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7.6.

2 Other drugs for anaemias

(eg <4–6 weeks before elective surgery) or when


7.6.2 Other drugs for anaemias oral treatment is not possible, not tolerated or not
effective (eg haemodialysis).
Iron deficiency anaemia Blood transfusion may be necessary in severe
Rationale for drug use anaemia (eg symptomatic despite iron treatment) or
Prevent or reverse complications of anaemia and when it may destabilise cardiovascular disease. Iron
iron deficiency, including lethargy, dyspnoea and treatment is still required to replenish iron stores.
decreased effort capacity. Special cases
Before starting treatment Renal failure
Establish that anaemia is due to iron deficiency. Give iron supplementation when anaemic, accord-
Serum ferritin is the most specific test for ing to iron saturation and serum ferritin, on advice
evaluating iron stores. Be aware that a normal of a renal physician.
serum ferritin concentration may occur with iron Pregnancy
deficiency in infective, inflammatory, malignant or Routine iron supplementation is not recom-
hepatic disease and in the elderly, requiring mended. Give supplementation only in women
assessment of other parameters, eg serum with low–normal haemoglobin where investiga-
transferrin saturation. tion shows iron deficiency.

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Assess for possible causes:
Duration of treatment
– blood loss (eg GI, heavy menstrual bleeding Continue oral treatment for at least 3 months
(p 808), drugs (eg NSAIDs, anticoagulants), (2–3 months in children) after the haemoglobin
7 blood donation, hookworm infection) level has returned to normal in order to replenish

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– increased requirements (eg infants, iron stores. Avoid unnecessary long-term use of
adolescents, pregnancy, breastfeeding) iron.
– malabsorption (eg coeliac disease, gastric Practice points
surgery) • do not wait for investigations before starting
– inadequate dietary iron.

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iron; if needed, iron can be temporarily stopped
Diet for investigations such as colonoscopy
Dietary changes alone will be insufficient for • expect haemoglobin to rise 20 g/L over 3–4 weeks
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treatment of iron deficiency anaemia. Give dietary • monitor haemoglobin for response to treatment;
advice if diet is a contributing factor. Encourage if no response detected after 3–4 weeks, review
increased intake of haem iron (red meat, chicken, the diagnosis and consider noncompliance or
fish) and non-haem iron (grains and cereals, coexisting problems, eg renal impairment,
legumes, eggs and vegetables) with vitamin C chronic inflammation, malabsorption, ongoing
(citrus fruit, broccoli, capsicum) to promote the occult bleeding. Specialist advice may be
absorption of non-haem iron. required
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A patient information leaflet can be found at • monitor complete blood count and serum ferritin
www.gesa.org.au/resources/patients/iron-deficiency. 1–2 weeks after treatment is ceased, then every
Treatment 3 months for 1 year
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See also Table 7–5 Oral products for treatment of iron • iron absorption (from the diet or supplements)
deficiency anaemia p 342 may be reduced by high intake of phytate (eg
Oral iron is first-line treatment for most patients. whole grain cereals), tea, coffee or calcium.
Consider parenteral iron for malabsorption, non- However, evidence regarding foods reducing
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compliance, if rapid iron replacement is needed iron absorption is poor and confusing

Table 7–5 Oral products for treatment of iron deficiency anaemia


Brand® & form (PBS) Iron salt (other active ingredient) Elemental iron Usual dose1
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ferrous sulfate 270 mg


Fefol capsule 87.4 mg 1–2 daily
(folic acid 300 mcg)
ferrous fumarate 310 mg
Ferro-F tablet (RPBS) 100 mg 1–2 daily
(folic acid 350 mcg)
Ferro-tab tablet (RPBS) ferrous fumarate 200 mg 65.7 mg 2–3 daily
Ferro-grad C, Ferrovance C, controlled ferrous sulfate 325 mg 105 mg 1–2 daily
release tablet (ascorbic acid 500 mg)
Ferro-grad, Ferrovance, controlled ferrous sulfate 325 mg 105 mg 1–2 daily
release tablet
adult: 15–30 mL daily
Ferro-Liquid oral liquid (PBS) ferrous sulfate 30 mg/mL 6 mg/mL child: 0.5–1 mL/kg daily

FGF controlled release tablet ferrous sulfate 250 mg 80 mg 1–2 daily


(folic acid 300 mcg)
Maltofer tablet iron polymaltose 370 mg 100 mg 1–2 daily
adult: 10–20 mL daily
Maltofer oral liquid iron polymaltose 37 mg/mL 10 mg/mL child: 0.3–0.6 mL/kg
daily
1 see also Dosage p 343 in Iron

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7.6.2 Other drugs for anaemias

Dosage
Iron All doses below are expressed in terms of
See also Iron deficiency anaemia p 342 elemental iron.
For drug interactions see Iron p 1013 1 mg elemental iron is approximately equivalent
to:
Mode of action
– ferrous fumarate 3 mg
Essential element required for the formation of
haemoglobin and myoglobin. – ferrous sulfate (dried) 3 mg
Indications
– ferrous sulfate (as liquid) 5 mg
Prevention and treatment of iron deficiency – iron polymaltose 3.7 mg.
anaemia Treatment of iron deficiency anaemia
Fixed-dose combination with folic acid See also Table 7–5 Oral products for treatment of iron
deficiency anaemia p 342, Duration of treatment
Prevention and treatment of iron and folate p 342
deficiency, particularly during pregnancy Oral
Precautions See also Practice points below.
Anaemia not due to iron deficiency—contraindicated. Adult, oral 100–200 mg daily.
Allergy to a parenteral iron product, eg iron polymaltose Child, oral 3–6 mg/kg (maximum 100–200 mg)

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—parenteral use generally contraindicated. daily.
However, in certain circumstances, eg chronic Parenteral
kidney disease, an alternative (eg iron sucrose)
Dose and administration according to local 7
may be considered; seek specialist advice.
protocol or product information (note, for iron

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Haemochromatosis, haemosiderosis—contraindicated. polymaltose, the preferred route is by slow IV
Transfusion-dependent anaemias—risk of iron infusion, see Parenteral in Practice points
overload; avoid iron supplementation. below).
Pregnancy Prevention of iron deficiency in children

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Safe to use. If possible, avoid parenteral iron Encouraging a diet rich in iron-containing foods is
products, particularly in the first trimester, due to preferable to using supplements.
risk of hypersensitivity reactions (some manufac- Child 4–12 months and breastfed, oral 1 mg/kg daily.
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turers of parenteral iron contraindicate use in the
Child >12 months (at risk, eg poor or restricted diet),
first trimester).
oral 1–2 mg/kg (up to 15–30 mg) daily.
Breastfeeding
Pregnancy, iron deficiency without anaemia
Safe to use; maternal supplements do not
Adult, oral 60–120 mg daily. See Practice points
significantly change the breast milk concentration
below.
of iron.
Fixed-dose combination with folic acid
Adverse effects
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For additional information see Folic acid p 343


Oral Oral, 1 or 2 tablets or capsules daily.
abdominal pain, nausea, vomiting, constipation,
diarrhoea (all dose-related), black discolouration of Counselling
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faeces Oral
Oral liquid: temporary black discolouration of teeth Ferrous salts are absorbed best if taken on an empty
stomach 1 hour before, or 2 hours after, food. If it
Parenteral upsets your stomach it can be taken with or shortly
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taste disturbance, nausea, vomiting, headache, after food. Avoid taking with tea or coffee.
hypophosphataemia, arthralgia, myalgia, tachy-
Iron polymaltose is absorbed best if taken during or
cardia, changes in BP, chest pain, fever, broncho-
immediately after a meal.
spasm, rash, hypersensitivity (below)
This medicine may cause your stools to turn black.
Injection site: permanent skin staining (particularly
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IM), pain and inflammation (IM) Tablets, capsules: swallow whole; do not crush or
chew.
Iron overload (haemosiderosis) may occur with
long-term use of parenteral iron. Liquid: dilute with water (can dilute Maltofer® with
juice) and drink through a straw to prevent dis-
Hypersensitivity reactions colouration of your teeth and follow each dose with
Fatal anaphylactic and anaphylactoid reactions a drink of plain water.
have occurred, including those with a negative
test dose or who tolerated a previous dose. Risk Practice points
is increased in patients with allergies (including • oral and parenteral iron should not be used
drug allergies), autoimmune or inflammatory together
conditions (eg rheumatoid arthritis). Monitor Oral
closely for at least 30 minutes after completing • all ferrous and ferric salts are effective; ferrous
infusion. If reaction occurs, stop infusion salts are better absorbed than ferric salts (iron
immediately. polymaltose)

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7.6.2 Other drugs for anaemias

• small, short-term studies in iron-depleted tab, iron 65.7 mg (as ferrous fumarate 200 mg), 60, Ferro-tab,
women suggest: PBS-R1/RPBS
– compared to giving oral iron 120 mg once tab, iron 100 mg (as iron polymaltose 370 mg), 30, Maltofer
daily, dividing the dose (60 mg twice daily) tab, iron 105 mg (as dried ferrous sulfate 325 mg) (controlled
release), 30, Ferro-grad, Ferrovance
does not increase total iron absorbed oral liquid, iron 6 mg/mL (as ferrous sulfate 30 mg/mL),
– a low dose (eg 60 mg) on alternate days may 250 mL, 1, Ferro-Liquid, PBS
optimise absorption compared to dosing on oral liquid, iron 10 mg/mL (as iron polymaltose 37 mg/mL),
150 mL, 1, Maltofer
consecutive days inj, iron 20 mg/mL (as iron sucrose), 5 mL, 5, Venofer,
• it is uncertain whether an alternate day regimen PBS/PBS-A2
(similar to above) will be adequate to treat inj, iron 50 mg/mL (as ferric carboxymaltose), 2 mL, 10 mL, 1,
moderate-to-severe iron deficiency anaemia 5, Ferinject, PBS[2x10 mL]
inj, iron 50 mg/mL (as ferric carboxymaltose), 20 mL, 1,
• GI adverse effects may be reduced by: Ferinject, PBS
– starting at a low dose and gradually inj, iron 50 mg/mL (as iron polymaltose), 2 mL, 5, Ferrosig,
increasing after 2–4 weeks or by dosing less PBS/PBS-A2
inj, iron 50 mg/mL (as iron polymaltose), 2 mL, 5, Ferrum H
frequently (eg on alternate days) inj, iron 100 mg/mL (as ferric derisomaltose), 5 mL, 1,
– taking with meals (but may reduce absorp- Monofer, PBS[3x5 mL]
tion) inj, iron 100 mg/mL (as ferric derisomaltose), 10 mL, 1,

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Monofer, PBS
• the iron content in multivitamin-mineral
products is too low to treat iron deficiency Fixed-dose combinations
• it is claimed that controlled release products tab, iron 80 mg (as dried ferrous sulfate 250 mg), folic acid
7 have fewer GI adverse effects, but they may also
300 mcg (controlled release), 30, FGF

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cap, iron 87.4 mg (as dried ferrous sulfate 270 mg), folic acid
have lower bioavailability 300 mcg, 30, Fefol
Parenteral tab, iron 100 mg (as ferrous fumarate 310 mg), folic acid
350 mcg, 60, Ferro-F, PBS-R1/RPBS
• consider parenteral iron only if oral iron is tab, iron 105 mg (as dried ferrous sulfate 325 mg), ascorbic
inadequate or inappropriate acid 500 mg (controlled release), 30, Ferro-grad C,

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• for iron polymaltose, IM route is generally Ferrovance C
avoided (causes pain and permanent skin 1 Aboriginal or Torres Strait Islander patients, see PBS
2
staining and is no safer than IV infusion); only iron deficiency anaemia in chronic haemodialysis patients,
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consider if IV route impractical, eg in remote see PBS
areas
• use IV iron in chronic kidney disease, including
dialysis
• facilities for management of anaphylaxis should
be available
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