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Letter to the Editor
Oral iron as treatment for iron deficiency: Should it always be the first choice?
Hierro oral como tratamiento de la ferropenia: ¿debe ser siempre la primera elección?
Carlos Jericó Albaa,d, José Antonio García Erceb,c,d,
Corresponding author
jagarciaerce@gmail.com

Corresponding author.
a Servicio de Medicina Interna, Hospital Sant Joan Despí-Moisés Broggi, Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Spain
b Banco de Sangre y Tejidos de Navarra, Servicio Navarro de Salud-Osasunbidea, Pamplona, Spain
c Grupo de Trabajo de la Sociedad Española de Transfusión Sanguínea «Hemoterapia basada en sentido común», Spain
d Grupo Multidisciplinar para el Estudio y Manejo de la Anemia del Paciente Quirúrgico, Spain1
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with interest the recent editorial by Dr Beneitez<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> and the comments in a responding letter by Dr Prieto de Paula et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Therein the recommended initial route for iron supplementation in iron deficiency&#44; with or without anaemia&#44; should be oral&#46; However this may be insufficient or ineffective in different clinical situations&#44; especially when a rapid repletion of iron deposits is required to stimulate erythropoiesis&#44; correct secondary anaemia and reduce transfusion risk&#44; or in patients affected by chronic inflammatory diseases in which the capacity for duodenal iron absorption is significantly reduced&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A large number of commercial oral iron formulations are available&#44; with ferrous salts being considered the first line of choice over ferric salts&#44; due to their apparent superior bioavailability at a lower cost&#46; However&#44; we are unaware of the existence of randomised clinical trials that have clearly demonstrated these pharmacokinetic differences or changes in the incidence of adverse effects&#46; Similarly&#44; although there are no studies to confirm the most suitable daily dose&#44; the common recommendation is 100&#8211;200<span class="elsevierStyleHsp" style=""></span>mg of elemental iron per day&#44; as shown in different clinical guidelines and drug agency recommendations&#46; These recommended daily doses greatly exceed the absorptive capacity of the intestine for iron&#44; that is &#40;10&#8211;20<span class="elsevierStyleHsp" style=""></span>mg a day&#41; and additionally it causes a marked increase in digestive side effects&#44; such as abdominal pain&#44; diarrhoea or constipation&#44; as a result of the greater elimination of non-absorbed iron salts&#46; In this respect&#44; several recent studies&#44; although all were observational&#44; have recommended the use of lower doses of oral iron &#40;40&#8211;80<span class="elsevierStyleHsp" style=""></span>mg per day&#41;&#44; dividing the dose so as to administer it twice a day&#44; and even recommending the administration of this dose every other day&#46; This can thus maximise absorption by reducing the effect of the absorbed iron on the hepcidin expression&#44; improving the adherence to treatment and reducing gastrointestinal adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In addition&#44; the intake of foods that are very common in our environment&#44; such as coffee&#44; milk and phytates &#40;present in whole grains and legumes&#41;&#44; and which are frequently taken at breakfast&#44; markedly reduce the absorption of oral iron&#46; The same happens with commonly used drugs&#44; such as proton pump inhibitors&#44; antacids or tetracyclines&#46; Therefore the usual recommendation is to take oral iron preparations separate to foods and drugs to favour their absorption&#46; However this is an accepted fact that is not clearly proven&#44; and it is associated with a marked increase in gastrointestinal adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Another point to consider about oral iron treatment is the possible confusion between its digestive side effects and the symptoms of pathologies that associate iron deficiency&#44; such as inflammatory bowel disease&#44; or the interference of the elimination of the non-absorbed remains of iron salts in diagnostic or therapeutic digestive endoscopic studies&#44; or with the detection of blood remains in patients with digestive pathologies that associate recurrent haemorrhaging&#44; such as intestinal angiodysplasias&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; the evaluation of the efficacy of oral iron treatment is of great importance&#44; as an increase of 1&#8211;2<span class="elsevierStyleHsp" style=""></span>g&#47;dL of haemoglobin at 2&#8211;4 weeks of treatment is expected&#44; if treatment is complied with&#46; Failure to respond to the treatment in the case of confirmed iron deficiency makes a study of the causes of this refractoriness mandatory&#44; and rather than increasing the dose of ferrous salt or changing the oral iron preparation&#44; perhaps i&#47;v iron treatment could be considered as an alternative&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Therefore&#44; oral iron may be the first therapeutic option for iron deficiency in patients with mild-moderate iron deficiency anaemia&#44; who do not have previous intolerance nor refractoriness to oral iron&#46; However&#44; in various clinical situations that present iron deficiency&#44; with or without anaemia&#44; treatment with i&#47;v iron becomes the most appropriate option for treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In this regard&#44; the possible although very infrequent adverse reactions to i&#47;v iron should be taken into account&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> But with a correct selection of patients&#44; and with the i&#47;v iron administered according to the drug agency recommendations&#44; the reluctance of professionals to use i&#47;v iron when indicated should be reduced&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authorship</span><p id="par0035" class="elsevierStylePara elsevierViewall">Shared authorship&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">Dr&#46; Jeric&#243; Alba&#58; He has given lectures and received fees as a consultant for Bial&#44; Vifor Pharma Espa&#241;a and Zambon&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Dr&#46; Garc&#237;a Erce&#58; He has given lectures&#44; chaired conference panels and seminars and organised courses with scholarships or financing for Alexion&#44; Amgen&#44; Braun&#44; Celgene&#44; Ferrer&#44; GSK&#44; Inmucor&#44; Jansen&#44; Novartis&#44; Octapharma&#44; Sanofi&#44; Sandoz&#44; Terumo&#44; Vifor&#44; Zambon&#46;</p></span></span>"
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Article information
ISSN: 23870206
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos