11/13/24, 8\:18 PM Guide | Iron counselling

Iron counselling

Table of contents

Background

Before starting the consultation, review the patient’s blood results to ensure that a recent full blood count and iron pro
available.
Review the haemoglobin (Hb) and mean cell volume (MCV); a low Hb (\< 130 in adult males or \< 115 in adult females) con
the patient is anaemic.
1
Iron-de typically presents with microcytic anaemia (i.e. an MCV of \< 80 fL).
If a patient has haemochromatosis, iron supplementation is contraindicated due to the risk of organ damage.
Iron studies
Iron studies include the following investigations\:
Ferritin\: this iron storage protein is the best marker of iron stores in the body. If ferritin is low, then your patient is iron-
de
reactant that can be raised in in
2
Transferrin\: this protein, made in the liver, helps to bind iron to blood plasma for transport around the body, and often
tends to be increased in iron de
Serum iron level\: as the name suggests, this is the amount of iron in the blood. As you might expect, this will be low if a
patient is iron de
% iron saturation\: the ratio of serum iron to total iron-binding capacity, in other words, how much of the space available
for carrying iron is actually being utilised.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain the reason for the consultation\:
“ I’ d l i k e t o t a l k t o y o u a b o u t i r o n s u p p l e m e n t a t i o n , w o u l d t h a t b e o k ?”
“ P l e a s e f e e l f r e e t o i n t e r r u p t m e a t a n y p o i n t , i f y o u h a v e a n y q u e s t i o n s .
"

Ideas, concerns & expectations

An important part of counselling a patient on any new medication is exploring their ideas, concerns and expectations (ICE).
Ideas
“ H a v e y o u h e a r d o f i r o n s u p p l e m e n t s b e f o r e ?"
“ D o y o u k n o w w h y i r o n i s i m p o r t a n t f o r h e a l t h ?”
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“ H a v e y o u e v e r b e e n t o l d t h a t y o u h a v e l o w i r o n b e f o r e ?”
Concerns
“ I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t t a k i n g i r o n ?"
“ H a v e y o u a n y c o n c e r n s a b o u t y o u r p h y s i c a l h e a l t h a t t h e m o m e n t ?”
Expectations
“ D o y o u u n d e r s t a n d t h e b e n e
" W h a t a r e y o u h o p i n g i r o n s u p p l e m e n t s w i l l d o f o r y o u ?"

The role of iron in the body

Iron is essential for a wide range of functions in the human body including\:
3
Transport of oxygen in red blood cells (as part of haemoglobin)
Providing oxygen to muscles, especially skeletal and cardiac muscle (as part of myoglobin)
Acting as a co-factor for important enzymes
Playing a role in immune response
Example
“ I r o n p l a y s a k e y r o l e i n l o t s o f d i
o x y g e n t o t h e r e l e v a n t t i s s u e s a n d h e l p i n g y o u r i m m u n e s y s t e m
"

Symptoms of iron-de

Explain to the patient that it's important to treat iron de
of symptoms such as\:
Fatigue/weakness
Shortness of breath
Palpitations
Headache
Pale skin
Dizziness
Feeling cold
Chest pain
Example
" I f l e f t u n t r e a t e d , i r o n-d e
a n d p a l p i t a t i o n s . I t c a n a l s o c a u s e y o u t o e x p e r i e n c e h e a d a c h e s a n d r e s u l t i n t h e c o l o u r o f y o u r s k i n b e c o m i n g p a l e r t h a n
u s u a l .
"

Causes of iron-de

The main causes of iron de
Blood loss
Lack of iron in the diet
Inability to absorb iron (e.g. coeliac disease, in
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Increased iron demand (e.g. pregnancy, childhood, adolescence)
You'll need to tailor your explanation to the cause of the patient's iron de
Example
" Y o u r i r o n l e v e l s a r e l o w b e c a u s e o f t h e b l o o d l o s s y o u e x p e r i e n c e d d u r i n g l a b o u r . w i t h s o m e i r o n s u p p l e m e n t s , y o u s h o u l d b e a b l e t o s t o p t a k i n g t h e m .
"
O n c e w e' v e t o p p e d u p y o u r i r o n s t o r e s
" Y o u r i r o n l e v e l s a r e l o w b e c a u s e y o u r c u r r e n t d i e t d o e s n o t i n c l u d e a n y f o o d s t h a t c o n t a i n a l a r ge a m o u n t o f i r o n . W e' l l
b e u s i n g i r o n s u p p l e m e n t s t o r e p l e n i s h y o u r i r o n s t o r e s , w h i l s t y o u t r y a n d i n c o r p o r a t e m o r e i r o n i n t o y o u r n a t u r a l d i e t .
"
" Y o u r i r o n l e v e l s a r e l o w b e c a u s e y o u h a v e c o e l i a c d i s e a s e , w h i c h r e d u c e s t h e a b i l i t y o f y o u r b o w e l t o a b s o r b i r o n f r o m
t h e f o o d s y o u e a t . Y o u' l l m o s t l i k e l y n e e d t o c o n t i n u e y o u r i r o n s u p p l e m e n t s l o n g t e r m .
"

When and how to take iron supplements

When to take iron supplements

Explain to the patient that iron is absorbed best if taken an hour before a meal, however, iron can irritate the stomach of
some people, causing them to feel nauseated, in which case iron may be best taken just after a meal.
Example
" T o a b s o r b a s m u c h i r o n a s p o s s i b l e y o u s h o u l d t a k e t h e i r o n t a b l e t a n h o u r b e f o r e a m e a l .
"
" U n f o r t u n a t e l y , i n s o m e c a s e s , i r o n c a n i r r i t a t e t h e s t o m a c h , c a u s i n g p e o p l e t o f e e l n a u s e a t e d . I n t h e s e c a s e s , w e
r e c o m m e n d t a k i n g t h e i r o n t a b l e t j u s t a f t e r a m e a l t o r e d u c e t h e s i d e e
i r o n a b s o r b e d .
"

How to take iron supplements

Explain the relevant iron supplement regimen to the patient, which will di
supplementation and the form of iron.
The most common form of oral iron supplement is ferrous fumarate.
Prophylactic supplementation
Prophylactic iron supplementation may be indicated for patients with borderline iron levels who have risk factors for iron
de
Example
" A s a r e s u l t o f y o u r d i e t a r y p r e f e r e n c e s , y o u' r e l i k e l y t o s t r u g g l e t o m a i n t a i n a n a d e q u a t e l e v e l o f i r o n . A s a r e s u l t , I t h i n k
l o n g t e r m i r o n s u p p l e m e n t a t i o n w o u l d b e o f b e n e
l e v e l s i n t h e f u t u r e .
"
Treatment dose supplementation
Treatment dose iron supplementation may be indicated for patients who have established iron de
iron stores. Typically treatment dose iron supplementation is prescribed for three to six months and iron levels are then re-
assessed to decide if long term prophylaxis is required (due to ongoing risk factors) or if treatment can be stopped completely
(e.g. if a patient had a single episode of blood loss which has now been treated/resolved).
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Example
" A s a r e s u l t o f t h e b l o o d y o u l o s t w h e n y o u e x p e r i e n c e d a b l e e d f r o m y o u r b o w e l , y o u r i r o n s t o r e s a r e c u r r e n t l y v e r y l o w .
T h e r e f o r e , I t h i n k y o u' l l n e e d a 3-6 m o n t h c o u r s e o f h i gh d o s e i r o n s u p p l e m e n t a t i o n t o r e p l e n i s h y o u r i r o n s t o r e s a n d w e
c a n t h e n c h e c k y o u r l e v e l s a n d c o n s i d e r i f y o u n e e d t o c o n t i n u e i r o n t a b l e t s l o n g t e r m .
"

Alternative routes of administration

Intravenous iron administration is only indicated in cases of severe iron de
tolerated or would take too long to replenish iron stores.
7
Monofer (iron isomaltoside) is a form of iron that can be administered via intravenous infusion. The dose depends on the
patient’s weight.
8
IV iron administration is associated with a risk of anaphylaxis, so all patients need to be monitored during an infusion in a
setting with adequate resuscitation facilities.

Side e

Common side e
5
Nausea
Constipation
Diarrhoea
Dark-coloured stools
Metallic taste
Make sure to explain to the patient that many of the side e
are struggling to cope with them.
Example
" A s w i t h a l l m e d i c a t i o n s , i r o n t a b l e t s a r e a s s o c i a t e d w i t h s o m e s i d e e
t i m e . S o m e o f t h e m o s t c o m m o n s i d e e
d i a r r h o e a . Y o u w i l l m o s t l i k e l y a l s o n o t i c e t h a t y o u r b o w e l m o t i o n s a p p e a r a d a r k c o l o u r d u e t o t h e p r e s e n c e o f i r o n . S o m e
p e o p l e a l s o e x p e r i e n c e a m e t a l l i c t a s t e i n t h e i r m o u t h . I f t h e s e s y m p t o m s b e c o m e d i
b a c k i n t o u c h a n d w e c a n r e-c o n s i d e r y o u r i r o n t r e a t m e n t o p t i o n s .
"

Dietary advice

Increasing iron intake

As well as prescribing oral iron supplementation, it is important to make patients aware of ways in which they can increase their
dietary iron intake. Often, patients will be able to maintain adequate iron levels by altering their diet.
6
Foods rich in iron include\:
Red meat (especially beef, lamb and pork)
Leafy vegetables (spinach, broccoli and cabbage)
Dried fruit (
Example
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" I n t h e l o n g t e r m , y o u m a y b e a b l e t o m a i n t a i n a d e q u a t e l e v e l s o f i r o n b y i n c o r p o r a t i n g i r o n-r i c h f o o d s i n t o y o u r d i e t .
S o m e e x a m p l e s o f f o o d s w i t h h i g h l e v e l s o f i r o n i n c l u d e r e d m e a t , s p i n a c h , b r o c c o l i , c a b b a ge , d r i e d f r u i t s a n d n u t s .
"

Vitamin C

Vitamin C (ascorbic acid) combines with iron to form an iron chelate complex, which makes iron more soluble and results in
increased uptake of iron in the small intestine.
There are tablets you can prescribe which combine oral iron with ascorbic acid, but it’s usually easier (and a lot tastier) for your
patients to just eat some citrus fruit or drink pure orange juice.
Example
" I t' s a l s o i m p o r t a n t t h a t y o u h a v e e n o u g h v i t a m i n C i n y o u r b o d y a s t h i s h e l p s y o u t o a b s o r b i r o n e
a n d o r a n g e j u i c e a r e t h i n g s y o u c a n e a t o r d r i n k t o m a i n t a i n a d e q u a t e l e v e l s o f v i t a m i n C . I f y o u s t r u ggl e t o i n c o r p o r a t e
v i t a m i n C i n t o y o u r d i e t , w e c a n a l s o c o n s i d e r o r a l s u p p l e m e n t s .
"

Closing the consultation

Summarise the key points back to the patient, to make sure they understand the importance of having adequate iron levels
and the side e
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Example
" J u s t b e f o r e w e
s e n s e . W e’ v e d i s c u s s e d t h e r o l e o f i r o n i n t h e b o d y , t h e s y m p t o m s o f i r o n d e
i n t o y o u r d i e t . W e' v e a l s o c o v e r e d h o w t o t a k e i r o n s u p p l e m e n t s a n d t h e p o t e n t i a l s i d e e
"
" D o y o u h a v e a n y q u e s t i o n s a b o u t a n y o f t h a t ? I r e a l i s e w e' v e c o v e r e d q u i t e a l o t o f i n f o r m a t i o n i n a s h o r t a m o u n t o f t i m e .
"
“ H e r e i s a l e a
”
a n d i f y o u h a v e a n y o t h e r q u e s t i o n s a f t e r r e a d i n g i t
" T h a n k y o u f o r y o u r t i m e t o d a y .
"

References

1. Gloucestershire Hospitals NHS Foundation Trust. H a e m a t o l o g y R e f e r e n c e R a n g e s . Available from\: [LINK]
2. The BMJ. I n t e r p r e t i n g r a i s e d f e r r i t i n l e v e l s . Published in 2015. Available from\: [LINK]
3. Open Educational Resources. I r o n F u n c t i o n s . Available from\: [LINK]
4. NICE Guidelines. I r o n-d e LINK]
5. Patient.info. I r o n s u p p l e m e n t s . Published in 2020. Available from\: [LINK]
6. BDA. I r o n \: F o o d F a c t S h e e t . Published in 2020. Available from\: [LINK]
7. Transfusion Guidelines. P a r e n t e r a l I r o n . Published in 2014. Available from\: [LINK]
8. Northern Devon Healthcare NHS Trust. M o n o f e r I n f u s i o n f o r i r o n d e LINK]
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