Treating Iron Deficiency

Iron deficiency is a common disorder and can have many causes.  Most patients are treated with oral iron because it is generally effective, readily available, inexpensive, and safe.  However side-effects (especially from the gut such as nausea, vomiting, discomfort, diarrhea, and constipation) are quite common (1) and are related to the dose of iron administered.

There are many iron formulations (see table) and there are a range of frequencies of reported side-effects.

It is generally not a good idea to use enteric-coated or sustained release capsules as the iron in them is released too far down the gastrointestinal tract to be well absorbed.  There is some evidence that taking iron every other day may result in better absorption.

Elemental iron will make your bowel movements dark or black so don’t worry if that happens.  Some pharmacies keep their iron behind the counter, so ask if you don’t see it on the shelves.

Suggested Approach to Taking Oral Iron (1,2):

1. Start with 1-3 pills per day of ferrous sulfate/gluconate/fumarate (as recommended by your doctor).  
   1. Do not take with food which decreases absorption
   2. Do not take with calcium supplements or milk, dietary fiber, tea, coffee, or eggs which decrease absorption.
   3. Do not take with antacids (you can take them two hours before or four hours after antacids).
   4. Iron is best taken along with vitamin C which increases absorption.  You can do this by taking your iron with a half glass or orange juice or with 250 mg of ascorbic acid (vitamin C).
2. If you have side-effects try the following:
   1. Lower the dose (ie number of pills per day)
   2. Take your pills every other day
   3. Make dietary modifications (take iron with food or milk – while this decreases absorption, at least you will be getting some iron intake).
   4. Switch from a tablet to a liquid which will allow you to start with a lower dose which can be gradually increased (eg ferrous sulfate).  Some doctors recommend washing your mouth with water after a dose to avoid potential staining of tooth enamel.
3. In a large review (1), the best-tolerated form of inorganic iron was iron protein succinylate – the only formulation of this that I was able to find is called ‘Iron Protein Plus’ from Life Extension.  You can get it by mail-order from the USA (here) or from a Canadian supplier (here) 
4. If you can’t tolerate the above formulations some of my patients have found less side-effects with the following (often available at health food shops):
   1. Heme iron (an organic form of iron) – multiple brands including Proferrin (available on Amazon.ca) 
   2. Vegetarian liquid ferrous gluconate by Salis (eg Floravit, Floradex)
   3. Organic plant-derived iron (Pranin Iron) – see Amazon.ca

For patients who fail the above approach (this has to be documented in the chart), intravenous iron therapy MAY be an option. However this is expensive and not covered in Ontario unless the following conditions are met:

1. You are younger that 25 OR older than 65
2. If you are between the ages of 25 to 65 you MAY get coverage IF YOU ARE ALREADY ENROLLED IN THE TRILLUM DRUG BENEFIT PROGRAM. To learn more about the program and apply for coverage, see here.

References

1. Tolerability of different oral iron supplements:a systematic review. MJ Cancelo-Hidalgo et al. Curr Medical Research & Opinion 2013:29(4):291-303.
2. Treatment of Iron Deficiency in Adults M Auerbach UpToDate 3/2020