Nick: Welcome to episode six of The Holy Gut Podcast. In this Podcast, we discuss iron infusions and gut health.
Hello, it's me Nick Kamp, co-host of The Holy Gut Podcast, with my cohosts Dr. Nathan Connelly and Nicole Starbuck-Connelly. Nathan is a gastroenterologist and Nicole is a registered nurse and practice manager of the Moonee Valley Specialist Centre here in Melbourne, Australia. Moonee Valley Specialist Centre provides a number of services related to gut health including FMT and bowel cancer screening.
Nick: I'm back speaking to Nathan. In this podcast we're talking about iron infusions. Hi there, Nathan, how are you?
Nathan: Good, Nick.
Nick: Okay so when we're talking about iron infusions, what type of patient requires an iron infusion?
Nathan: Generally speaking patients are iron deficient and there's different levels of iron deficiency. There's people who just have low iron levels and whether they benefit from iron infusions or not is somewhat debated. Certainly patients who have a lower blood count, what we call anemia. When patients are anemic with low iron levels then they generally will need to have an iron infusion. Patients can have aural iron but that's often slow to work and about 30% of patients it doesn't work at all. So, generally patients with iron deficiency, iron deficiency anemia, the nerve responds to tablets or inability to take tablets with the patients we generally see having iron infusions.
Nick: I see. So when we're talking about iron deficiency are we really talking about oxygen in red blood cells ?
Nathan: So the anemia when the blood cells are deficient we actually have less blood cells. Patients with that definitely have a decreased oxygen carrying ability if they're anemic. And by far the commonest cause of anemia in the community would be iron deficiency anemia. So that's true. It's been debated whether patients with a normal blood count have, who are iron deficient, have decreased oxygen carrying capability. They probably do. It probably doesn't matter in people who are doing normal activities. Although, it might matter in people who are high end athletes. So it has been shown for example that female athletes who are commonly iron deficient, the ones that are iron deficient have less of an ability to burn oxygen than those that aren't iron deficient., what's called the v-max if you're doing a test for it. So, we think that iron deficiency without anemia is functionally important, especially people who are active.
Nick: When someone is iron deficient, how would they feel? What symptoms would they have?
Nathan: The symptoms with iron deficiency and anemia are very vague and they're highly variable. So some people will fine even with a low blood count. Where as other people might have a low iron level with a normal blood count and feel quite unwell. So they're highly variable. Symptoms are vague mostly consisting of tiredness, sometimes dizziness, sometimes shortness of breath. Also, has some very quirky symptoms associated with iron deficiency such as ice craving and itchiness.
Nick: Ice craving? So a cold ice cube?
Nathan: Yeah it's a craving with women who are commonly iron deficient you often see them crunching ice all the time. It's just one of those, it's called a pica, P-I-C-A. There are other picas associated with iron deficiency such as eating dirt or licking rubber mallets. These strange-
Nick: What?
Nathan: Yeah, we do see some pregnant women crave certain smells or the taste of certain things because they're so iron deficient and it's called the pica. Which is eating or wanting to eat strange substances due to nutritional deficiency. Medical oddity.
Nick: I see. So, when requires an iron infusion I guess we should understand what they're really getting. So what is an iron infusion and what's its purpose?
Nathan: An iron infusion is a way of bypassing the absorption of iron as a limiting factor in how much iron you have in your body. The body's absorption of iron is very tightly regulated and that regulation is prone to a number of different factors affecting it. Therefore, iron absorption is generally a slow process and it's very hard to speed it up. If you want to get a large amount of iron in quickly, especially in someone who is anemic, you have to give it directly to the vein. You can't just use iron. The iron molecule has to be connected to a sugar molecule. Otherwise, it causes sever allergic reactions. The sugar molecule that's connected to has changed over the years. The one we use these days which is called carboxymaltose is very very safe. It enables us to use quite large doses of iron directly into the vein in a fairly, sort of, low level outpatient setting without any risk of allergic reactions. Which is a major advance from where we were 30 years ago.
Nick: And that since they're perfectly safe are there any side effects?
Nathan: There is the risk of allergic reactions although again with the [inaudible 00:05:36] with the carboxymaltose it's very, very rare. We've done over a thousand of these rooms and never had a severe allergic reaction. Occasionally, a patient might have a little bit of rash but that's very rare. Another common, well not common, but another worry side effect if the iron leaks out of the vein, the skin it can cause staining of the skin, called tattooing. That can be a little bit of an issue but honestly we've never had one of these in our rooms because Nicole is extraordinarily careful about how she does the infusions. She watches all the infusions, she stares, at the cannula and she makes sure it's a good cannula. We haven't had any extravasation episodes in our rooms, despite the thousand.
The other thing is some people notice is because the presence of iron causes the bone marrow to start working and to start producing red cells. That can cause the release of certain substances that cause the person to feel like they got the flu. Called the cytokine release. These cytokines are what are released when you have the flu can be released by very rapid red cell formations. Sometimes people complain of aches and pains. Maybe a low grade fever for a day or two but that generally blows over very quickly and is manageable with just a bit of Panadol. Again, we don't see any major issues with it.
Nathan: Generally, very very safe. Thousands are done around Melbourne every week. They're safe enough to give in outpatient settings so we would consider the side effects to be minimal.
Nick: Other than having an iron infusion to replenish your iron, would there be other reasons to get an iron infusion? Are there other sort of side benefits to getting an iron infusion?
Nathan: Not that we know of. The big debate is whether people who are not anemic should have an iron infusion. And that's, people saying they're tired and their iron level is low and you, you know, they'll want an iron infusion. You have to tell them that listen we can't guarantee you'll feel any different. Sometimes they do, sometimes they don't. It really depends on whether that mild iron deficiency is the cause of their tiredness or whatever symptom they have. You really can't work that out until you give them the infusion and see if they get better. It's one of those wait and see things but beyond that, beyond replenishing a low iron level, there's no evidence that having a higher iron level is than normal is of any benefit. And indeed, having too much iron is not good either.
Nick: Okay.
Nathan: There are some long term health risks associated with high iron levels. There is a medical condition associated with having too high iron levels. That's a condition called hemochromatosis. You're not going to get that through normal iron infusions. But if you had some 20 iron infusions over the course of a couple years and you didn't need them it might cause problems with iron overload. In general, apart from restoring levels that are low there's no benefit beyond that.
Nick: I see. So what you mentioned long term iron deficiency. What are the problems related to that and are they serious or can you be long term iron deficient and be fine and healthy?
Nathan: As far as iron deficiency without anemia, there's not a lot of evidence that having slightly low iron levels and having a normal blood count, which is extraordinarily common. I would suggest that the vast majority, not vast majority, but a significant amount, a significant number of women who have menstrual periods will be iron deficient without being anemic. There is no evidence of being like that causes any harm. It might stop you winning the Olympic marathon run or the Tour de France for women but it's not going to stop them from living a normal, healthy life. The women are actually very, very tolerant generally of iron deficiency and anemia. So many mild degrees of anemia. There's no known harm in that, medical long term harm that I know of. It's just that people often don't feel well with it. They feel like their quality of life is poor, thay have poor exercise and even sometimes just doing the washing and normal activities a daily living. That's on an individual basis. I've had women come in with a hemoglobin of 70, which is half what it should be, and they feel perfectly fine.
Nick: OK.
Nathan: Some women who have an iron level that's low but their blood count is 140, and that's normal, who feel terrible. They swear blind they feel better without an iron infusion. There's a wide variety of wide spectrum of symptoms associated with being iron deficient and anemic. You can't of generalise I don't think. You really can't.
Nick: Okay can we get clear on the difference between iron, being iron deficient and being anemic?
Nathan: Iron deficiency is when you have a low iron level. The iron test that they do is what is called iron studies. And the iron studies were a blood test that are commonly performed that do require a bit of interpretation. They're not normally straight forward numbers like anemia is. Generally though, if you've got an ferritin level, which is the test we use less than 100, and the transparent saturation, which is the level part of our test that is low then you're iron deficient.
Anemia is where you have a low blood count. Anemia is the end point of iron deficiency. Once your blood count starts to drop then you are very iron deficient. Actually you have no iron at that point. But anemia can be caused by other diseases. Anemia can be caused by acute blood loss. It can be caused by problems with the bone marrow. It can be caused by deficiency of other vitamins such as B12 and folate. It's very common in patients who have kidney problems, cancer, chronic infections, chronic inflammatory disorders like rheumatoid arthritis. Anemia can be caused by multiple things, not just iron deficiency. The reason why people think that anemia and iron deficiency are the same thing is because iron deficiency is the commonest cause especially in people who are otherwise well. It's very, very common to see iron deficiency anemia in women who have periods or women who are pregnant. Both of which we'll consider to by physiological states I.e. normal states.
Nick: I see. So you could be anemic but not iron deficient?
Nathan: Correct and vice versa.
Nick: So we, people shouldn't have the assumption I'm anemic I need an iron infusion.
Nathan: That's right, they should get their iron levels checked. That's absolutely correct.
Nick: Now relating iron deficiency to, can we relate it to gut health?
Nathan: Yeah we can. So iron deficiency is commonly caused by gut disorders. This is particularly true of women who haven't got periods, so women who are finished having periods. And also men or women. No man should be iron deficient, even vegetarian men shouldn't be iron deficient. If people are iron deficient and they don't have an obvious reason to be iron deficient then it commonly comes down to being a gut problem. That can be either losing blood in the gut or can be absorbing blood from the gut. So I'll give you a couple of examples.
Bowel cancer is one of the lead commonest, is a very common cancer. The commonest way that presents is iron deficiency. The cancer just leaks blood into the gut and the person becomes gradually iron deficient. The colon polyps can do it. Inflammation in the bowel like you see with ulcerative colitis or Crohn's disease can do it. Stomach ulcers, stomach cancers, cancer anywhere in the gut, bad reflux disease, all of these diseases can leak blood into the gut without any other symptoms and cause progressive iron deficiency.
In people that shouldn't be iron deficient we often do gastroscopy and colonoscopy to exclude all those conditions. On the other side of the ledger, non absorbing iron is commonly seen in celiacs disease which is a disease you've probably heard of. It is a inflammation of the gut caused by gluten and it affects 1% of the population and a common presenting problem with iron deficiency.
So yes, if you're not losing blood from having periods and you're not losing blood from donated blood or you're not losing blood from being involved with vampires then it's likely that you've got a gut problem.
Nick: Okay and that would suggest eating a diet that's not high in iron.
Nathan: Dietary iron deficiency is another cause. It's probably not that. In the end it might not be that common. People, the body is quite good at absorbing iron when it needs too. And often the people you see nutritional iron deficiency as we call it, are in people who have another reason to be iron deficient. So your average woman having periods often they don't eat a lot of red meat. Red meat is by far the best source of iron. They'll have a combined iron deficiency due to combined menstrual blood loss as well as a diet low in red meat. The men for example, men really don't need that much iron. The amount of iron found in fruit, vegetables and nuts, et cetera under normal circumstances is enough that vegetarian men should not be iron deficient either. I have yet to see a male that who is iron deficient. They've got a gut problem to prove otherwise because they just don't commonly get nutritional iron deficiency. You just don't need that much. If you're having periods, yeah, you need a lot because you're losing a lot of iron every month in the menstrual blood loss.
But men and women who don't have periods really they really shouldn't be iron deficient even if they don't eat a lot of red meat. Children are not the group that need, they're growing, it's a physiological need. If you're growing, if you're pregnant, if you're having periods you have increased needs. In those people, nutritional iron deficiency is much more likely. Your average Joe blow is not blood donating and doesn't losing blood by having the operation. They really shouldn't be iron deficient regardless of diet.
Nick: Okay so in saying that, why, that's assuming they've been getting enough iron in their diet, why would they be, why would men be iron deficient?
Nathan: They're losing blood in the gut. So they got a problem. So Iron deficiency is commonly a symptom of a gastrointestinal problem or pathology as we call it.
Nick: Yup
Nathan: So any man who is iron deficient, unless there is a really obvious reason like they donate blood or they just had three joint replacements in six months, you know operations for example that lose a lot of blood. If there's no obvious reason they haven't got a problem.
Nick: Okay so if you're a male and you go see your GP and you're just getting a regular blood test done and its come back being iron deficient and the GP says "just get more iron in your diet". That's probably not the best advice.
Nathan: No.
Nick: I have another question that came up in the research I did. Do iron infusions make you gain or lose weight.
Nathan: No.
Nick: No.
Nathan: Hang on. Having said that. If you're feeling really tired and lethargic and you spend all day sitting on the couch watching television, and having a pica for some food that contains iron that's fattening and then you get an iron infusion and you feel fantastic then you might go around and lose weight. You might do more exercise and walk more and stop sitting on the couch eating foods you shouldn't. So there is, you know, I would say if you're iron deficient you're more likely to gain weight than lose weight. The other thing is that iron deficient patients, especially those who are anemic, they often retain fluid. So anemia causes fluid retention. It's a big problem in patients with heart problems or kidney problems because they retain more fluid than would otherwise. It's quite possible when you treat that they lose fluid and lose weight. So there are links but they can be pretty tenuous if you like.
Nick: So we'll wrap up this podcast with one final question. When do you advise people to get an iron infusion?
Nathan: That's a complex question. If the patient is anemic and especially if they have ongoing increased needs for iron, either about to have an operation, they're actively bleeding, they're having periods, they're pregnant. If they're anemic and iron deficient and especially if they have failed aural iron, like they have tired aural iron and they don't tolerate it or it doesn't work. Then most patients absolutely need an iron infusion. And that's a no brainer.
When people are mildly iron deficient and mildly anemic who don't have ongoing increased needs. Either they've stopped bleeding or stopped being pregnant or whatever the reason is then those patients someone should give them a trial of aural iron and see how they go. In patients who are iron deficient and not anemic they can choose to have an iron infusion and choose to try aural iron. That's kind of, you discuss that with the patient but often these patients are very tired, very lethargic, they've tried aural iron before. It doesn't work or gives them horrible side effects like abdominal pain or constipation. They don't want to try it again you just get the iron infusion. So it's very much Nick, decided to say on an individual basis. But if you're anemic and iron deficient you probably should have an iron infusion.
Nick: I guess this depends on the person and their needs but to your patients who take regular iron infusions, they have one every three months?
Nathan: That's very frequent but there are people who, if you're very anemic you often need to have two. One to get the blood cells to go back to normal. The next one to give you some iron stores and to finish up getting your blood cells back to normal. So some people need two in a fairly rapid sequence to get back to normal.
Some people who, especially, the classical story is the woman over the age of 40 who is having very heavy periods, as women often do toward the end of their reproductive life, who don't want to have any treatment of that. So they don't want to have any strict or uterine ablation or hormonal therapy or whatever treatment you're giving for that problem which is called menorrhagia. They don't want to have treatment of menorrhagia because they don't like the treatment or they just don't want them. Therefore they are what we call iron dependent. They need to keep having iron infusions to get by until their periods stop naturally. So we do have a number of patients in our practice who might have and iron infusion every 6 to 12 months for that purpose. Some people do need to have them.
Nathan: Patients with inflammatory bowel disease, Crohn's disease, ulcerative colitis often need to have them. Patients with kidney failure often need to have them very frequently. There's a number of patient groups that do require ongoing iron infusions.
Nick: Okay well let's finish there. Thank you very much for your time.
Nathan: No problem, Nick.
Nick: This episode was brought to you by the Moonee Valley Specialist Center and Liver Scan Australia. To learn more about the liver fibrous scan or to make a booking, please visit liverscanaustralia.com.au. Moonee Valley Specialist Center is Victoria's only private liver scan facility. There is no waiting list and no referral required. Go to liverscanaustralia.com.au to book your liver scan.
