A: Iron is an essential nutrient that provides oxygen and energy to the body.
The symptoms of iron deficiency including feeling tired and exhausted, but there are also a broad range of physical and mental health aspects: –
PHYSICAL, feeling short of breath or ‘air hunger’ climbing stairs with dizziness, palpitations and chest pain. Headaches, and in severe iron deficiency, restless legs, itching or bruising. Hair loss can be a particular issue with increased breaking and shedding.
MENTAL, brain fog, forgetfulness, inability to think clearly or cope as well as reduced libido. These can often be manifest as symptoms of anxiety or depression. About 1 in 6 people who have an iron infusion have been medicated for anxiety or depression when in fact they are iron deficient.
We need iron so our body can make new haemoglobin and red blood cells to carry the oxygen your body requires. Therefore, it is very important to have enough iron in our blood. In addition, iron is also essential for muscle function, energy, brain function, immune system, and enzyme functions in the body.
A: Your blood results have shown that the amount of iron you have in your blood is low. Iron Deficiency is measured by a profile of tests including two main proteins: Ferritin and Transferrin saturation.
Iron Deficiency = Ferritin <30
https://cks.nice.org.uk/topics/anaemia-iron-deficiency/
A: You need iron so your body can make new haemoglobin and red blood cells to carry the oxygen your body requires. Iron is the ‘building block’ of red blood cells. Lack of iron leads to reduced production of haemoglobin and also reduced production of red blood cells. When production falls the amount of red cells in the blood circulation falls leading to anaemia. This is defined as a concentration of haemoglobin [Hb] in the blood:
Definition of anaemia: [Hb] < 120g/L women or [Hb] < 130g/L men
In iron deficiency even before anaemia develops, the red blood cells produced are also poor quality, being smaller than normal (microcytic seen by a low MCV on your blood test) and with reduced haemoglobin (low MCH on you blood test). Therefore, it is very important to have enough iron in your blood
A: Iron is predominantly held in the red blood cells and muscles of the body. At any one time you have about 4000mg of iron in your body, most of this (2500mg) is used to make the ‘red stuff’ in your blood called haemoglobin. As red blood cells get old they are broken down by the spleen and the iron is recycled. The body is very good at recycling iron. A small amount of iron is lost every day (from the skin and sweat), about 2-3mg a day, and this is replenished from the diet to ‘maintain iron stores, so you normally have plenty of iron in reserves.
Iron (latin = ferrum) is moved around the body by ‘transport the iron’ = transferrin
Iron is stored in the ‘biscuit tin’ = iron-in the-tin = Ferritin.
You hold about 1000mg of iron in reserves in Ferritin. The rest of the iron (500mg) is used by cells, particularly muscle and nerves. In the cells iron is an essential component of the enzymes involved in aerobic metabolism where energy is made from food and oxygen.
A:
Nutritional deficiency i.e. not enough iron in the diet, is a common cause. Meat is the main source of iron as 10-20% of iron in meat is bioavailable whereas only 1-2% of plant based iron is bioavailable, so people who follow vegetarian or vegan diets are more at risk. However, other iron rich foods include cereals, soya, and pulses such as lentils. About 2-4mg of iron needs to absorbed in a day from your diet. An acid environment in the stomach is needed, and antacids (omeprazole etc.) will reduce absorption. Drinking tea within an hour of eating will also reduce absorption, whereas vitamin C can help absorb iron. Simple changes to diet may help improve the absorption of iron in your diet.
In women, the commonest cause of iron deficiency is blood loss due to periods. ‘Normal’ menstrual loss should not be underestimated as this can be up to 40mg of iron every month.
Heavy menstrual bleeding (HMB) is surprisingly common, affecting a third of women at some point in their life; HMB can be defined as two of the following:
This can be a real problem as the extra blood loss can be over 80ml per cycle and this adds up to one litre of blood over a year!
The Iron Clinic team can help guide and advise about menstrual health and tranexamic acid can be given to help reduce blood loss
Pregnancy is a common cause for iron deficiency as the baby needs a lot of iron from their mother (about 1400mg), this can be exacerbated by blood loss at childbirth (A Caesarean section loses about 500ml of blood or 250mg of iron).
Other causes of iron deficiency can include Coeliac disease (an intolerance to gluten that reduces absorption of nutrients from the gut), IBD (inflammatory bowel disease such as Ulcerative Colitis or Crohn’s disease). Inflammation seen in arthritis or chronic disease, or in patients who have illness from other conditions such as arthritis or diabetes.
Surgery is a cause following blood loss or following weight loss (Bariatric) surgery as the part of the gut that absorbs iron is bypassed.
A:
A well-balanced diet rich in meat, pulses and soya is important and supplementation with iron tablets is effective for many people; particularly those with mild iron deficiency and few symptoms.
Most iron tablets are the same and the main ingredients are Iron + sulphate / gluconate / fumarate / bisglycinate. These are termed ‘iron salts’. The important bit: – it’s all about the amount of ‘elemental iron’ i.e. the dose: If a 200mg tablet, you need to read the ingredients on the back to see the actual ‘dose’ of ‘elemental iron it may be the dose is 65mg.
However, Iron is very poorly absorbed and only about 4-6mg of this iron is absorbed into the body from the gut, which works out about 180-240mg per month. There are several factors that can effect iron absorption:
Iron Tablet treatment
One 200-300mg tablet a day is sufficient.
If side effects of abdominal pain, constipation or diarrhoea develop, stop for 5 days and restart one tablet alternate days
Most patients need 4-6 weeks to see their anaemia improve and need to be on iron supplements for 3-9 months, to fully replenish normal iron stores.
It is important to recheck your blood levels regularly (Hb & Ferritin) 2-3 months after starting N.B. stop iron tablets for 3-5 days.
Iron tablets should be continued until Ferritin > 50.
If on repeat blood test at three months the ferritin has not improved towards 30, then this may be failure of oral iron and an iron infusion should be considered.
A: In the last decade years’ new preparations of iron were developed. These enable an individual to receive a ‘total dose’ infusion safely in 15 to 30 minutes. This means we can safely and effectively give you a larger dose of iron needed to replenish normal iron stores. An iron infusion is a considerably faster and more effective method to correct anaemia than iron tablets.
Typically, your doctor will prescribe 500mg to 1500mg of iron to be given. So, this is a ‘total dose’ infusion which will improve your body’s iron stores rapidly. Also, as the iron is delivered directly to the blood so supplying the muscles and bone marrow, where it is needed.
People can feel better in a matter of days and as the treatment is a total dose, you may not need any further treatment or tablets.
A: Overall an iron infusion is a safe procedure. We encourage people not to be nervous as this should be no more concern than an injection of antibiotics. We have also found having the consultation in advance on zoom gives people the opportunity to read this patient information and discuss any concerns before coming for their infusion so they are full prepared and know what to expect.
Before arriving to the clinic please ensure you have had a normal breakfast and lunch. Also, that you are well hydrated (we have plenty of toilets!). This is important as at the start, the clinic doctor or nurse will place a drip in your arm. It’s important that this is sitting well within a vein so they will check this with a flush of cold water that you may feel going up the arm. In unfortunate cases the line sometimes tissues or leaks, this can leave a brown stain or tattoo. Hence, we are fastidious about how lines are placed and particular attention is spent to ensure the line runs without problems, this may include a second flush or a saline drip before the iron infusion. In some cases, we may re-site the cannula to another location or use an ultrasound; rarely we ask people to return another day. Every attempt is made to reduces this risk of a stain as they can be permanent. An iron stain is rare but we have had 2-3 in the last 5-6000 infusions.
With the infusion there are some common side effects. It is not recommended to give pre-medications as these can cause side effects themselves.
Flushing reactions (Fishbane) can occur in about 1-2 in a 100 cases these can be unpleasant and you might feel a flushed, lightheaded, develop a dry cough, chest tightness feel queasy or dizzy. They are not related to the dose of iron and not an allergic reaction but a response of the blood vessel to iron, the same flushing that people can get during a CT or MRI scan when contrast is injected. Flushing can develop within minutes of the infusion starting, so we start the infusion slowly and you are under close observation. If a flushing does happen we often spot this before the patient and stop the infusion. The symptoms normally resolve in 20-40 seconds. The team may give an antihistamine medication (hay fever tablet) or sometimes a steroid injection. Normally following a period of observation they will restart and finish the infusion slowly over 30 minutes.
Hives, or a rash can develop at any stage in about 1 in 200-500 people and this why we ask people to wait for 30 minutes after their infusion. These normally settle with Piriton or an anti-histamine. If you are prone to allergy or hives we may suggest taking an anti-histamine before treatment.
Other side effects and severe reactions are rarer following treatment of iron include swelling of the hands and feet, and very rarely, anaphylactic like reactions (e.g. paleness, swollen lips, itchiness, weakness, sweating, dizziness, feeling of tightness in the chest, chest pain, fast pulse, difficulty in breathing). The team are all trained and the necessary equipment and protocols are in place.
Overall, about 3% of people who receive intravenous iron do feel some side effects, the vast majority of which are mild and self-limiting. The major risk is calculated at less than 10 people in a million. In a recent detailed review (JAMA 2016) it was suggested that the risk of the new types of IV iron (which we use) carried the same risk as many other infusions such as an antibiotic and overall, about one third the risk of receiving a blood transfusion.
Once the infusion has stopped we check you are well, repeat your observations then remove the cannula. We ask you to remain in the waiting room for 30 minutes and if you have any concerns (rash or hives) let a member of the team know. After this you will be allowed to go home.
It is common for many people to develop a Post Infusion Flu, this affects about 1 in 4 people. This develops about 24 hours later and can be like a bad flu with aches and pains, feeling unwell and a mild temperature. We are not sure why this occurs and termed a ‘serum sickness’. It is self-limiting normally within 24-28 hours but occasionally can last up to a week. It important to keep well hydrated and take normal painkillers from the chemist if required.
With some preparations of IV iron, a fall in blood levels of Phosphate can occur in half of patients 2-3 weeks after the infusion. It seems more of an issue with Ferric Carboxymaltose (injectafer) and happens in about half of FCM infusions (about 10% of others) but this is normally without any clinical symptoms. In a trial of healthy women there was no correlation of post infusion symptoms with phosphate levels.
However, it has been reported to be a problem on bone health in some people requiring repeat infusions (e.g. patients with Inflammatory bowel disease requiring 5-10 infusions p.a.). As a policy we do not give repeat doses of Ferinject and use Monofer in long term patients.
We have seen 1-3 potential cases of hypophosphataemia in the last 5 years with 3-4000 patients since the issue has been highlighted. Symptoms reported are of fatigue and ‘feeling drained’.
There does not appear to be any recognised risk factors in otherwise health individuals and current guidelines suggest that taking phosphate supplements is not beneficial and that routine checking of phosphate levels are not recommended.
In cases of Hypophosphatemia there is no agreed treatment. Additional phosphate (either IV or tablets) may not be beneficial. Vitamin D will likely do no harm and may help. Most cases are self correcting allowing time for it to resolve. Please discuss any concerns with your doctor.
At The Iron Clinic we are active in updating information about iron deficiency and treatments. It is always important to note there have been >60 million IV iron infusions given in the last decade and it can be transformative for people with iron deficiency and anaemia – so everything must be taken in context and consideration. No treatment is without risk but every attempt is made to minimise these.
Our staff are available and happy to answer your every question.
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