Do you withhold ferrous fumarate (iron supplement) in cases of infection or bleeding?

From the Guidelines

Ferrous fumarate should be withheld in cases of active infection or bleeding. During infections, the body naturally reduces iron availability as a defense mechanism against pathogens that require iron for growth. Administering iron supplements during infection may fuel bacterial proliferation and potentially worsen the infection, as suggested by a systematic review and meta-analysis that found intravenous iron to be associated with an increased risk of infection 1. In cases of active bleeding, the priority should be to identify and address the source of bleeding rather than supplementing with iron. Once the bleeding is controlled and the patient is stable, iron therapy can be resumed. If iron deficiency anemia is severe despite these concerns, the decision to administer iron should be made on a case-by-case basis, weighing the risks of infection exacerbation or continued bleeding against the benefits of treating anemia.

When considering the management of iron deficiency anemia, guidelines recommend initial treatment with oral iron supplements, such as ferrous sulphate, fumarate, or gluconate, at a dose of one tablet per day, with adjustments as needed for tolerance 1. However, in the context of infection or bleeding, these recommendations must be balanced against the potential risks. The most recent expert review suggests that oral iron supplements should be used initially to replenish iron stores, even in patients with portal hypertensive gastropathy and iron-deficiency anemia, with intravenous iron therapy reserved for those with ongoing bleeding who do not respond to oral iron therapy 1.

Key considerations in the management of iron deficiency anemia in the context of infection or bleeding include:

• Withholding iron supplements during active infection to avoid fueling bacterial growth
• Prioritizing the control of bleeding over iron supplementation
• Resuming iron therapy once the patient is stable
• Making case-by-case decisions for patients with severe iron deficiency anemia, weighing the risks and benefits of treatment.

From the Research

Withholding Ferrous Fumarate in Infection/Bleeding

• The decision to withhold ferrous fumarate in cases of infection or bleeding is complex and depends on various factors, including the severity of the anemia, the underlying cause of the infection or bleeding, and the patient's overall health status 2.
• In cases of infection, iron supplementation may be withheld to prevent providing iron to the invading pathogens, which could exacerbate the infection 2.
• However, in cases of bleeding, iron supplementation may be necessary to replenish iron stores and prevent or treat iron-deficiency anemia 3, 4, 5, 6.
• The use of intravenous iron therapy has been shown to be effective in correcting iron-deficiency anemia in patients with bleeding or other conditions that lead to iron deficiency 4, 6.
• It is essential to evaluate and manage the underlying cause of the anemia, whether it be bleeding, infection, or another condition, to determine the best course of treatment 3, 5.

Considerations for Iron Supplementation

• Iron supplementation should be guided by patient symptoms and preferences, as well as the patient's hemoglobin concentration and iron stores 3.
• Oral iron therapy is typically the first-line treatment for iron-deficiency anemia, but intravenous iron therapy may be necessary in cases where oral iron is not tolerated or absorbed adequately 5.
• The risk of infection and iron overload should be considered when deciding whether to supplement with iron, particularly in patients with underlying conditions that may increase this risk 2.