Options to improve absorption and tolerability of oral iron supplements

Improve absorption^*

Avoid enteric coated or timed-release products
Take separately from foods that may impair absorption
- Meals
- Coffee
- Eggs
- Oxalates (spinach, kale, beets, nuts, chocolate, tea, wheat bran, rhubarb, strawberries, some herbs)
- Phytates (soy, fiber, cereals, some nuts, beans, lentils, peas)
- Tannates (tea, cocoa, some spices, some berries)
- Calcium (milk, yogurt, cheese, some greens, fish)
Minimize exposure to medications that decrease gastric acidity
- Antacids (take iron 2 hours before or 4 hours after the antacid)
- Histamine receptor blockers (discontinue if no longer needed)
- Proton pump inhibitors (discontinue if no longer needed)
Take with foods/supplements that may increase absorption
- Vitamin C
- Orange juice

Improve tolerability*

Use a titratable (eg, liquid) form^¶
Change from every-day to every-other-day dosing
Dietary modifications (eg, take with food)^Δ
Take a product with less elemental iron^Δ
Use a stool softener or laxative

Patient values and preferences thus play a large role in the decision to use 1 or more of these interventions. The magnitude of benefit for many of these interventions and the best way to implement them (eg, how much time to wait before or after eating) has not been well-established and may differ in different patient populations (eg, those with iron deficiency anemia versus those with iron deficiency and normal hemoglobin). Absorption is inferred from improvements in hemoglobin and ferritin.

* If the hemoglobin does not increase or tolerability does not improve, consider switching to intravenous iron. There may be other reasons for persistent anemia and/or iron deficiency that require additional evaluations or interventions, such as:

Non-adherence
Ongoing blood loss
A concomitant cause of anemia that does not respond to iron (eg, vitamin B12 deficiency, thalassemia, myelodysplastic syndrome)

¶ Liquid oral iron may cause tooth discoloration if some remains in the mouth after swallowing. Patients should be encouraged to swish and swallow 4 to 6 ounces (approximately one-half cup or 120 mL) of water after taking liquid oral iron.

Δ May decrease absorption/efficacy.

Graphic 142465 Version 2.0

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Options to improve absorption and tolerability of oral iron supplements