kirstabelle
Well-Known Member
Why Iron Salts Don’t Work for US
Written by Leona Oknee Dove
I have been reading and frustrated by a great deal of miss-information posted here regarding iron supplements, and certain members questioning my credentials and loyalties. Granted I graduated from nursing school in 1986 and have not graced the halls of a post-secondary institution as a student in 28 years, but that does not mean that I have not participated in continuing education in that time. I worked for over 20 years in the field of Trauma and Emergency nursing, I am a researcher and co-writer of CTAS, a five level triage system currently used worldwide and have traveled as an educator on this subject. I am licensed and continue to work as a “field triage specialist” with many volunteer Heavy Urban Search and Rescue (HUSAR) Agencies as a volunteer. My last major international deployment was the Haitian Earthquake.
After leaving the Emergency Trauma setting I entered the field of pharmaceutical research and performed phase one through phase four pharmaceutical research, writing licensing applications, policy and procedure, and administration guidelines for many medications. In 2008 longing for patient care I assumed the role of Blood Conservation Coordinator, a big fancy title meaning “gas station attendant”. My role in health care is to treat simple anemia with modalities other than blood transfusion.
The most common cause of anemia is iron deficiency. I work at the oldest Ontario Centre of Excellence for Bariatric Surgery, and while a bulk of my practice is pre-operative anemia, I do see a number of patients with: “iron deficiency related to malabsorption secondary to bariatric surgery”. In my research I have learned a great deal about iron supplements how and where they are absorbed and side effects that can predict compliance. In my practice I seldom use iron salts, while they may be cheaper they are not as effective as heme or polysaccharide irons. Here is what I know about iron salts (ferrous fumerate, palafer, ferrous gluconate, eurofer, ferrous sulfate, carbonyl iron, ferrous anything…).
In a normal unaltered surgical gut only 8% of this iron is absorbed. Absorption depends on its digestion and conversion to the type of iron our body like to absorb. This conversion takes place in the presence of acid which is excreted into the stomach. The conversion continues into the first section of the small intestine where a majority of the converted iron is absorbed. What is not absorbed continues through the digestive tract and is expelled through the colon as a black tarry constipated stool. Patients who are on medication that decrease the acid in their stomachs (Prevacid, Nexium, Losec etc.) are not able to convert the iron salt to the type of iron our body likes to absorb so a majority of it gets flushed.
Non-Salt irons, aka heme iron and polysaccharide iron are digested and absorbed in the second segment of the small intestine; it does not need to be converted as it is already the type of iron our body likes to absorb. Approximately 30-60% of polysaccharide iron is absorbed; that which is not absorbed draws water into the colon as it travels to excretion resulting in a looser than normal stool rather than constipation. While many may see this as an advantage, those with irritable bowel syndrome may have issue with this common side effect. According to the manufacturer of Canada’s only Heme product, Proferrin 70-100% of its iron content is absorbed in the upper portion of the second section of the small intestine.
Now let’s translate that information into the surgically altered gut of a WLS patient. Our stomach is anywhere from 40-90% smaller so the digestion and acid secretory surface for iron salts is greatly diminished. A majority of those with Sleeves are on Proton Pump inhibitors or H2 Inhibitors (medication to decrease the acid in the stomach) as are many gastric bypass and duodenal switch patients. As noted above, “any patient on a PPI or H2 Inhibitor should not be prescribed iron salts”. Moving on to the absorption surfaces for iron salts knowing that less than 8% has been digested and converted to the type of iron our body can absorb, the absorption surface has also be greatly decreased in gastric bypass patients, and virtually eliminated in the duodenal switch procedure. In addition to the decrease in absorption surface there is the issue of increased motility (the length of time food is in contact with the absorptive surface). So less than 8% is digested and converted, less still is absorbed, what is not converted or absorbed travels through the colon and excreted as a black tarry stool and flushed fortifying the sewer system.
Heme and polysaccharide irons are digested and absorbed in the second segment of the small intestine which in many cases remains intact, granted motility does remain an issue however the bioavailability of the iron means more of a chance of it being absorbed.
Many patients go to their physician complaining of what is referred to as the triad of Iron Deficiency (Chronic fatigue, Irritability, and Difficulty concentrating). The doctor will do a CBC to check for anemia (stage three iron deficiency) which may come back as normal. Seldom do they check an iron panel, (which would indicate Stage two iron deficiency) or a Ferritin Level (which would identify a stage one iron deficiency). Prolonged use of the wrong iron will deplete the iron in your bone marrow and finally the stores in your liver at which time you will finally show to be anemic in the CBC. The triad of iron deficiency appears in stage one iron deficiency, if acted upon anemia needs never to occur. So the choice is as always yours, you can take the appropriate iron now, speak to your doctor about why iron salts don’t work for you now or wait until you are anemic and need iron infusions and/or blood transfusions in the future. While waiting to deteriorate to a stage three iron deficiency your symptoms will escalate, exercise intolerance, insomnia, hair loss, brittle nails…
Finally I would like to publically disclose that I do work for Biosyent as a professional consultant. I was hired after they witnessed a talk I gave on iron deficiency in the bariatric patient to an Ontario Bariatric Event last October. Many who know me know I have been promoting the use of non-salt irons in both the bariatric and general population since 2009. Biosyent also is the financial backer of my new blog “The Iron Maiden”. Med Futures, the manufacturer of the only heme iron available in Canada (Proferrin) has provided a financial stipend for the development of an algorithm to help doctor identify and treat iron deficiency before it progresses to anemia in collaboration with another nurse working in the field of blood conservation. I have received funding for various presentations on the topic of iron deficiency and its treatment to professionals and patient interest groups across North America.
Written by Leona Oknee Dove
I have been reading and frustrated by a great deal of miss-information posted here regarding iron supplements, and certain members questioning my credentials and loyalties. Granted I graduated from nursing school in 1986 and have not graced the halls of a post-secondary institution as a student in 28 years, but that does not mean that I have not participated in continuing education in that time. I worked for over 20 years in the field of Trauma and Emergency nursing, I am a researcher and co-writer of CTAS, a five level triage system currently used worldwide and have traveled as an educator on this subject. I am licensed and continue to work as a “field triage specialist” with many volunteer Heavy Urban Search and Rescue (HUSAR) Agencies as a volunteer. My last major international deployment was the Haitian Earthquake.
After leaving the Emergency Trauma setting I entered the field of pharmaceutical research and performed phase one through phase four pharmaceutical research, writing licensing applications, policy and procedure, and administration guidelines for many medications. In 2008 longing for patient care I assumed the role of Blood Conservation Coordinator, a big fancy title meaning “gas station attendant”. My role in health care is to treat simple anemia with modalities other than blood transfusion.
The most common cause of anemia is iron deficiency. I work at the oldest Ontario Centre of Excellence for Bariatric Surgery, and while a bulk of my practice is pre-operative anemia, I do see a number of patients with: “iron deficiency related to malabsorption secondary to bariatric surgery”. In my research I have learned a great deal about iron supplements how and where they are absorbed and side effects that can predict compliance. In my practice I seldom use iron salts, while they may be cheaper they are not as effective as heme or polysaccharide irons. Here is what I know about iron salts (ferrous fumerate, palafer, ferrous gluconate, eurofer, ferrous sulfate, carbonyl iron, ferrous anything…).
In a normal unaltered surgical gut only 8% of this iron is absorbed. Absorption depends on its digestion and conversion to the type of iron our body like to absorb. This conversion takes place in the presence of acid which is excreted into the stomach. The conversion continues into the first section of the small intestine where a majority of the converted iron is absorbed. What is not absorbed continues through the digestive tract and is expelled through the colon as a black tarry constipated stool. Patients who are on medication that decrease the acid in their stomachs (Prevacid, Nexium, Losec etc.) are not able to convert the iron salt to the type of iron our body likes to absorb so a majority of it gets flushed.
Non-Salt irons, aka heme iron and polysaccharide iron are digested and absorbed in the second segment of the small intestine; it does not need to be converted as it is already the type of iron our body likes to absorb. Approximately 30-60% of polysaccharide iron is absorbed; that which is not absorbed draws water into the colon as it travels to excretion resulting in a looser than normal stool rather than constipation. While many may see this as an advantage, those with irritable bowel syndrome may have issue with this common side effect. According to the manufacturer of Canada’s only Heme product, Proferrin 70-100% of its iron content is absorbed in the upper portion of the second section of the small intestine.
Now let’s translate that information into the surgically altered gut of a WLS patient. Our stomach is anywhere from 40-90% smaller so the digestion and acid secretory surface for iron salts is greatly diminished. A majority of those with Sleeves are on Proton Pump inhibitors or H2 Inhibitors (medication to decrease the acid in the stomach) as are many gastric bypass and duodenal switch patients. As noted above, “any patient on a PPI or H2 Inhibitor should not be prescribed iron salts”. Moving on to the absorption surfaces for iron salts knowing that less than 8% has been digested and converted to the type of iron our body can absorb, the absorption surface has also be greatly decreased in gastric bypass patients, and virtually eliminated in the duodenal switch procedure. In addition to the decrease in absorption surface there is the issue of increased motility (the length of time food is in contact with the absorptive surface). So less than 8% is digested and converted, less still is absorbed, what is not converted or absorbed travels through the colon and excreted as a black tarry stool and flushed fortifying the sewer system.
Heme and polysaccharide irons are digested and absorbed in the second segment of the small intestine which in many cases remains intact, granted motility does remain an issue however the bioavailability of the iron means more of a chance of it being absorbed.
Many patients go to their physician complaining of what is referred to as the triad of Iron Deficiency (Chronic fatigue, Irritability, and Difficulty concentrating). The doctor will do a CBC to check for anemia (stage three iron deficiency) which may come back as normal. Seldom do they check an iron panel, (which would indicate Stage two iron deficiency) or a Ferritin Level (which would identify a stage one iron deficiency). Prolonged use of the wrong iron will deplete the iron in your bone marrow and finally the stores in your liver at which time you will finally show to be anemic in the CBC. The triad of iron deficiency appears in stage one iron deficiency, if acted upon anemia needs never to occur. So the choice is as always yours, you can take the appropriate iron now, speak to your doctor about why iron salts don’t work for you now or wait until you are anemic and need iron infusions and/or blood transfusions in the future. While waiting to deteriorate to a stage three iron deficiency your symptoms will escalate, exercise intolerance, insomnia, hair loss, brittle nails…
Finally I would like to publically disclose that I do work for Biosyent as a professional consultant. I was hired after they witnessed a talk I gave on iron deficiency in the bariatric patient to an Ontario Bariatric Event last October. Many who know me know I have been promoting the use of non-salt irons in both the bariatric and general population since 2009. Biosyent also is the financial backer of my new blog “The Iron Maiden”. Med Futures, the manufacturer of the only heme iron available in Canada (Proferrin) has provided a financial stipend for the development of an algorithm to help doctor identify and treat iron deficiency before it progresses to anemia in collaboration with another nurse working in the field of blood conservation. I have received funding for various presentations on the topic of iron deficiency and its treatment to professionals and patient interest groups across North America.
