Infusion longer lasting and faster acting than iron supplements, finds Tanzania study

01 Dec 2020 --- Iron infusion can be more effective than common iron supplements to treat women with iron-deficiency anemia after childbirth in low-income settings in sub-Saharan Africa.

In a new Lancet-published study, researchers from the Swiss Tropical And Public Health Institute (TPH) and the Tanzanian Ifakara Health Institute assessed the safety and efficacy of intravenous iron substitution with ferric carboxymaltose versus oral iron tablets.

They found that iron infusion was not only safe but yielded a faster, more durable hemoglobin response than oral iron in their research in Bagamoyo and Dar es Salaam. 

Moreover, the differences in the restoration of iron stores were “even more important than expected,” co-author Dr. Fiona Vanobberghen from the Swiss TPH, tells NutritionInsight. 

“The women who received iron infusions had on average good ferritin levels even one year after receiving treatment, but only a low proportion of women who were given oral iron tablets achieved such restoration.”

Intravenous versus oral supplementation
Childbirth is a “very vulnerable time,” warns Vanobberghen, especially when medical care is limited and brief.

To tackle iron-deficiency anemia, iron supplements are often a go-to option because they are much cheaper than intravenous supplementation. 

“However, the difference in efficacy is clear,” senior author Dr. Sandrine Meyer-Monard, independent hematologist, also tells NutritionInsight.

At six weeks, 80 percent of participants in the intravenous iron group had normalized hemoglobin concentrations, compared to 51 percent in the oral iron group. 

Iron infusions help reduce iron-deficiency anemia in low-income settings. (Credit: Danielle Powell, Swiss TPH)Why not increase tablet dosage?
Oral iron treatment consisted of three 200 mg dried ferrous sulfate tablets containing 60 mg of elementary iron and 5 mg of folic acid every morning. This is the “optimal dose” for iron deficiency, says Meyer-Monard.

When asked if increasing the dosage would help the tablets achieve similar results to the intravenous group, she replies: 

“Even this dose often leads to side effects, mostly gastrointestinal symptoms, leading to poor compliance. Higher doses have not been proven to be more effective and toleration is worse.”

That does not necessarily mean that there is no place for oral iron supplements. “Oral iron supplementation in sufficient doses and accompanied by intensive counseling to avoid poor compliance is still a valuable alternative,” explains Meyer-Monard.

However, the study shows that even in a clinical trial, it is difficult to achieve good compliance. This was also in line with experiences from everyday practice in resource-rich settings, where intravenous iron supplementation is broadly used.

Applicable to low-income settings
The research authors detail that intravenous iron can be delivered safely in district hospitals in resource-limited settings.

The study emphasizes that ferric carboxymaltose can be stored without refrigeration at room temperature (<30°C) and has a shelf life of three years from manufacture. 

“With ferric carboxymaltose, the total required dose can be delivered in just one or two doses and without a test dose as is needed for iron sucrose,” the study details. 

Participants with (A) normalized hemoglobin concentration of over 115 g/L and (B) normalized ferritin concentration of over 100 μg/L. Moreover, hospital attendance for delivery is used to provide medical prevention strategies such as vaccinations and also offers an ideal opportunity to deliver a straightforward and effective iron supplementation strategy before discharge, after which individuals might become lost to medical care.

Intravenous iron is already a standard treatment in various settings of iron deficiency in resource-rich settings. 

Before it can become a standard recommendation in low-income countries, the drug must first be registered to be made available. 

“A physician aims to and shall give their patient the best available treatment. Extensive registration and therefore uptake will help to lower costs so it can be affordable for a much wider population,” Meyer-Monard maintains.

Beyond childbirth
If parents in low-income settings can be more in control of their health, they are more likely to provide better health standards for their children, opening doors to education and economic opportunities. 

“The socio-economic gain of an effective treatment also has to be considered and should be the focus of further studies,” Vanobberghen pinpoints. 

Last week, the International Alliance of Dietary/Food Supplement Associations (IADSA) launched an online platform highlighting how important iron supplementation can be in reducing anemia. 

Specifically, the resource aims to help halve rates of women of reproductive age by 2025, considering anemia carries a greater risk for both pregnant women and their fetuses.

In strides to make more affordable iron supplements, Nestlé Research developed a highly absorbable iron compound that can be used to effectively fortify bouillon to address deficiency in low-income countries.

By Anni Schleicher