Management

IRON MOM: a simplified and patient-driven approach to the treatment of iron deficiency in pregnancy.

Management Algorithm

The IRON MOM app will tell your patient to start on an oral iron supplement.

Prefilled prescription pads are available in your clinic.

 

 

 

Which Pill is Best?

The best oral iron supplement is the one that your patient tolerates, takes properly, and takes consistently. If your patient is already on a daily iron supplement and tolerating it well, keep going – there is no need to switch supplements.

The IRON MOM app will inform your patient about iron supplements.

As per WHO guidelines, all pregnant women should be taking an oral iron supplement daily. We suggest a supplement that contains 60 mg to 150 mg of elemental iron per dose (pill).

Start all of your pregnant patients on Ferrous Sulfate 1 tablet (300mg) once daily. We recommend Ferrous Sulfate because it is inexpensive and generally well-tolerated. Ferrous Sulfate is available over-the-counter and some patients may qualify for coverage by the Ontario Drug Benefit Plan.

Almost all iron pills should be taken as 1 iron pill per day, this will help reduce side effects and make it easier for your patient to remember. There are several formulations of oral iron (see Table below). They come in tablets, capsules, powder or liquid form. They even come as a cast iron fish.

Iron supplements are available over-the-counter but are kept behind the counter with the pharmacist.

Types of Oral Iron Supplementation:

Iron Pill Generic Trade Name Examples Elemental Iron/pill Price (per month)*

Dietary Considerations

Ferrous fumarate

Take 1 pill per day

Palafer ®,  Eurofer ®

100 mg

$8

Gluten-tree, Lactose-free, Soy-free

Ferrous sulfate

Take 1 pill (or liquid dose) per day

Fer-in-Sol ®, Feosol ®, Fer Iron ®

60 mg

$6

Vegan, Gluten-tree, Lactose-free, Soy-free

Ferrous gluconate

Take 1 pill per day

Fergon ®

35 mg

$3

Vegan, Gluten-tree, Lactose-free, Soy-free

Polysaccharide-iron complex

Take 1 pill (or powder dose) per day

Feramax ®, Triferrex ®, Polyride Fe ®

150 mg

$22-$30

NOT automatically vegetarian, but vegan options are available for Feramax and Triferrex – so please talk to your pharmacist

Heme iron polypeptide

Take 2-3 pills per day**

Proferrin-ES ®, OptiFer®Alpha

11 mg

$30-$80

NOT vegetarian (comes from red blood cells)

Lucky Iron Fish

(1L water boiled with the cast iron fish, https://luckyironfish.com/ 

 

60 mg dissolved in 1L of water

$33 for one fish that can be reused many times

 Vegan

*approximate values
** Heme iron polypeptides contain less elemental iron per pill compared to other formulations.

Encourage your patient to speak with their pharmacist for Kosher or Halal options if that is important to them.

How to get your patient to take iron properly?

Tell them to download the IRON MOM app

The IRON MOM app will essentially tell them the following:

  • Prenatal multivitamins are not a solution to ID in pregnancy because they do not contain enough iron and because they contain divalent cations (e.g. calcium) which interfere with iron absorption.
  • To take an iron supplement on an empty stomach (i.e. two hours from last meal) with water before bed and at least two hours from their prenatal multivitamin. This is because many foods and medications interfere with effective iron absorption. Iron can also interfere with absorption of certain medications.

Iron should NOT be taken within 2 hours of:

If patients would like to take their iron supplements with food, foods with vitamin C can actually improve iron absorption (e.g. oranges, tangerines, apples, tomatoes). Vitamin C facilitates iron absorption by forming a chelate with ferric iron at acid pH, which remains soluble at the alkaline pH of the duodenum (where iron is absorbed).

BOTTOM LINE: Iron is best taken on an empty stomach (>2 hours from meal, and prenatal multivitamin) with water. The IRON MOM app will help guide and counsel your patient. Remind them to download it.

 

Cook JD, Dassenko SA, Whittaker P. Calcium supplementation: effect on iron absorption. The American journal of clinical nutrition. 1991 Jan 1;53(1):106-11.

Lynch SR, Cook JD. Interaction of vitamin C and iron. Annals of the New York Academy of Sciences. 1980 Dec;355(1):32-44.

Management of side effects

Tell your patient to download the IRON MOM app.

Iron supplements can sometimes cause side effects, usually involving the gastrointestinal tract. Nausea, stomach upset, bloating, abdominal pain, diarrhea and/or constipation occur in about 30% of people. The symptoms are usually mild, can be easily tolerated and improved. Dark stools occur in all patients who take iron pills – this is normal and expected.

The IRON MOM will help your patient manage GI side effects (e.g. suggest alternate day dosing, suggest alternative iron supplement, suggest over-the-counter medications for constipation).

What if my patient has pregnancy associated nausea and vomiting?

Early in pregnancy some women experience nausea, stomach upset and vomiting – because of this you might suggest that your patient delay taking an iron pill daily until these symptoms have improved, or until they are >20 weeks pregnant (whichever comes first). If this is the case, the IRON MOM can prompt them to start iron later in the pregnancy.

 

Tolkien, Z., et al., Ferrous sulfate supplementation causes significant gastrointestinal side-effects in adults: a systematic review and meta-analysis. PLoS One, 2015. 10(2): p. e0117383.

Managing Expectations: Clinical Response

In pregnancy, do not expect ferritin levels to increase after prescribing oral iron. During pregnancy, iron is directed to the fetus and bone marrow to produce red blood cells. Our goal is to increase, or at minimum stabilize the hemoglobin throughout pregnancy with oral iron supplementation.

Many women notice an improvement in their symptoms as early as 4 to 8 weeks after initiation of iron replacement.

When to refer to hematology?

Follow the algorithm below.

Timing of the referral matters. It is best to refer early as many women require multiple infusions of intravenous iron and it takes a minimum of 4 weeks to achieve maximal erythropoietic response. So, please refer early so we can get your patient’s hemoglobin up in time for delivery.

 

Who shouldn’t get iron? (Exceptional cases)

Do not start iron in pregnant women with a personal history of:

  • Severe inherited red blood cell disorder like thalassemia major, thalassemia intermedia or sickle cell anemia (this does not apply to people with thalassemia minor or sickle cell trait)
  • Need for chronic blood transfusions for a blood disorder
  • Inherited iron overload problem (hereditary hemochromatosis)