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Iron is a medication used in the management and treatment of iron deficiency anemia. This activity illustrates the indications, action, and contraindications for iron supplementation as a valuable agent in the management of iron-deficient states such as iron deficiency anemia, iron deficiency without anemia, nutritional deficiency, malabsorption, blood loss, or an increase in the body's need for iron. This activity will highlight the mechanism of action, adverse event profile, and other key factors (e.g., off-label uses, dosing, pharmacodynamics, pharmacokinetics, monitoring, relevant interactions) pertinent for members of the healthcare team in the management of patients with iron deficiency and related conditions. Objectives: Identify the mechanism of action and administration of iron supplementation. Describe the adverse effects and contraindications of iron supplementation. Review the appropriate monitoring and toxicity of iron supplementation. Summarize interprofessional team strategies for improving care coordination and communication to optimize iron supplementation and improve outcomes. Access free multiple choice questions on this topic.

Toxicity is often dose-dependent and can manifest with cardiovascular, metabolic, central nervous, and hepatic instability and damage. Symptoms of overdose include initial GI upset that slowly develops to acute metabolic encephalopathy, seizures, tachycardia, metabolic acidosis, arrhythmia, hypoxia. Amounts up to  20 mg/kg of elemental iron is usually well-tolerated, but may have mild GI symptoms.  Amounts between 20 to 60 mg/kg is mild to moderately toxic, and over 60 mg/kg can cause severe symptoms and morbidity due to circulatory collapse.[10] Accidental iron ingestion in children under the age of 6 has been a leading case of fatal poisoning.[12] Iron overdose can have therapy using gastric lavage with an iron chelator such as deferoxamine or GI decontamination procedures such as lavage solutions and whole-bowel irrigation.[13]

Initiating iron supplementation to address an iron-deficiency state is often managed by the primary care provider, however, sometimes it may be managed by specialists including the hematologist, gastroenterologist, or nephrologist, depending on the underlying cause of the anemia. In the early stages, anemia may be present on routine bloodwork. Initial testing includes a complete blood count (CBC) with differential, which includes values such as WBC count, hemoglobin, hematocrit, RBC count, RBC indices. A reticulocyte count is helpful, as well.  If asymptomatic, the patient can be monitored with yearly CBC to check for any changes.  If symptomatic, more aggressive methods to identify the underlying cause are necessary. If iron deficiency is suspected, these patients should have iron studies assessed to check for serum iron, total iron-binding capacity (TIBC), transferrin saturation, and ferritin levels to determine if it is iron deficiency anemia, the most likely cause of microcytic anemia vs. other etiologies. Other tests that the clinician can order are hemosiderin and hepcidin, but are not necessary. Once the iron-deficiency is confirmed, then iron supplementation may be started. [Level 5] It is the responsibility of the primary provider and other health professionals to ensure that the patient is not assumed to have iron deficiency anemia based on a CBC and receiving unnecessary iron supplementation without a complete workup. Anemia is a significant global health issue, and healthcare professionals must coordinate to ensure that if the patient is not improving with oral iron supplementation, to try another route of administration, or to check for another underlying cause of the anemia.[14][15] [Level 5] If their anemia is indeed due to iron deficiency, then supplementation should have tangible improvements on repeat CBC and bloodwork.[16] [Level 1] The need for care coordination of all healthcare professionals on the interprofessional team involved in the management of the patient is the recommended approach to provide symptomatic relief and improve outcomes.