QUESTION: How do I assess whether a patient needs IV Iron? Why can they sometimes not get enough orally? What are the best forms to use IV?
ANSWER: Below is an outline of cases and resultant research into non-cancer / non-renal induced anemias in the chronically ill (which fall often between the criteria and rules for Fe deficient –vs- Anemia of chronic disease (ACD)). In our patients we see this a lot and it becomes an incredible impediment to cure as it stalls much of their former normal physiology.
– If a hematologist is giving IV-Fe, ferritin is likely low and IV Fe is needed. If ferritin is elevated then reasons for inflammatory disease have to be ruled out (especially cancer and infections).
– If the ferritin is low and the patient just can’t ever replete even with a little IV Fe then she has what I describe above as that middle ground between Fe deficiency and ACD. SO the system for Fe absorption and transport is so broken that you can supplement and feed Fe orally till the cows come home and they will never replete.
– The “Catch-22” here is that the GI tract becomes so dysfunctional that until it is rehabbed nothing changes. And in my experience oral repair is insufficient in the really bad cases.
– Often they have low or high level autoimmunity, thyroid problems and systemic and/or GI infections that are undiagnosed. All these feed the Catch-22.
– In our worst patients what we observe is that we give the GI repair as tolerated and screen for GI infections and autoimmunity. If GI infections are present clear them before doing oral Fe. If autoimmunity is present work on that. If thyroid issues present (almost 100% of the time) work on that, but they often won’t tolerate as much thyroid Tx as they need until the GI and other stuff is fixed.
– They all have big mitochondrial defects (functional and maybe heritable) which are not able to be fixed until the body can tolerate enough thyroid and iron (the two primary drivers of OxPhos) to allow the mitochondria to ’run’ while it heals.
– This mitochondrial business is partly why the GI tract can’t help with the iron absorption and transport. Once it is fixed the gut ‘magically’ starts absorbing the Fe.
– In advanced cases I have seen it take 1 year to get them healed enough they can tolerate much for oral Tx. (this is with weekly IV’s alternating Fe and support nutrients with our Mitochondrial formula.) Most cases are easier than that. As you IV the support nutrients they percolate through the body including the GI cells and they slowly heal up.
– Often once you get the ferritin over 30 you will see oral Fe absorb better as well due to an undoing of this Catch-22 effect.
– When we give IV—Fe we typically run a following IV with methylated B12 and folate as well as B complex, and Mg, Zn etc. Most of these folks are low Mg and almost all with infections are low or low normal Zn.
Below is an excerpt from a paper I wrote on IVs for FMS-CFS. It speaks to IV Fe.
Iron Status and Ferritin: Ortancil et.al include a statement that significantly correlates with my clinical experience: “Our study implicates a possible association between FM and decreased ferritin level, even for ferritin in normal ranges. We suggest that iron as a cofactor in serotonin and dopamine production may have a role in the etiology of FMS.” Most commonly oral repletion of iron stores via diet and supplement interventions is preferred. In the authors experience in those with the other mentioned comorbidities and low ferritin of over five years duration injectable iron may be required. Clinical experience and the study by Ortancil indicate that a ferritin level over 40 (and ideally 50-75) is required to replete the mitochondrial iron reserves as well as hematologic requirements. Both primary targets of iron stores (mitochondrial and hematologic) contribute significantly when iron stores are low. Injectable iron is known to have a higher incidence of anaphylaxis and other high grade adverse events than most other nutrients. As such the clinician should have very specific and proper training before attempting injectable iron formulas, as well as available emergency medications and interventions should an adverse event occur. In the authors clinical experience spanning over 3000 iron injections the use of Iron Dextran is limited to Z-Track IM injection (due to the high rates of anaphylaxis when Dextran is infused) and the Gluconate and Sucrose forms of Iron are reserved for IV infusion. Used appropriately, all forms can raise ferritin and iron status faster than any oral repletion ever can, and are clinically associated with faster positive outcomes in low ferritin patients.
Admin: I only use Venofer or Ferelecit in IV form. I do NOT subscribe to the “push” formulas that the manufacturer suggests as we have no catheter problems or other issues when we dilute it. I do a 1 AMP test dose on all Fe patients with Venofer or Ferelecit in 100-250 ml solution (D5 or NS). Then Tx with 2 AMP’s per IV. As with all nutrient infusions (especially HDIVC) a larger post IV flush is required to keep the Hickman or Groshong clear so we normally do 20 mL NS flush and then heparinized saline or not depending on catheter type. If giving Fe and Nutrient IV we often do the Fe first then run the nutrient bag then the flush. If concerned we will run a whole 100 mL NS bag after. After literally thousands we have no problems doing it this way.
Some good overview material: PMID: 12380952;
Anemia of Chronic Disease