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This guide provides a structured approach to iron supplementation counselling in an OSCE setting. For more information on iron deficiency anaemia, see the Geeky Medics guide here.
Background
Before starting the consultation, review the patient’s blood results to ensure that a recent full blood count and iron profile are available.
Review the haemoglobin (Hb) and mean cell volume (MCV); a low Hb (< 130 in adult males or < 115 in adult females) confirms the patient is anaemic.1
Iron-deficiency anaemia typically presents with microcytic anaemia (i.e. an MCV of < 80 fL).
If a patient has haemochromatosis, iron supplementation is contraindicated due to the risk of organ damage.
Iron studies
Iron studies include the following investigations:
- Ferritin: this iron storage protein is the best marker of iron stores in the body. If ferritin is low, then your patient is iron-deficient. However, if it is high, it doesn’t necessarily mean they have too much iron, as ferritin is also an acute-phase reactant that can be raised in inflammatory states (e.g. infection, trauma).2
- Transferrin: this protein, made in the liver, helps to bind iron to blood plasma for transport around the body, and often tends to be increased in iron deficiency.
- Serum iron level: as the name suggests, this is the amount of iron in the blood. As you might expect, this will be low if a patient is iron deficient.
- % iron saturation: the ratio of serum iron to total iron-binding capacity, in other words, how much of the space available for carrying iron is actually being utilised.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain the reason for the consultation:
- “I’d like to talk to you about iron supplementation, would that be ok?”
- “Please feel free to interrupt me at any point, if you have any questions.”
Ideas, concerns and expectations
An important part of counselling a patient on any new medication is exploring their ideas, concerns and expectations (ICE).
Ideas
- “Have you heard of iron supplements before?”
- “Do you know why iron is important for health?”
- “Have you ever been told that you have low iron before?”
Concerns
- “Is there anything that worries you about taking iron?”
- “Have you any concerns about your physical health at the moment?”
Expectations
- “Do you understand the benefits of taking iron supplements?”
- “What are you hoping iron supplements will do for you?”
The role of iron in the body
Iron is essential for a wide range of functions in the human body including:3
- Transport of oxygen in red blood cells (as part of haemoglobin)
- Providing oxygen to muscles, especially skeletal and cardiac muscle (as part of myoglobin)
- Acting as a co-factor for important enzymes
- Playing a role in immune response
Example
“Iron plays a key role in lots of different processes within the body including allowing your red blood cells to transport oxygen to the relevant tissues and helping your immune system fight infections.”
Symptoms of iron-deficiency anaemia
Explain to the patient that it’s important to treat iron deficiency as it can lead to anaemia, which is associated with a wide range of symptoms such as:
- Fatigue/weakness
- Shortness of breath
- Palpitations
- Headache
- Pale skin
- Dizziness
- Feeling cold
- Chest pain
Example
“If left untreated, iron-deficiency anaemia can cause a wide range of symptoms including feeling tired, out of breath, dizzy and palpitations. It can also cause you to experience headaches and result in the colour of your skin becoming paler than usual.”
Causes of iron-deficiency
The main causes of iron deficiency include:
- Blood loss
- Lack of iron in the diet
- Inability to absorb iron (e.g. coeliac disease, inflammatory bowel disease)
- Increased iron demand (e.g. pregnancy, childhood, adolescence)
You’ll need to tailor your explanation to the cause of the patient’s iron deficiency, some examples are included below.
Example
“Your iron levels are low because of the blood loss you experienced during labour. Once we’ve topped up your iron stores with some iron supplements, you should be able to stop taking them.”
“Your iron levels are low because your current diet does not include any foods that contain a large amount of iron. We’ll be using iron supplements to replenish your iron stores, whilst you try and incorporate more iron into your natural diet.”
“Your iron levels are low because you have coeliac disease, which reduces the ability of your bowel to absorb iron from the foods you eat. You’ll most likely need to continue your iron supplements long term.”
When and how to take iron supplements
When to take iron supplements
Explain to the patient that iron is absorbed best if taken an hour before a meal, however, iron can irritate the stomach of some people, causing them to feel nauseated, in which case iron may be best taken just after a meal.
Example
“To absorb as much iron as possible you should take the iron tablet an hour before a meal.”
“Unfortunately, in some cases, iron can irritate the stomach, causing people to feel nauseated. In these cases, we recommend taking the iron tablet just after a meal to reduce the side effects, at the cost of a reduction in the amount of iron absorbed.”
How to take iron supplements
Explain the relevant iron supplement regimen to the patient, which will differ depending on the indication for supplementation and the form of iron.
The most common form of oral iron supplement is ferrous fumarate.
Prophylactic supplementation
Prophylactic iron supplementation may be indicated for patients with borderline iron levels who have risk factors for iron deficiency such as poor dietary intake or malabsorption. This typically involves taking an iron supplement once a day.
Example
“As a result of your dietary preferences, you’re likely to struggle to maintain an adequate level of iron. As a result, I think long term iron supplementation would be of benefit. This would involve taking one iron tablet a day to maintain your iron levels in the future.”
Treatment dose supplementation
Treatment dose iron supplementation may be indicated for patients who have established iron deficiency to replenish their iron stores. Typically treatment dose iron supplementation is prescribed for three to six months and iron levels are then re-assessed to decide if long term prophylaxis is required (due to ongoing risk factors) or if treatment can be stopped completely (e.g. if a patient had a single episode of blood loss which has now been treated/resolved).
Example
“As a result of the blood you lost when you experienced a bleed from your bowel, your iron stores are currently very low. Therefore, I think you’ll need a 3-6 month course of high dose iron supplementation to replenish your iron stores and we can then check your levels and consider if you need to continue iron tablets long term.”
Alternative routes of administration
Intravenous iron administration is only indicated in cases of severe iron deficiency where the oral route is unlikely to be tolerated or would take too long to replenish iron stores.7
Monofer (iron isomaltoside) is a form of iron that can be administered via intravenous infusion. The dose depends on the patient’s weight. 8
IV iron administration is associated with a risk of anaphylaxis, so all patients need to be monitored during an infusion in a setting with adequate resuscitation facilities.
Side effects of oral iron
Common side effects of taking oral iron can include:5
- Nausea
- Constipation
- Diarrhoea
- Dark-coloured stools
- Metallic taste
Make sure to explain to the patient that many of the side effects will reduce with time but that they should get in touch if they are struggling to cope with them.
Example
“As with all medications, iron tablets are associated with some side effects, most of which become less of an issue over time. Some of the most common side effects include feeling sick after taking the medication, constipation and/or diarrhoea. You will most likely also notice that your bowel motions appear a dark colour due to the presence of iron. Some people also experience a metallic taste in their mouth. If these symptoms become difficult to deal with, you should get back in touch and we can re-consider your iron treatment options.”
Dietary advice
Increasing iron intake
As well as prescribing oral iron supplementation, it is important to make patients aware of ways in which they can increase their dietary iron intake. Often, patients will be able to maintain adequate iron levels by altering their diet.6
Foods rich in iron include:
- Red meat (especially beef, lamb and pork)
- Leafy vegetables (spinach, broccoli and cabbage)
- Dried fruit (figs, apricots and dates) and nuts (brazil nuts, hazelnuts and almonds)
Example
“In the long term, you may be able to maintain adequate levels of iron by incorporating iron-rich foods into your diet. Some examples of foods with high levels of iron include red meat, spinach, broccoli, cabbage, dried fruits and nuts.”
Vitamin C
Vitamin C (ascorbic acid) combines with iron to form an iron chelate complex, which makes iron more soluble and results in increased uptake of iron in the small intestine.
There are tablets you can prescribe which combine oral iron with ascorbic acid, but it’s usually easier (and a lot tastier) for your patients to just eat some citrus fruit or drink pure orange juice.
Example
“It’s also important that you have enough vitamin C in your body as this helps you to absorb iron effectively. Citrus fruits and orange juice are things you can eat or drink to maintain adequate levels of vitamin C. If you struggle to incorporate vitamin C into your diet, we can also consider oral supplements.”
Closing the consultation
Summarise the key points back to the patient, to make sure they understand the importance of having adequate iron levels and the side effects to look out for and report to their GP.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Example
“Just before we finish, I’d like to quickly summarise the conversation we’ve just had, to make sure everything has made sense. We’ve discussed the role of iron in the body, the symptoms of iron deficiency and ways to incorporate more iron into your diet. We’ve also covered how to take iron supplements and the potential side effects.”
“Do you have any questions about any of that? I realise we’ve covered quite a lot of information in a short amount of time.”
“Here is a leaflet that summarises everything we’ve discussed today, and if you have any other questions after reading it please feel free to get in touch.”
“Thank you for your time today.”
Editor
Dr Chris Jefferies
References
- Gloucestershire Hospitals NHS Foundation Trust. Haematology Reference Ranges. Available from: [LINK]
- The BMJ. Interpreting raised ferritin levels. Published in 2015. Available from: [LINK]
- Open Educational Resources. Iron Functions. Available from: [LINK]
- NICE Guidelines. Iron-deficiency anaemia. Available from: [LINK]
- Patient.info. Iron supplements. Published in 2020. Available from: [LINK]
- BDA. Iron: Food Fact Sheet. Published in 2020. Available from: [LINK]
- Transfusion Guidelines. Parenteral Iron. Published in 2014. Available from: [LINK]
- Northern Devon Healthcare NHS Trust. Monofer Infusion for iron deficiency in adults. Published in 2020. Available from: [LINK]
