While more research is needed to implement a new standard of care, the first few studies on iron supplementation and hepcidin have had promising results. This new research can lead to a positive discussion between patient and provider. It can also give us an alternative to offer if patients simply cannot stick to the standard dosing regimen. Regarding our own education, it offers physicians a new insight into a decades-old condition.
By Anna Augustin, DO, PGY-2
Who is at risk?
Even without clinical signs of anemia, iron deficiency can have a negative impact on an individual. Iron plays an essential role in cognitive development, immune function, viable gestation and normal growth.
With these important considerations in mind, it is no surprise that the highest groups at risk for iron deficiency are young children and pregnant women.Consuming iron fortified foods or supplementing products with iron is considered the first line of deficiency treatment and prevention. In industrialized parts of the world, education and dietary coaching may be an adequate first line of therapy. In resource limited areas, however, increasing iron intake through diet alone is not feasible and the mainstay of treatment is oral supplementation.
What about oral supplements?
Oral iron is recommended for both iron deficiency anemia patients as well as groups at high risk for iron depletion that cannot supplement this element through diet alone. However, the side effects of oral iron supplementation can deter patients from adhering to a typical once-daily treatment plan. These side effects include nausea, vomiting, constipation, diarrhea and dark stools. In patients requiring increased dosages, these side effects become exponentially more severe and treatment adherence rates are low. Fortunately, some new studies have emerged that may make treatment of this common condition more tolerable to both the patient and their GI tract.
How has hepcidin affected iron supplementation?
With the discovery of hepcidin’s long half-life, the utility of daily or multi-dosing regimens may not necessarily coincide with underlying iron physiology. In line with prior guidelines, most iron deficient individuals are placed on 60 mg of iron daily (in children, 2 mg/kg) for a duration of at least three months. Some patients are even placed on twice-daily dosing regimens. With these high levels of iron intake, hepcidin levels increase with each dosing. As hepcidin increases, the total amount of iron absorbed becomes minimal while the adverse gastrointestinal side effects of oral iron remain constant. It is no surprise that patients placed on these high dose regimens often discontinue treatment due to adverse effects. Ultimately, treatment adherence rates fall with increased oral supplementation.
What has new research shown?
New research has indeed confirmed that after patients take an oral iron supplement, hepcidin levels increase and impair absorption of the subsequent daily dose. Recent trials have started to compare daily dosing to alternate day iron supplementation. Although the studies have been small, they have shown that total iron absorption is equivocal when comparing daily and alternate day dosing. Alternate day iron supplementation has been shown to be as efficacious as a daily dosing regimen. These pilot studies have opened a new frontier in research opportunities involving the most common nutritional deficiency affecting our world.
What is the bottom line?
As physicians, awareness of an alternative to traditional iron supplementation can help us connect with our patients on many levels. Patients can feel overwhelmed at times when taking multiple pills, and alternate-day dosing can help alleviate any anxiety about medication burden an individual may have. Additionally, it can help lower medication cost by halving the required dosing amount for uncomplicated iron deficiency. Although not yet proven in studies, alternate day dosing can theoretically lower gastrointestinal side effects and increase treatment compliance rates. For patients struggling with unwanted treatment side effects, a new alternative can offer a patient some needed reprieve regarding side effect profiles. In discussing viable treatment alternatives and addressing patient concerns, the family doctor can foster a greater physician-patient relationship and bolster patient compliance to a needed treatment plan.
While more research is needed to implement a new standard of care, the first few studies on iron supplementation and hepcidin have had promising results. This new research can lead to a positive discussion between patient and provider. It can also give us an alternative to offer if patients simply cannot stick to the standard dosing regimen. Regarding our own education, it offers physicians a new insight into a decades-old condition. With the ever-changing world of research, it shows us how continued questioning can positively contribute to our understanding of disease. Most importantly, it gives us a reason to stay current on the latest research: our patients will ultimately reap the benefits.