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Scenario

Technician Vicky is talking to Kirsty Baldwin.

“I’m not sure about these iron tablets, you know Vicky,” starts Kirsty. “I thought they were supposed to make me feel better, but I feel dreadful.”

“Remind me what you are on them for,” replies Vicky.

“It’s anaemia. I went to the doctor because I was feeling so incredibly tired, and it turned out that my iron level was through the floor. He gave me these tablets and told me to take them three times a day,” Kirsty holds up a packet of ferrous sulfate, then continues: “Do you think three times a day is too much? Honestly, my stomach is churning, I’m horribly constipated and when I do manage to go, my poos are black. It’s all terribly unpleasant. I’m starting to dread taking them, and as I take them before food, it means I’m kind of dreading mealtimes too.”

Answer

While gastrointestinal side effects are common with ferrous sulfate, Kirsty does seem to be having a particularly bad reaction. One thing she could try is taking the tablets after meals, instead of beforehand, as the presence of food in the stomach should help ease the nausea. Reducing the dose isn’t really an option, as she is being treated for iron deficiency anaemia rather than being on the tablets to prevent the condition occurring.

If Kirsty is really struggling, she should return to her doctor and explain the issues she is having. Iron supplements come in many different salt forms (ferrous gluconate and ferrous fumarate are among the most common, in addition to ferrous sulfate) and formulations, and changing to another product may resolve the side effects she is experiencing. It is important, however, to maintain the amount of elemental iron she is receiving from the supplement, which a doctor or pharmacist can check for her.

Kirsty also needs to know that this isn’t a quick fix – it can take three to four weeks for haemoglobin levels to return to normal, and a further three months for the iron stores to be replenished.

The bigger picture

In iron deficiency anaemia, the body is unable to produce the required amount of red blood cells. This means oxygen doesn’t get to all the body’s organs and tissues as effectively as usual, leading to symptoms such as tiredness, lack of energy, shortness of breath and a pale complexion. If not picked up and treated, other symptoms may occur such as tinnitus, altered taste, itchiness, hair loss, a sore or smooth tongue, pica (a desire to eat non-food items), difficulty swallowing and spoon-shaped nails.

There are lots of reasons why iron deficiency anaemia happens, such as a stomach ulcer, often as a result of NSAID use; problems absorbing iron from the diet, as can happen in conditions such as coeliac disease; heavy periods; and pregnancy. If left untreated, it can cause further problems, from increased susceptibility to infections due to the immune system becoming compromised, an abnormally fast heart rate and heart failure.

While iron deficiency anaemia is particularly prevalent in the developing world, it remains a problem in the UK. It is believed to affect up to a quarter of pregnant women, just under 15 per cent of non-pregnant women, and up to five per cent of adult men and post-menopausal women in this country.

Extend your learning

• Look in the British National Formulary for iron supplements to get an idea of the range available. Look also at the some of the multivitamin supplements available on the shop floor and compare the amounts of iron
• Would you feel confident in recommending the equivalent dose of another iron containing product to Kirsty? Look at the comparisons in Medicines Complete or in the BNF to improve your understanding
• Iron supplements are sometimes used for children, but adherence can be an issue. A leaflet from Medicines for Children provides more information
• Learn about ways in which iron levels can be boosted through the diet from NHS Blood and Transplant
• Discover what else can cause low haemoglobin levels (and the reference range) from Lab Tests Online.