6 years/ male. Came for non responding anaemiaHb 3 months ago was 6.5, started on Iron lll polymaltose complex, Hb after 3 months was 7.2.Compliance checked, no occult loss of blood from GIT or other sourcesPut on oral ferrous salt , marked symptomatic improvement within 1 week, Hb 9.3 in 3 weeksSubsequent reports of poor efficacy of IPC ..
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1. Newer iron preparation Dr Sudhir Sane
2. 6 years/ male Came for non responding anaemia
Hb 3 months ago was 6.5, started on Iron lll polymaltose complex, Hb after 3 months was 7.2.
Compliance checked, no occult loss of blood from GIT or other sources
Put on oral ferrous salt , marked symptomatic improvement within 1 week, Hb 9.3 in 3 weeks
Subsequent reports of poor efficacy of IPC .
3. Scope of the talk What is new
4. Different hats In practice we wear different hats
Assume role of neonatologist, pulmonologist,
Above all general pediatrician
5. Pediatricians hat Focus on iron preparations commonly used in practice
Some information about Intravenous iron preparations
6. What is new?
7. 13 or more salts Not unlike medical degrees
Add ferrous /ferric & any compound = new iron salt
Why so many preparations needed
8. Why is new needed Iron absorption foundation fact Ferrous sulfate the standard effective , economical, easy to administer
Iron is absorbed in ferrous form
fumarate, gluconate, succinate,lactate, glutamate
Ferrous sulfate unstable in liquid form hence sorbitol based preparations
Fumarate is tasteless, poorly water soluble but soluble in acidic medium of stomach
9. Why newer salts are needed 5 ‘P’s Poor absorption: food (Phytates), antacids inhibit
Poor compliance: ~30% are recorded poor compliant
Prolonged therapy of at least 3 months needed
Poisoning potential: mucosal barrier is overwhelmed with larger doses
10. Newer iron salts Complexed with chelators to decrease side effects; sodium feredetate
Combined with absorption enhancer : ascorbate
More tolerability due to small particle size; carbonised Fe
Have different mechanism of absorption
Many have been tried as food fortifiers & not as medicine
Scanty data in standard journals, not many non sponsored articles
11. Iron lll polymaltose complex Not strictly newer iron
Iron in ferric form gets absorbed with help of two ligands
Absorption resembles natural process of iron absorption from intestine
Less side effects & less teeth staining
As absorption depends on ‘ligands’. In overdose saturation of ligands prevents excessive absorption.
12. Held promise but…… Reports of failure of Hb rise in many preparations
Probably dependent on pH and other physical properties of the preparation.
Report by Mehta et al(ref: ineffectiveness of iron polymaltose in treatment of iron deficiency anemia.J Assoc Physicians India 2003:51,419-421)
13. Carbonyl iron Very small ,uniform particles of pure iron in pure metallic form
In stomach acid reduces iron to ferrous (ionic ) form
Absorption is self limited & slow depends on rate of gastric acid secretion
Antacids , milk, food interfere with absorption
Similar effectiveness as FS in pregnant women, no study on children
14. Carbonyl iron Does not change colour or flavour of food
Mainly used as food fortifier in wheat floor
Certain issues about bioavailability in humans Ref:Low bioavailability of carbonyl iron in man: studies on iron fortification of wheat fIour13
LeifHallberg, MD, Mats Brune, MD, and Lena Rossander, Dr Med Sc Am J C/in Nuir l986;43:
15. Ferrous ascorbate Combination of ascorbic acid with ferrous iron
Iron absorption enhancer
Probably also helps in incorporation of absorbed iron into Hb.
Known as ‘reference iron’ in US
Many studies in pregnant women
Can cause some GI intolerance
16. Ferrous bis-glycinate Iron amino acid chelate
Came as food fortifier
Less irritant to stomach
High bioavalability in presence of inhibitors
Good safety potential
Studies document comparative efficacy as ferrous ascorbate
Other in group ferrous Glycine sulphate
17. Sodium fereditate Contains iron in an un-ionised form.
Iron is “insulated” or “sequestered” with the EDTA to form a chelate.
Not astringent and does not discolour teeth.
Iron absorption is enhanced in iron-deficiency states.
Tastes better, can be mixed with fruit juices or milk
18. Preparations with additions Addition of ascorbic acid to iron preparations increase iron absorption
Stability of ascorbic acid is issue
Optimum ratio of ascorbic acid & FS varies as per amount of inhibitors in diet.
Trace element, vitamins & other hematinics do not increase response to ferrous salt(Nelson’s text book) and are irrational
19. Microencapsulated form Once a day as sprinkler fortifying diet is as effective as TDS FS in treatment of anaemic children in Ghana. American Journal of Clinical Nutrition, Vol. 74, No. 6, 791-795, December 2001
Ferrous fumarate with ascorbic acid
Most food fortification is for prevention
Future of anaemia treatment. RefEur J Clin Nutr. 2009 Mar;63(3):437-45. Epub 2007 Dec 19. Multiple micronutrient fortification of salt. Vinodkumar M, Rajagopalan S
20. At one glance
21. Summary of oral iron preparations Most of them are effective
newer iron preparations have better safety profile.(lesser toxic potential than FS )
Some of them may not give consistent Hb rise
Use any but monitor effectiveness
Be on look out for microencapsulated form.
22. Monitoring effectiveness Rise of Hb @ 0.1mg/dl/day ~2gm/dl after 3 weeks
What if not effective: compliance is major issue
The etiology not properly looked into (e.g. GI bleed)
Associated systemic inflammatory disease
Very poor absorptive capacity: celiac disease
23. Parentral iron IM or IV
Iron dextran, sodium ferric gluconate, Iron sucrose
Some newer forms are under study :ferroxybutol
Supposed uses in end stage renal disease (ESRD), preterm babies along with EPO, in patients with IBD & other rheumatological conditions
Patients poorly compliant to oral iron therapy or who do not record Hb rise after 3 months of at least 2 different oral salts
24. Parentral iron: basic facts Increases iron store rapidly
Rate of HB rise is similar to oral iron
Some studies have documented faster rise of Hb ( within 1 week) of initiation
Can be one indication . When faster rise of Hb is desired e.g. pre-operative patients.
Shorter course (2-3 days) with iron sucrose is described.
25. Intravenous iron Some chance of life threatening anaphylactic reaction, least with iron sucrose.
Iron sucrose is with least potential to have serious side effects
Transient hypotension, facial flushing, pruritis and pica!!!
In pre terms rise of ferritin is described. (may be indicative of oxidative injury)
26. Parentral iron preparations IM : high adverse effects , skin tattooing, serum sickness like reaction, anaphylaxis
Discontinued in US, UK 5-6 years ago
27. Practical utility for us Not much used at least in Mumbai by pediatric nephrologists, rheumatologist & hematologist
May be indicated : only occasional patient who is intolerant to oral iron or where faster Hb rise is desirable preop ( decreases need for blood transfusions)
28. To conclude IV iron is only occasionally used in every day clinical practice
Out of many iron preparations available choose according to cost , tolerability, effectiveness ( elemental iron content & % of iron absorbed)
Monitor response to the therapy
29. Thank you Sincere thanks to Dr Ratna Sharma : Pediatric hemat,Mumbai
Dr Khubchandani: Ped rheumatolgist, mumbai
Dr Pankaj Deshpande: Ped Nephro, mumbai
Dr Prakash Vaidya
For sharing their experience & thoughts