Guidelines & Protocols Advisory Committee
Appendix A: Oral Iron Formulations and Adult Doses
This Appendix is a supplement to the BC Guideline Iron Deficiency – Investigation and Management.
One iron preparation is not preferred over another; patient tolerance should be the guide. While polysaccharide and polypeptide
formulations can be taken with food to reduce GI side effects, they are more expensive than the iron salt formulations and are not
a PharmaCare benefit. Remind patients that products are kept behind the counter in the pharmacy and to see a pharmacist to
confirm the product.
Adverse GI reactions (nausea, vomiting, dyspepsia, constipation, diarrhea, and dark stools) are dependent on the dose of elemental
iron. These adverse reactions are temporary and will likely disappear with continued treatment, with the exception of dark stools
which can remain for the duration of therapy.
Therapeutic doses can range from 100 to 200 mg of elemental iron/day,21, 47 depending on severity of symptoms, ferritin levels, age of
the patient, and GI side effects. If poor tolerability with oral iron, consider a lower dose, a different formulation or alternative dosing
schedules (such as every other day dosing).24 Resolution of symptoms and replenishment of iron stores may take longer.
Formulation Usual Adult Cost per 30 Days‡ and
Iron Product Therapeutic Considerations42, 21 †
(elemental iron) Daily Dose Pharmacare Coverage
ferrous sulfate Tablets 300 mg 1 tablet BID-TID • Needs acid in the stomach to get absorbed. $4–8
(60 mg Fe) • To increase absorption, take on an empty stomach — at (Regular benefit)
least 1 hour before or 2 hours after eating, with 600–1200
Suspension 30mg/mL 10 mL BID-TID mg vitamin C51. $ 20–35
(6 mg Fe/mL) • Absorption may be decreased if taking antacids or (Regular benefit)
ferrous Tablet 300 mg (35 mg Fe) 1–2 tablet BID-TID medications that reduce stomach acid. § $5–10
gluconate (Max 5 tablets/day) • To reduce adverse GI reactions with iron salts, start with (Regular benefit)
a low dose and increase gradually after 4 to 5 days. If
ferrous Capsule/Tablet 300 mg 1 capsule OD-BID bothersome, take initially with food and gradually shift the $6–12
fumarate (100 mg Fe) timing away from meals to improve absorption. (Regular benefit)
Suspension 60 mg/mL 5 mL OD-BID • Iron suspension formulations may stain teeth. This can $ 20–35
(20 mg Fe/mL) be prevented by drinking through a straw or mixing with (Regular benefit)
water or fruit juice.
Tablet 200 mg 1 tablet BID-TID $6–10
(65.7 mg Fe) (Non-benefit)
polysaccharide Capsules 150mg 1 capsule OD • Taken with or without food. $20-25
iron (150 mg Fe) • Does not need acid in the stomach to get absorbed. Good (Non-benefit)
Powder 60 mg/teaspoon 1 tsp BID-TID choice if taking medications that reduce stomach acid. $35–100
(60 mg Fe) • Capsule can be opened and contents mixed into water or (Non-benefit)
sprinkled over soft food.
• Virtually tasteless.
heme iron 11 mg heme Fe 1 tablet OD-TID • More bioavailable than nonheme iron. $20–80
polypeptide • Taken with or without food. (Non-benefit)
• Does not need acid in the stomach to get absorbed. Good
choice if taking medicines that reduce stomach acid.
• Contains animal (cow) products.
Abbreviations: BID twice daily; Fe elemental iron; GI gastrointestinal; IV intravenous; IM intramuscular; mg milligrams; mL milliliters; PO orally; TID three times daily.
† Treatment with oral iron may take as long as six to eight weeks in order to fully ameliorate the anemia, and as long as six months to replenish iron stores.
‡ Estimated retail prices as of January 2019 based on the adult dose range. All prices are subject to change. In most situations, oral iron products are least
expensive when purchased over the counter. However, PharmaCare benefits may reduce the cost to the patient when a prescription is provided. PharmaCare
coverage is subject to the patient’s plan rules, including any deductible requirement. Patients can discuss with their pharmacist for more information.
§ Iron absorption may be decreased by antacids or supplements containing aluminum, magnesium, calcium, zinc, proton pump inhibitors, and histamine2
receptor antagonists.
BCGuidelines.ca: Iron Deficiency – Diagnosis and Management (2019): Appendix A: Oral Iron Formulations and Adult Doses 1
Guidelines & Protocols Advisory Committee
Appendix B: Parenteral Iron Formulations and Adult Doses
This Appendix is a supplement to the BC Guideline Iron Deficiency – Investigation and Management.
Cost per 30 Days
Iron Formulation Usual Adult
Adverse Reactions Therapeutic Considerations** and PharmaCare
Product (elemental iron) Daily Dose
Coverage††
iron Injection (IV): 100 to 300 mg IV CNS: headache, fever • Hypotension may occur from rapid $405/1000mg
sucrose 20 mg Fe/mL intermittent per CVS: hypotension IV administration; doses greater than (Non-benefit)
session, given as a total GI: metallic taste, 300 mg associated with significant
cumulative dose of nausea, vomiting hypotension.
1000 mg over 14 days MSK: muscular pain,
cramps
iron Injection (IV or Based on body weight CNS: fever • A test dose of 25mg elemental $297/1000 mg
dextran IM): 50 mg Fe/mL and hemoglobin; IV MSK: arthralgia, myalgia iron (0.5 mL) must be given before (Regular benefit)
complex intermittent (maximum administering the first therapeutic dose.2
1000 mg/day); or IM up • Total dose depends on patient’s weight
to 100 mg Fe per site and hemoglobin level.2
(maximum 250 mg/day) • IM iron therapy is not recommended
because risks include unpredictable
absorption and local complications (e.g.
pain, permanent staining of the skin).
ferric Injection (IV): 125 mg (10 mL) IV per CNS: generalized • Indicated for treatment of iron- $460/1000 mg
gluconate 12.5 mg Fe/mL dose; up to 1000 mg seizures deficiency anemia in patients 6 years (Non-benefit)
complex over 8 sessions CVS: hypotension, and older with chronic kidney disease
hypertension, undergoing hemodialysis in conjunction
vasodilation with supplemental erythropoietin
GI: diarrhea, nausea therapy.
Maximum hemoglobin response to IV iron usually occurs within 2 to 3 weeks of the last dose.
Abbreviations: BID twice daily; CNS central nervous system; CVS cardiovascular system; Fe elemental iron; GI gastrointestinal; IV intravenous; IM intramuscular;
max maximum; mg milligrams; mL milliliters; MSK muscular skeletal.
Reference: Vancouver Coastal Health Pharmaceutical Sciences Clinical Services Unit. Iron Dextran and Iron Sucrose. Vancouver Coastal Health Parenteral Drug
Manual. Vancouver British Columbia. Vancouver Coastal Health – 2008.
Iron Dextran dose: total dose (mg) required to restore hemoglobin (Hgb in g/L) to normal: 50 x (0.00442 [desired Hgb – observed Hgb] x LBW + [0.26 x LBW])
LBW in kg (male) = 50 kg + (2.3 x inches over 5 feet)
LBW in kg (female) = 45.5 kg + (2.3 x inches over 5 feet)
†† Prices are estimates as of January 2019 based on the maximum adult dose. All prices are subject to change.
BCGuidelines.ca: Iron Deficiency – Diagnosis and Management (2019): Appendix B: Parenteral Iron Formulations and Adult Doses 1
Guidelines & Protocols Advisory Committee
Appendix C: Algorithm for investigation of iron deficiency in non-anemic adults
This Appendix is a supplement to the BC Guideline Iron Deficiency – Investigation and Management.
This algorithm does not address patients with active inflammation, infection or chronic conditions. Refer to page 4.
Ferritin values occur on a continuum. Cut-offs are suggested and clinical interpretation is required. The likelihood of iron deficiency
increases with lower ferritin concentrations, including those that overlap with the normal reference interval. The normal reference
interval is derived from healthy outpatients without signs of iron deficiency or chronic illness.
Clinical symptoms and/or risk factors for iron deficiency. Refer to Table 1 for risk factors
Measure serum ferritin.
Ferritin <15 ug/L Ferritin 15-30 ug/L Ferritin 30-100 ug/L Ferritin >100 ug/L
Iron stores are relatively low. Normal iron stores. Clinical
Diagnostic of iron deficiency Probable iron deficiency Iron deficiency is unlikely to symptoms are not related
explain the clinical symptoms. to iron deficiency.
1. Manage known risk factors for iron
deficiency (Table 1). If ferritin is persistently
Manage known risk factors for
2. Investigate for additional causes ≥ 600 ug/L, consider test
iron deficiency (Table 1).
(if not already established), including for iron overload.
potential malignancy.
3. While investigating, provide iron Consider iron supplementation*
supplementation* to treat symptoms primarily to increase stores to
and increase stores to protect against protect against future losses
future losses (pregnancy, surgery). (pregnancy, surgery).
*Iron replacement therapy should begin as soon as iron deficiency is detected, whether or not anemia is also present. The exception
is: patients with microcytic anemia should not be given iron supplements until iron deficiency is confirmed by testing ferritin. Low
MCV in the setting of normal ferritin may indicate hemoglobinopathies such as thalassemia. Long term iron therapy is harmful for
these patients.
BCGuidelines.ca: Iron Deficiency – Diagnosis and Management (2019): Appendix C: Algorithm for investigation of iron deficiency in non-anemic adults 1
Guidelines & Protocols Advisory Committee
Appendix D: Pediatric iron doses and liquid formulations
This Appendix is a supplement to the BC Guideline Iron Deficiency – Investigation and Management. Refer to page 7 for guidance on
diagnosis, monitoring and treatment of iron deficiency and iron deficiency anemia in children.
• Advise patients that iron can be toxic to children and should always be safely stored.
• Provide dietary counselling. Dietitian referral is recommended. Patients and caregivers can call a dietitian at 8-1-1. Refer to
Associated Documents for recommended dietary intake and a list of iron-rich foods.
• Recommend infants and toddlers with iron deficiency begin treatment with liquid oral iron.
• It is important to specify the strength (in mg elemental Fe/mL) in addition to dosing instructions (often in mL) to aid in selection
of the intended product and prevent dosing errors. Remind patients that products are kept behind the counter in the pharmacy
and to see a pharmacist to confirm the product.
Recommended treatment doses of elemental iron for infants and toddlers32
Age group Dose Daily maximum
Infants up to 12 months Up to 3 mg of elemental Fe/kg/day (including iron from formula and other sources) 15 mg/day
Toddlers 12 months and over 3–6 mg elemental Fe/kg/day in either once a day or divided doses 60 mg/day
Pediatric liquid iron products
Cost per 30 Days
Formulation
Iron Product Therapeutic Considerations21, 42 and Pharmacare
(elemental iron)
Coverage‡‡
ferrous sulfate Suspension 250, 500 mL bottles • Liquid iron formulations may stain teeth. This can be $4/500 mg Fe
30mg/mL prevented by drinking through a straw or mixing with (Regular benefit)
(6 mg Fe/mL) water or fruit juice.
• For optimal absorption, iron salts (ferrous sulfate or
Drops 50 mL bottles fumarate) should be taken on an empty stomach with $7/500 mg Fe
75mg/mL water or juice, and not with dairy. (Regular benefit)
(15 mg Fe/mL) • To reduce adverse GI reactions with iron salts, start with
ferrous Suspension 100 mL bottles a low dose and increase gradually after 4 to 5 days. If $3/500 mg Fe
fumarate 60 mg/mL bothersome, take initially with food and gradually shift the (Regular benefit)
(20 mg Fe/mL) timing away from meals to improve absorption.
• Adverse GI reactions (nausea, vomiting, dyspepsia, constipation, diarrhea, and dark stools) are dependent on the dose of
elemental iron. These adverse reactions are temporary and will likely disappear with continued treatment, with the exception
of dark stools which can remain for the duration of therapy. If poor tolerability with oral iron, consider a lower dose, a different
formulation or alternative dosing schedules (such as every other day dosing).22 Resolution of symptoms and replenishment of
iron stores may take longer.
‡‡ Prices are estimates as of January 2019. All prices are subject to change.
BCGuidelines.ca: Iron Deficiency – Diagnosis and Management (2019): Appendix D: Pediatric iron doses and liquid formulations 1
