Iron-- WWYD?

So at my last visit with my surgeon he prescribed Ferrous Fumarate (324mg 2x/day). I told him I'd started taking OTC iron, and he said he wasn't fond of the OTC types because they don't absorb well in bypass patients. He mentioned a few OTC types that don't absorb well, but he didn't mention the one I was taking (carbonyl iron). 

I picked up the prescription but haven't started it yet. The script cost $23 for a 30 day supply; and the way my insurance works a 90-day supply would cost $46. That's a tad pricey for the long run (though I can afford it-- but would rather not if I have a choice.)

I've not started the prescription iron yet, I'm still taking the carbonyl iron. I was thinking of having my PCP run blood work to see if taking the carbonyl made any effect on my iron levels to see if I could continue with just that.

Or, knowing RNY's patient's long history with iron deficiencies, would you just bite the bullet and take the prescription iron?

 

 

I would ask to have a baseline test run and then think about whether the prescription iron is needed.  I did not take iron for the first five years and my levels were fine.  When they dropped the surgeon put me on Ferrous Gluconate.  My levels came back up.  Too much iron can cause problems too so I am surprised that your surgeon is prescribing without testing first. 

Bypass patients do develop deficiencies so it is something to keep an eye on.

I wasn't clear, there was a test done first, which is why he prescribed the iron. I don't have it handy at the moment, but the base range was 12 I believe, mine was at 9. When it was tested I was taking no iron supplements at all. I started the carbonyl iron just after getting that result back. Then the doc ended up prescribing the fumarate. 

Which number was 9? There's a big difference in having hemoglobin at 9, and havving ferritin at 9.

Always look at the label to see how much elemental iron is in a tablet. That's the iron you're looking to absorb. Ferrous fumarate, if I remember correctly, is 106 mg of elemental iron in a 325 mg tablet. The rest of the 325 mg is not iron, and helps to constipate you. Ferrous sulfate, I think, is 65 mg of elemental iron in a 325  mg tablet. So even less iron, and more constipating and nauseating.

The carbonyl iron I have seen has been 100% elemental iron. It is absorbed better than any of the ferrous salts, is not constipating, and doesn't cause stomach upset. The brand I use, Sundown Perfect Iron, are tiny, and have 25 mg elemental iron in a 25 mg pill. They are $4.99 for 200 pills.

Your doc has you on 2 of the ferrous fumarate per day, or about 212 mg of elemental iron. You'd need 8.5 of the tiny Sindown Perfect Iron to hit 212 mg of iron per day. So a 30 day supply of those would cost $6.38, compared to $23 for the same amount of iron in you prescription. And it's absorbed even better. I'd stick with the carbonyl.

There are a few things you can do to help iron absorption. First, take Vitamin C with your iron. 200 mg of Vitamin C for each 30 mg of elemental iron. So you'd need 1400 mg of Vitamin C, or most likely 3 of the common 500 mg Vitamin C tablets. I've seen some docs and nutritionists recommend orange juice, because we all know OJ has Vitamin C. But you'd need at least 15 glasses of OJ, depending on the brand, to get that much Vitamin C. And each glass of OJ has the same amount of sugar as full sugar Coke or Pepsi. Not good choices. Orange juice as a healthy food is one of the most brilliant marketing scams ever perpetrated on consumers.

The other things you should do to increase iron absorption is to avoid taking iron with other things. Don't take iron with calcium supplements, or with foods containing calcium, like milk, cheese, or other dairy products. Calcium blocks iron from being absorbed. Coffee and tea also decrease iron absorption. Tea blocks about 80% of iron from being  absorbed. Lots of other foods are pretty bad as well. Soy products are a major culprit.

What I do, and many others as well, is take our multivitamins at breakfast and dinner. We most often take a multi without iron, or ignore the iron if it has any. Take 500 mg of calcium citrate (citrate, not carbonate!) with the multis. Take another calcium citrate at lunch, 2 hours apart from the other doses. Then take iron and Vitamin C at bedtime, at least 2 hours after food, calcium citrate, coffee, tea, etc. That will maximize your chances of absorbing all the iron your body will absorb. Iron at night works better than morning for obvious reasons -- only hardcore coffee and tea addicts drink those beverages before bed, but most people do so in the morning.

Having said all that, there are some people after WLS, and particularly RNY, who just don't absorb oral iron very well. Besides carbonyl, heme iron is very good, but pretty pricey. But even that may not absorb well. It is common to see people needing iron infusions periodically. Oral iron can help it from plunging too fast, but won't stop the slide completely. For myself, I have to make sure I don't take too much carbonyl, as my numbers can get too high.

One final note (this got really long, sorry). KEEP TRACK OF YOUR LABWORK. GET IT IN WRITING. DON'T ACCEPT A PHONE CALL FROM SOMEONE IN THE DOC'S OFFICE THAT SAYS YOUR LABS "LOOK GOOD" OR ARE "IN RANGE." This is your health. Take control of it, just like you've done with your weight.

There are different lab tests that show iron levels. Hematocrit and hemoglobin are measures of the iron in your blood right now, working to bring oxygen to cells throughout your body. Think of hematocrit and hemoglobin like counting the money in your pocket, ready to spend.

The next most important iron lab is skipped very often, and should NOT be ignored. That is ferritin. Ferritin is iron stored, not for immediate use, but for future need. Think of it as a savings acccount. Your hematocrit and hemoglobin might be ok, but if your ferritin is low, you are in dangerous territory. Spend that money in your pocket, and you are broke.

The range on labs for ferritin is a joke. They vary a little between labs, but are usually around 12 to 300. If your ferritin gets low, you will be constantly fatigued and weak, suffer from headaches, irritability, restless leg issues, have heart palpitations. Really low iron can induce a heart attack. Some people start to get these symptoms when their ferritin gets below 50. But your doc might say you are fine with a level of 13, because it is "in range."

This is why tracking each set of labs is crucial. If your first ferritin level is 150, then 90, then 50, then 20, guess where the next one will be. Sure, you are in range now, but not for long. If you increased your oral iron when the level dropped from 150 to 90, you might be back ip to 150 now. But at 13, I would run, not walk, to a hematologist for iron infusions. Oral iron would not get it back in a good range.

I apologize for making this so long. And I apologize to pwachpie if yhis seemed like a lecture aimed at her. It wasn't. It's just that there is a lot of bad information out there, and peachpie asked the question that flipped my switch.

 

 

Wow, this is a good post! Wish my printer was working so I could print it up & put on the fridge. I still remember your money in the bank vs money in your wallet analogy from a prior post. This is good for the main boards, maybe cross post?  I think this is the most I've seen you write in 1 post & its all good. Maybe we can flip your switch more often! 

Tough luck on the people who blocked you, look at everything they'll miss!

Thanks for the detailed response Grim. I was concerned about becoming constipated as a result of the prescription iron, and since it seems like its  mostly 'fillers' then my concern seems justified. I'm not taking enough of the Sundown Iron, so I'll add a second dose later in the day. I hold off on more lab work from my PCP until I've been taking the correct dosage of iron for a bit. 

I printed my labs from surgery going forward and will make a spreadsheet tonight of the things I need to track. It'll save me from thumbing through pages of results trying to compare what was where when.

It look like ferritin was never tracked in any of my lab work. The range I said was a 9 was "Iron saturation". Its at 9%, range is 15-55. And thats a big drop from the prior lab work i have which was at 14%. I believe that was the # that prompted him to prescribe the fumarate.  

My hemoglobin and hematocrit were both within range, hemoglobin just made it @ 12.5 g/dL, base of the range is 11.1 g/dL. Hematocrit sat at 39.9% range is 34-46.6. 

 

 

 

Grim and White Dove gave excellent advice.

My PCP wanted me on the same iron you were prescribed, as she said some folks just don't absorb all iron supplements the same. But, like every other iron I have taken, with the exception of Sundown's Perfect Iron, it made me very nauseous. I couldn't continue it after about 10 days, as I'd vomit immediately.

Unfortunately, my iron levels did drop low enough to warrant iron infusions. However, if your levels are dropping and other types of iron supplements are not working, you could give it a try. However, from your post, it doesn't seem like others have been tried. If that is the case, I guess it is your decision if you want to try the prescription route first. 

Hi peachpie,

When my hair was falling out and my iron got really low I reached out to my mentor Charlie that helped me when I had surgery.  Here is what she sent me and it has worked like a charm.  Check with your doctor first :-)

 

Kathy, this works.  Liquid is best but it stains teeth so if you do this, make sure to toss the iron back or use a straw to keep if off teeth.  Try this until your next test.  I take a whole ounce every day.  We need more than the average person.  Here is a site to order liquid and it's on sale for $5 a bottle.  Good buy.  I mix it with about 2 ounces of OJ or grapefruit juice.  Makes it way easier to take.  But you can chew Vitamin C supplement with it and it's best on an empty stomach.  I just take it last thing at night then I have the 2 hours 'after' covered :)   Iron Supplement (Ferrous Sulfate) Liquid 16 oz., 1 Bottle

				Iron Supplement (Ferrous Sulfate) Liquid 16 oz., 1 Bottl... McKesson, Iron Supplement (Ferrous Sulfate) Liquid 16 oz., 1 Bottle, Betty Mills Price: $5.08 Per Bottle, MON 16162700, MON16162700, Generic OTC Meds, Minerals...
				View on www.bettymills.com	Preview by Yahoo

  Here are my iron rules.   Charlie's Iron Rules: 1.      Do not take calcium supplements or vitamins containing calcium within 2 hours either side of taking iron.  Calcium and iron bind together and leave the body with no benefit of either.  2.      Take only liquid iron and take it with a little orange juice or a chewable vitamin C....iron needs acid to absorb.  Liquid isn't as constipating as pills, but if it's a problem, increase fiber during the day. 3.      NO coffee or tea (herbal is ok) within 2 hours either side of taking iron.  It's not the caffeine; it's the tannic acid that inhibits iron absorption. 4.      NO soy products within 2 hours either side of taking iron. 5.      Very important.....NO dairy within 2 hours either side of taking iron.  That includes butter, milk, cream, cream cheese, ice cream, yogurt, cottage cheese.....NO DAIRY.   6.      Try not to eat foods that are high in calcium or calcium supplemented when eating iron rich foods.  IE.....don't have butter and sour cream on a baked potato when you have that steak J 7.      Cook as much as you can in cast iron.   Some iron rich foods include: ·        Red meat ·        Egg yolks ·        Dark, leafy greens (spinach, collards) ·        Dried fruit (prunes, raisins) ·        Iron-enriched cereals and grains (check the labels) ·        Mollusks (oysters, clams, scallops) ·        Turkey or chicken giblets ·        Beans, lentils, chick peas and soybeans ·        Liver ·        Artichokes Some calcium rich foods include: ·        Cheese ·        Yogurt ·        Milk ·        Sardines ·        Dark leafy greens like spinach, kale, turnips and collard greens ·        Fortified cereals ·        Fortified orange juice ·        Soybeans ·        Fortified soymilk   ·        Enriched breads, grains and waffles    

If you want or need to get serious, heme iron is awesome.   I needed iron infusions every couple of years until I found heme.  It's not constipating, doesn't make me nauseous and has maintained my numbers nicely for 5 years now.  

As Grim said,  at $60 per 90 tabs, it's spendy but cheaper than my co-pay for infusions!!!