Treatment of iron deficiency anemia

1. Ferrous salts of iron are absorbed much more readily and are generally preferred. Commonly available oral preparations include ferrous sulfate, ferrous gluconate and ferrous fumarate (Hemocyte). All three forms are well absorbed. Ferrous sulfate is the least expensive and most commonly used oral iron supplement.

Oral Iron Preparations

(%)

Typical dosage

Elemental iron per dose

Ferrous sulfate

20

325 mg three times daily

65 mg

Ferrous sulfate, exsiccated

(Feosol)

30

200 mg three times daily

65 mg

Ferrous gluconate

12

325 mg three times daily

36 mg

(%)

Typical dosage

Elemental iron per dose

Ferrous fumarate (Hemocyte)

33

325 mg twice daily

106 mg

2. For iron replacement therapy, a dosage equivalent to 150 to 200 mg of elemental iron per day is recommended.

3. Ferrous sulfate, 325 mg of three times a day, will provide the necessary elemental iron for replacement therapy. Hematocrit levels should show improvement within one to two months of initiation of therapy.

4. Depending on the cause and severity of the anemia, and on whether there is continuing blood loss, replacement of low iron stores usually requires four to six months of iron supplementation. A daily dosage of 325 mg of ferrous sulfate may be necessary for maintenance therapy.

5. Side effects from oral iron replacement therapy are common and include nausea, constipation, diarrhea and abdominal pain. To minimize side effects, iron supplements should be taken with food; however, this may decrease iron absorption by 40 to 66 percent. Changing to a different iron salt or to a controlled-release preparation may also reduce side effects.

6. For optimum delivery, oral iron supplements must dissolve rapidly in the stomach so that the iron can be absorbed in the duodenum and upper jejunum. Enteric-coated preparations are ineffective since they do not dissolve in the stomach.

7. Causes of resistance to iron therapy include continuing blood loss, ineffective intake and ineffective absorption. Continuing blood loss may be overt (eg, menstruation, hemorrhoids) or occult (e.g., gastrointestinal malignancies, intestinal parasites, nonsteroidal anti-inflammatory drugs).

a. Ineffective iron intake may be the result of poor compliance because of gastrointestinal side effects. Iron uptake and absorption may be impaired by the use of antacids, H2-receptor blockers and proton pump inhibitors. Caffeinated beverages, particularly tea, will also reduce iron absorption.

b. Ineffective absorption of iron may also be the result of malabsorption states, such as celiac disease, Crohn's disease or pernicious anemia.

c. If the patient does not respond adequately to oral iron supplementation, parenteral treatment with iron dextran (Infed) should be considered.

d.Unpredictable absorption and local complications of intramuscular administration make the intravenous route preferable for parenteral iron treatment. Parenteral iron dextran may be administered as a single dose. The total dosage required to replenish body stores is determined with the following formula: Dose of iron (mg) = 0.3 x body wt (lb) x (100 - {[Hb (g/dL)/14.8] x 100})

e. Injectable iron dextran, containing 50 mg of iron per mL, is supplied in a 2-mL single-dose vial. Adverse reactions include headache, dyspnea, flushing, nausea and vomiting, fever, hypotension, seizures, urticaria, anaphylaxis and chest, abdominal or back pain. A small test dose (0.5 mL) should be given to determine whether an anaphylactic reaction will occur. If the patient tolerates the test dose, the full-dosage may then be given at a rate of 50 mg per minute, up to a total daily dosage of 100 mg.

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