Iron loss or lack of absorption?

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DEAR DR. ROACH: My daughter’s iron level has been dangerously low for several years. One measurement was as low as 5, but mostly it is between 9 and 15. She took iron pills, which affected her in many other ways.

She was given one iron injection, which affected her negatively. She refused the second one. She has been on an antidepressant and an antipsychotic med for bipolar disorder for 10 years. She is 45. They cannot figure out why her iron stores are so low. She had an endometrial ablation done two years ago, and her menstruation stopped. Her iron stores are still low. She is taking iron pills to keep her functioning. What causes a person to NOT store iron? — M.S.

ANSWER: I don’t think the issue is her being unable to store iron; rather, the issue probably is that she isn’t absorbing it. Whatever endometrial problem she had that required ablation probably caused her to bleed, and the bleeding caused her to reduce her iron stores. Over time, her bone marrow and liver ran out of iron almost completely. (The blood levels of 5-15 indicate very little iron in the blood. A low ferritin level would confirm low iron stores.)

Iron by injection is an effective way of replacing iron. There are several formulations available, some of them quite new (with fewer side effects than older preparations), so it may be worth trying a different preparation from the one she did not react well to.

If she is not replenishing her iron stores despite adequate oral iron, then either she is not absorbing it or she is losing it elsewhere. Both are possible. Common causes of poor iron absorption include celiac disease, inflammatory bowel disease, pernicious anemia and tropical sprue. Many people simply do not take oral iron because it can cause stomach upset, constipation and other problems, so it is critical to make sure people are actually taking it.

Ongoing blood loss can confuse the issue. Hidden inflammatory bowel disease, such as Crohn’s, may produce blood loss with no symptoms.

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Given how long your daughter’s problem has been going on, I think it’s time for a fresh evaluation and rethinking of her issue.

DEAR DR. ROACH: Are synthetic pain medications more addictive than natural opiates? I feel they are. I face going back on pain medications. Is there any new research on new non-opioid pain medications? — A.F.

ANSWER: An opiate is a drug derived from the opium poppy. These include opium, heroin, morphine and codeine. An opioid includes opiates, but also synthetic drugs that work on the same receptor in the brain. Synthetic opioids include oxycodone, hydrocodone and fentanyl. All the natural and synthetic opioid drugs have not only the ability to help relieve pain in the short term, but also can be accidentally or deliberately misused, with the possibility of serious consequences, including death — more than 42,000 deaths per year in the U.S. alone. These are dangerous drugs that need to be used with extreme caution and only after considering other options. New evidence shows that opioids are not effective for chronic non-cancer pain for most people (although a few people do well).

Although NSAID drugs and acetaminophen (Tylenol) are pain relievers, they are not very effective for severe pain. Often, pain specialists use combinations of medications, also using medications approved for other conditions but which may help relieve pain. Anti-depression and anti-seizure medicines frequently are used. There are ongoing trials on new medications.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at 628 Virginia Dr., Orlando, FL 32803. Health newsletters may be ordered from www.rbmamall.com.

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