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Iron Deficiency Iron is

Iron Deficiency Iron is an essential mineral found in every cell of the body. Iron boosts the immune system, helps fight infections and is vital for normal child growth and intellectual development. It is also used to make haemoglobin, which is the substance in red blood cells responsible for transporting oxygen around the body. Iron is stored in the liver, spleen and bone marrow. Iron requirements are higher during periods of rapid growth and development – such as during early childhood, adolescence and pregnancy. Low body iron levels can also be caused by: • surgery, medical conditions that cause blood loss (eg, heavy menstruation, haemorrhoids, gastrointestinal bleeding), or clotting disorders • frequent blood donation, especially in women of child-bearing age • chronic malabsorption syndromes (ie, people with coeliac disease) • kidney failure • poor dietary intake (eg, vegetarians). People who engage in regular, intense exercise – especially if they are female or vegetarian – are also at a higher risk of iron deficiency. It is uncommon for adult men or postmenopausal women to become iron deficient. Symptoms of iron deficiency include tiredness, pallor (pale complexion) and weakness. A person’s ability to exercise may be reduced and shortness of breath, fast heart rate, fainting and unusual food cravings may also be present. The condition usually comes on slowly, so may go unrecognised for some time. Iron-deficiency anaemia (IDA) occurs when the iron deficiency is severe enough to affect the production of red blood cells. Blood tests are required to confirm IDA, so it is important to refer people who suspect they are iron deficient to the doctor. The amount of haemoglobin in the blood will be measured, along with the amount of iron present within the blood or stored. The doctor will also carry out a physical examination and conduct a history to try to determine the cause of IDA. Many other types of anaemia and even haemochromatosis (a medical condition where too much iron is absorbed) can cause similar symptoms, so do not assume the diagnosis is iron-deficiency anaemia without blood test results. Too much iron can be toxic, especially to children, and iron supplements should not be taken routinely without a doctor's advice. Haem iron and non-haem iron Two types of iron exist. Haem iron and non–haem iron. Haem iron is the iron contained within myoglobin and the blood pigment haemoglobin, and approximately 30% of haem iron ingested is absorbed. It is found in animal foods, such as beef, lamb, chicken, egg yolks and fish. Offal foods (eg, liver, kidneys) are particularly good sources of haem iron; however, these offal meats also contain large amounts of vitamin A which is known to cause birth defects, so should not be eaten in large quantities by pregnant women. Red meat also contains non-haem iron. Non-haem iron is found in plant foods such as dried beans, dark green leafy vegetables, tofu, fortified breakfast cereals, flours and whole grains. In the past, non-haem iron was considered inferior to haem-iron because less is absorbed. However, our bodies have more control over plant-based sources of iron and absorption can be improved if non-haem iron is consumed with products high in vitamin C such as kiwifruit, citrus fruit, orange juice, and capsicums. Research has also found that vegans are no more susceptible to iron deficiency than the general population. TREATMENT OPTIONS Category Examples Comments Iron supplements Iron supplements in combination with other minerals or vitamins [GENERAL SALE] eg, Douglas Carbonyl Iron (=elemental iron 18mg), Natures Own Liquid iron (=elemental iron 7.5mg), Sanderson Superior Organic Iron (=elemental iron 24mg), Spatone 100% Natural* (=elemental iron 5mg), [PHARMACY ONLY MEDICINE] eg, Ferrograd (=105mg elemental iron) [GENERAL SALE] eg, Blackmores Bio Iron, Clinicians Iron Boost, Fab Iron, Floradix Floravital Liquid Iron and Vitamin Formula, Incremin Iron Mixture, Iron Melts, Solgar Gentle Iron, Spirulina [PHARMACY ONLY MEDICINE] eg, Elevit with Iodine, FabFol Plus with Iodine (=elemental iron 60mg) eg, Ferrograd C (=105mg elemental iron + vitamin C 500mg) eg, Ferrograd F (=105mg elemental iron + folic acid 0.35g) Iron supplements contain either the ferrous or ferric form of iron. Of the two, the ferrous form is better absorbed and is available as either ferrous sulphate, ferrous fumurate or ferrous gluconate. Each one of these ferrous salts contains a different amount of available iron, called elemental iron. Iron dosages should be based on the amount of elemental iron contained within the product, not the amount of ferrous salt present. Recommended daily intakes (RDIs) of iron vary according to age and gender. Pregnant women also require higher daily intakes of iron. RDIs can be found on the NZ Nutrition Foundation’s website ( Higher dosages of iron are best taken as divided doses as the amount of iron absorbed decreases as dosages get larger. Iron supplements prescribed for anaemia may need to be taken for up to six months, or for three months after haemoglobin concentration is normal, to build up iron stores. Iron supplements may cause nausea, constipation and/or diarrhoea, and make the stools a dark colour. Taking iron tablets with food may help settle gastrointestinal problems. Be aware iron is dangerous in overdose and tablets must be taken as directed for the recommended course. Keep all iron products out of reach of children. Sip iron liquid through a straw to avoid tooth discolouration. Combination formulations may contain vitamin C, folic acid, B vitamins (ie, B1, B6, or B12) and other vitamins. Many act as co-factors to facilitate absorption. If iron levels are very low, follow a doctor’s advice with regards to dosage. Products with an asterisk have a detailed listing in the Iron Deficiency section of OTC Products, starting on page 249. READY, SET, LEARN! Page 100 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION Iron •• Iron deficiency is reasonably common among New Zealand children. »» Maori and Pacific Island children are more at risk. •• Supplements may be appropriate for some customers, but pharmacists should oversee all new sales to determine need, and refer customers to a doctor for further investigation. •• Supplements are used to treat people with confirmed iron deficiency from blood tests, or people at high risk of becoming iron deficient. Initial assessment Iron supplementation is not without controversy and is not generally recommended unless a customer has a formal diagnosis of IDA. Iron supplementation is also best done under medical supervision as absorption of other nutrients (ie, calcium, zinc) may be reduced. Advise customers that iron-rich foods are preferred over supplements and suggest ways to improve iron absorption from their diet. Refer any customers with "yes" answers to the Refer to Pharmacist questions to a pharmacist. Advice for customers • Lean red meat is the best source of easily-absorbed iron. Chicken, other poultry, pork and fish also contain easy-to-absorb iron. • Combine vitamin C rich foods with sources of non-haem iron to increase absorption (eg, kiwifruit and cereal, beans and tomatoes, tofu and broccoli). • Combining haem foods with non-haem foods also increases iron absorption (eg, meat and salad). • Avoid drinking tea and coffee at mealtimes as they both reduce iron absorption. • Babies are born with sufficient iron supplies to last for approximately six months. After that time, iron-rich foods should be gradually added to their diets to meet their body’s iron requirements. • Ensure children and teenagers going through growth spurts are getting enough iron in their diet. • Iron stores in pregnant women have to serve the increased blood volume of the mother as well as the needs of the growing baby. »» Some pregnant women may be prescribed iron supplements by their doctor; however, there is controversy regarding routine supplementation. • Supplemental iron may cause gastrointestinal side effects such as nausea and constipation. • Some forms of supplemental iron (eg, heme iron polypeptides, carbonyl iron, iron amino-acid chelates) may have fewer side effects than ferrous or ferric salts. Refer to PHARMACIST All customers who have not had a formal diagnosis of iron-deficiency anaemia (eg, with blood tests) will need to speak to a pharmacist who should then refer them to a doctor. The following questions aim to identify customers who would benefit from further input from a pharmacist. Your initial assessment may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the person have any other health conditions (eg, heart or lung problems, immunosuppression, diabetes, haemochromatosis, is pregnant or breastfeeding)? • Does the person take any other medication, either prescribed by a doctor or bought from a shop or supermarket (including herbal/ complementary medications)? • Is the person a baby or a child? • Has the person had any other symptoms (eg, joint pain, unexplained weight loss)? • Has the person noticed blood in the stools (note that iron tablets will make the stools look dark)? • Have the symptoms persisted despite regular iron tablets? • Is the person an elderly person? • Are the iron tablets causing unacceptable side effects? • Does the person have a good reason for wanting iron supplements? • Is the person unsure of what dosage of iron is needed? • Does the person have any allergies to medicines? Locate this icon throughout the Healthcare Handbook. Then find the corresponding Pharmacy Today and ELearning articles. Read all three to unleash learning prizes and giveaways! Page 101

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