transfusions once anaemia develops.

Serum ferritin is a marker of the iron stores in the body. When the blood concentration falls below 30ng/mL, the body no longer has enough iron and a patient is probably experiencing many of the symptoms of iron deficiency. Only with serum ferritin levels above 100ng/mL can we be sure that we have enough iron in our body.

Women at highest risk

Women are most at risk of iron deficiency due to regular menses. For every 1mL of blood that is lost we lose 0.5mg iron. Over a year, a woman with heavy menses can have annual losses exceeding 500mg iron. Considering that most women only have about 3,000mg or iron in their body it is easy to understand why so many are at risk of iron deficiency.

To make things worse, during pregnancy the growing baby will require about 500mg of iron from the mother. As 40% of women are already iron deficient when trying to conceive, , the additional requirement of iron forthe baby may result in iron not being available to make red blood cells and can lead to iron deficiency anaemia during pregnancy – which, in very severe cases, could require a blood transfusion. . During child birth there is further loss of blood (often >500mL) which equates to another 250mg iron that may be lost,placing the mother in a more iron deficient state. During labour, women need as much energy and alertness as possible which can be severely affected if they are experiencing Iron Deficiency. Beyond fatigue and tiredness, other significant consequences can include post-partum depression, low birth weight, etc.

How to increase iron levels in the body?

Humans cannot make iron so we are 100% reliant on external sources like our diet. Iron is best absorbed from red meat, fish, seafood and chicken which is haem iron. Whilst many vegetables have high iron content our bodies cannot absorb this non-haem form of iron as effectively. The addition of vitamin-C with food sources, both haem and non-haem can aid in the absorption of iron (as it helps increase the acidity in the stomach which is required to absorb iron).

When patients are diagnosed with iron deficiency, the first line of treatment recommend is oral iron. Unfortunately, this option can often cause constipation and nausea and is not usually tolerated well by many patients, hence needs to be closely monitored. Another option is an intravenous Iron Infusion, which is a rapid repletion of iron stores resulting in faster correction of the symptoms of iron deficiency such as fatigue, depression, hair loss, etc.

If you are experiencing any of these symptoms, Check your ferritin and know your iron!

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TREATMENT: INTRAVENOUS IRON INFUSION

Treatment of iron deficiency, with or without anaemia, through inravenous (IV) iron is recommended if oral iron is not effective or prompt correction of iron deficiency is needed.

The latest generations of IV iron (such as iron carboxymaltose or iron isomaltoside), are effective forms of treatment of iron deficiency and usually improve symptoms in less than a week.

Although the risk of serious adverse side effects is low, IV iron should be administered in a monitored setting by trained medical staff.

The standard dose given at The Iron Suites Medical Centre is 500mg iron. This is usually administered as a slow bolus injection allowing our qualified medical staff to continuously monitor our patients closely during the procedure. When considering different healthcare providers that administer iron infusions, we recommend you ask which iron they are using and check what dosage will be given (as you will usually need at least 500mg). The older generation of IV irons deliver 100-200mg with each dose so multiple sessions will be required to achieve iron repletion.

From a calculation perspective, an increase in Haemoglobin (Hb) by 1 point (i.e., from 11 to 12) requires ~200mg iron whilst an increase by 10 points in ferritin (i.e., from 10 to 20) requires ~80mg iron. It is important to note that the human body will preferentially use the iron administered to replenish red blood cells (i.e., increasing Hb) and correct anaemia, before replenishing the body’s iron stores (ferritin).

At The Iron Suites Medical Centre, we not only aim to correct any existing iron deficiency and accompanying anaemia, but our resident doctor will also conduct a thorough consultation with you to illicit the underlying cause for your iron deficiency. After a discussion with you, he will develop mutually agreed management plans that will address your root cause and minimise the chance of iron deficiency reoccurring.

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TREATMENT: ORAL IRON

Traditionally, oral iron is usually prescribed as a first line treatment of iron deficiency with or without anaemia.

In order to achieve the best absorption rates of oral iron with the lowest rates of side effects, it is recommended to take tablets on alternate days on an empty stomach and without any other medications. Unfortunately, most oral iron supplements will have their absorption impaired by food - tea can even further impair absorption by up to 90%.

Oral iron is often recommended with vitamin C - is that always required? The addition of vitamin C to oral iron supplements is probably not necessary. In fact, there is a chance that this will increase common GI side effects.

The most commonly used (and cheapest) iron supplements are ferrous salts (e.g., ferrous sulfate or ferrous fumerate). The ferrous (or Fe2+) form of iron is absorbed by the body in both a controlled and uncontrolled manner. It is this uncontrolled uptake that can lead to oversaturation of the iron transfer system and lead to unwanted side effects such as nausea, constipation or diarrhoea plus continued unregulated use could potentially lead to iron overload. Just to make things worse, ferrous iron formulations have a rust or blood like taste further decreasing most people’s desire to take routinely and for the required, many months.

At The Iron Suites we prescribe ferric (Fe3+) iron compounds which are absorbed via a controlled manner (similar to the iron from food) and not the uncontrolled manner. Clinical trials with ferric iron compounds have shown significantly fewer GI related side effects.

Additionally, they have the benefit of being able to be taken with food or other supplements (meaning you can take them any time of the day) as well as often having a preferable taste.

The other reason for our preference for the ferric form of iron is the very low chance of overdosing. For instance, if 30 tablets of ferrous sulfate or ferrous fumerate were accidentally ingested by you or your child there would be a very high risk of severe or even fatal outcomes (due to the uncontrolled absorption) whilst the ferric forms will pass straight through with very low (if any) risk for toxicity.

Independent of the oral iron formulation used, the response after commencing should be checked. Not everyone will be able to absorb supplements to the degree needed to correct iron deficiency. Checking after ~1 month is important for iron deficient anaemic patients and ideally an increase of at least 1g/dl should be observed. For the patient with iron deficiency (and normal Hb levels), we aim to see an increase in ferritin from baseline and ideally a concentration of greater than 30ng/mL after 3 months of continuous use.

To help understand the above timing for re-assessments, an increase in Haemoglobin (Hb) by 1 point (i.e., from 11 to 12) needs ~200mg iron and after Hb is corrected, the iron stores (measured by serum ferritin), need ~8mg to increase by 1 points (i.e., to increase from a ferritin of 10 to 20ng/mL will require ~80mg iron). The average woman loses ~2mg iron per day and with oral iron (or even an optimised diet) combined with optimised absorption the iron intake may reach ~10-15mg iron per day (or ~200-300mg per month).

This is why we like to see at least 1g/dL increase in Hb by 1 month. Once Hb is normalised, then the iron should be going to the stores (as long as it is being absorbed) and that is why we look at ferritin at ~3 months.

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