Oral iron supplements are the best way to restore iron levels for people who are iron deficient, but they should be used only when dietary measures have failed. Iron supplements cannot correct anemias that are not due to iron deficiency.
Iron replacement therapy can cause gastrointestinal problems, sometimes severe ones. Excess iron may also contribute to heart disease, diabetes, and certain cancers. Doctors generally advise against iron supplements in anyone with a healthy diet and no indications of iron deficiency anemia.
Treatment of Anemia of Chronic Disease. In general, the best treatment for anemia of chronic diseases is treating the disease itself. In some cases, iron deficiency accompanies the condition and requires iron replacement. Erythropoietin, most often administered with intravenous iron, is used for some patients.
Oral Iron Supplements
Supplement Forms. There are two forms of supplemental iron: ferrous and ferric. Ferrous iron is better absorbed and is the preferred form of iron tablets. Ferrous iron is available in three forms: ferrous fumarate, ferrous sulfate, and ferrous gluconate.
The label of an iron supplement contains information both on the tablet size (which is typically 325 mg) and the amount of elemental iron contained in the tablet (the amount of iron that is available for absorption by the body.) When selecting an iron supplement, it is important to look at the amount of elemental iron.
A 325 mg iron supplement contains the following amounts of elemental iron depending on the type of iron:
- Ferrous fumarate. 108 mg of elemental iron
- Ferrous sulfate. 65 mg of elemental iron
- Ferrous gluconate. 35 mg of elemental iron
Dosage. Depending on the severity of your anemia, as well as your age and weight, your doctor will recommend a dosage of 60 - 200 mg of elemental iron per day. This means taking one iron pill 2 - 3 time during the day. Make sure your doctor explains to you how many pills you should take in a day and when you should take them. Never take a double dose of iron.
Side Effects and Safety. Common side effects of iron supplements include:
- Constipation and diarrhea are very common. They are rarely severe, although iron tablets can aggravate existing gastrointestinal problems such as ulcers and ulcerative colitis.
- Nausea and vomiting may occur with high doses, but taking smaller amounts of medicine can control the problem. Switching to ferrous gluconate may help some people with severe gastrointestinal problems.
- Black stools are normal when taking iron tablets. In fact, if they do not turn black, the tablets may not be working effectively. This problem tends to be more common with coated or long-acting iron tablets.
- If the stools are tarry looking as well as black, if they have red streaks, or if cramps, sharp pains, or soreness in the stomach occur, gastrointestinal bleeding may be causing the iron deficiency. The patient should call the doctor promptly.
- Acute iron poisoning is rare in adults but can be fatal in children who take adult-strength tablets. Keep iron supplements out of the reach of children. If your child swallows an iron pill, immediately contact a poison control center.
Other Tips for Safety and Effectiveness. Other tips for taking iron are as follows:
- For best absorption, iron should be taken between meals. Iron may cause stomach and intestinal disturbances, however. Low doses of ferrous sulfate can be taken with food and are still absorbed but with fewer side effects.)
- Drink a full 8 ounces of fluid with an iron pill. Taking orange juice with an iron pill can help increase iron absorption. (Some doctors also recommend taking a vitamin C supplement with the iron pill.)
- If constipation becomes a problem, take a stool softener such as docusate sodium (Colace).
- Certain medications, including antacids, can reduce iron absorption. Iron tablets may also reduce the effectiveness of other drugs, including the antibiotics tetracycline, penicillin, and ciprofloxacin and the Parkinson's disease drugs methyldopa, levodopa, and carbidopa. At least 2 hours should elapse between doses of these drugs and iron supplements.
- Avoid taking milk, caffeine, antacids, or calcium supplements at the same time as an iron pill as they can interfere with iron absorption.
- Tablets should be kept in a cool place. (Bathroom medicine cabinets may be too warm and humid, which may cause the pills to disintegrate.)
The hematocrit should return to normal after 2 months of iron therapy. However, iron supplementation should be continued for another 6 - 12 months to replenish the body's iron stores in the bone marrow.
In some cases, supplemental iron is administered intravenously. Intravenous iron is used to treat iron-deficiency anemia. It may be recommended for:
- Patients who are unable to absorb oral iron or whose anemia has continued to worsen after taking oral iron Patients with very severe iron deficiency or blood loss
- Patients with serious gastrointestinal disorders, such as inflammatory bowel disease, who cannot take iron therapy by mouth.
- People undergoing hemodialysis and others who receive supplemental erythropoietin therapy.
Intravenous iron may be given in the form of iron dextran (Dexferrum, INFeD), iron sucrose (Venofer), or ferric gluconate (Ferrlecit). Your doctor may refer you to a hematologist (a doctor who specializes in blood disorders) to oversee this treatment.
Intravenous iron can cause an allergic reaction. It is important to administer a test dose before you receive your first infusion. The risk for allergic reactions is higher with iron dextran than with other forms of intravenous iron. Intravenous iron should never be given at the same time as oral iron supplements.
Transfusions are used to replace blood loss due to injuries and during certain surgeries. They are also commonly used to treat severely anemic patients who have thalassemia, sickle cell disease, myelodysplastic syndromes, or other types of anemia. In certain cases, blood transfusions may be used to treat severe anemia associated with heart disease.
Some patients require frequent blood transfusions. Iron overload can be a side effect of these frequent blood transfusions. If left untreated, iron overload can lead to liver and heart damage.
Iron chelation therapy is used to remove the excess iron caused by blood transfusions. Patients take a drug that binds to the iron in the blood. The excess iron is then removed from the body by the kidneys.
Deferasirox (Exjade) is a drug that is given as a once-daily treatment for iron overload due to blood transfusions. It does not require injections. Patients mix the deferasirox tablets in liquid and drink the medicine.
Erythropoietin is the hormone that acts in the bone marrow to increase the production of red blood cells. It has been genetically engineered as recombinant human erythropoietin (rHuEPO) and is available as epoetin alfa (Epogen, Procrit, and Eprex). Novel erythropoiesis stimulating protein (NESP), also called darbepoetin alfa (Aranesp), lasts longer in the blood than epoetin alfa and requires fewer injections. These medications are also called “erythropoiesis-stimulating drugs.”
Levels of erythropoietin are reduced in anemia of chronic disease. Injections of synthetic erythropoietin can help increase the number of red blood cells in order to avoid receiving blood transfusions. Synthetic erythropoietin can cause serious side effects, including blood clots, and is approved only for treating patients with anemia related to the following conditions:
Cancer. For select patients, erythropoietin is used to treat the anemia associated with chemotherapy.
Chronic kidney disease. Erythropoietin is an important anemia treatment for patients with chronic kidney disease, including those with end-stage renal disease who are on dialysis. In 2012, the FDA approved a new erythropoiesis-stimulating drug peginesatide (Omontys) specifically for patients on kidney dialysis. The manufacturer recalled the drug a year later due to serious and fatal allergic reactions.
HIV/AIDS. Erythropoietin helps treat the anemia caused by zidovudine (AZT) therapy.
Erythropoiesis-Stimulating Drugs and Cancer. Erythropoietin may be used to treat anemia caused by chemotherapy. Erythropoietin treatment does not help prolong survival, but can improve quality of life during cancer treatment by improving anemia.
However, these drugs can shorten lifespan and cause some tumors to grow faster. In general, the lowest effective dose should be used. The risks of early death and increased tumor growth are greatest when these drugs are used to boost the hemoglobin level to 10 - 12 g/dL or higher. The American Society of Clinical Oncology and the American Society of Hematology recommend starting erythropoietin only if a patient’s hemoglobin level is less than 10 g/dL.)
Discuss with your doctor whether an erythropoiesis-stimulating drug is appropriate for you.
Erythropoiesis-Stimulating Drugs and Chronic Kidney Disease. For patients with chronic kidney disease or kidney failure, the FDA currently recommends that erythropoiesis-stimulating drugs be used to maintain hemoglobin levels between 10 - 12 g/dL. (The exact level within this range varies by individual.) There is a greater risk of death and serious cardiovascular events, such as heart attack, stroke, and heart failure when these drugs are used to achieve higher hemoglobin levels (13.5 - 14g/dL) compared to lower hemoglobin levels (10 - 11.3 g/dL).
Warning Symptoms. Contact your doctor if you have any of the following symptoms while being treated with an erythropoiesis-stimulating drug:
- Pain or swelling in the legs
- Worsening in shortness of breath
- Increases in blood pressure (be sure to regularly monitor your blood pressure)
- Dizziness or loss of consciousness
- Extreme fatigue
- Blood clots in hemodialysis vascular access ports
Vitamin Replacement for Megaloblastic Anemia
Megaloblastic anemia is marked by abnormally large red blood cells. (Pernicious anemia is a type of megaloblastic anemia). It is caused by impaired absorption or insufficient intake of vitamin B12 or folate (vitamin B9). If folate deficiency is responsible, treatment usually involves taking a daily oral folic acid supplement for at least several months as well as increasing intake of foods rich in folate. When vitamin B12 deficiency is responsible, vitamin B12 may be administered in tablets, injections of cyanocobalamin or hydroxocobalamin, or as a nasal spray.