What is a recommended prescription oral iron supplement for a patient with iron deficiency?

Recommended Prescription Oral Iron Supplement for Iron Deficiency

Ferrous sulfate 200 mg once daily is the recommended first-line prescription oral iron supplement for patients with iron deficiency anemia due to its effectiveness, low cost, and established evidence base. 1

Selection of Oral Iron Preparation

First-Line Option:

• Ferrous sulfate 200 mg once daily (contains approximately 65 mg of elemental iron per tablet)
  • Most cost-effective option (as low as $0.30 for 30 pills) 1
  • Well-established efficacy profile
  • Supported by current guidelines 1

Alternative Ferrous Salt Options (if ferrous sulfate is not tolerated):

• Ferrous gluconate (27-38 mg elemental iron per tablet)
• Ferrous fumarate (106-150 mg elemental iron per tablet)

Dosing Recommendations

• Once daily dosing is optimal - More frequent dosing increases side effects without improving absorption 1
• Consider alternate-day dosing if daily dosing causes intolerable side effects 1
• Traditional three-times-daily dosing is no longer recommended as it increases hepcidin levels, which paradoxically blocks further iron absorption 1

Optimizing Absorption

• Add vitamin C (ascorbic acid) 500 mg with iron supplementation to enhance absorption 1
• Take iron on an empty stomach when possible for best absorption
• Avoid taking with:
  • Tea or coffee (wait at least 1 hour after iron intake)
  • Calcium-containing foods or supplements
  • Proton pump inhibitors (may significantly reduce iron absorption) 2

Monitoring Response

• Hemoglobin should increase by approximately 2 g/dl after 3-4 weeks of therapy 1
• Ferritin levels should show improvement within one month of starting therapy 1
• If no improvement after 4 weeks of compliant therapy, consider:
  1. Ongoing blood loss
  2. Malabsorption issues
  3. Incorrect diagnosis
  4. Need for intravenous iron therapy

When to Consider Intravenous Iron Instead

Intravenous iron should be considered when:

• Patient has intolerance to at least two oral iron preparations 1
• Poor compliance with oral therapy
• No improvement in iron parameters after adequate oral iron trial
• Conditions with impaired absorption:
  • Active inflammatory bowel disease
  • Post-bariatric surgery
  • Ongoing significant blood loss exceeding oral absorption capacity 1

Common Side Effects and Management

• Gastrointestinal side effects (reported in clinical trials):

  • Constipation (12% of patients)
  • Diarrhea (8%)
  • Nausea (11%) 1

• Management strategies:

  • Reduce dose temporarily
  • Switch to alternate-day dosing
  • Try a liquid preparation if tablets are not tolerated 1
  • Consider switching to another ferrous salt formulation

Important Caveats

1. No single oral iron formulation has proven superiority in effectiveness or tolerance, despite marketing claims 1
2. Patients taking proton pump inhibitors may have significantly reduced iron absorption and might require higher doses or longer treatment duration 2
3. The hemoglobin response should be monitored, as failure to improve may indicate ongoing blood loss or other underlying conditions requiring investigation 1
4. While investigating the cause of iron deficiency is essential, treatment should not be delayed while awaiting diagnostic results

By following these evidence-based recommendations, you can optimize iron repletion while minimizing side effects and improving patient adherence to therapy.