GPs probe supplements with ‘little more iron than a bowl of cornflakes’

For advance practice pharmacist Joy Gailer, recent headlines about low-dose iron supplements with little or no impact is hardly a shock.
 
Working as the practice support clinical pharmacist at Chandlers Hill Surgery in Adelaide, Ms Gailer has long held an interest in the area.
 
As well as doing educational visits to general practices on iron deficiency management, she helped develop guidelines for SA Health for administering intravenous iron in primary care.
 
The concerns surrounding supplements, which are sold online and in supermarkets, with ‘little more iron than a bowl of cornflakes’ is ‘not a surprise at all’, she told newsGP.
 
‘There has been this absolute flood of products on the market,’ Ms Gailer said.
 
‘It’s made it more confusing for the consumer and potentially misleading as well.’
 
With some iron supplements containing as little as five milligrams, she queries their value, as does her colleague Dr Danny Byrne, a long-serving GP and practice partner at Chandlers Hill Surgery.
 
For him, concerns around ineffective iron supplements reflect a broader issue and are ‘just another example of over-the-counter products that are not in our patients’ best interests’.
 
It follows a recent Therapeutic Goods Administration (TGA) crackdown on products with potentially harmful quantities of vitamin B6 – products which line supermarket shelves and are readily available to all Australians.
 
‘I’ve known for a long time that a lot of the iron supplements that you can buy over the counter with only five milligrams are a waste of time,’ Dr Byrne told newsGP.  

‘It’s a bit rich that they’re sold with no side effects. That’s because they’ve got no iron in them. They don’t do anything, they’re a big waste of time.’
 
Many such supplements are listed medicines with an AUST-L number issued by the Therapeutic Goods Administration (TGA), but have never been scrutinised for efficacy – a fact clearly acknowledged by the TGA.
 
‘If we reviewed all low-risk products for efficacy before they were permitted on the market, the additional costs would likely be passed on to consumers and it would take significantly more time for new products to become available,’ it says.
 
While listed medicines that have undergone a TGA efficacy assessment are given an AUST-L (A) number, there is limited consumer understanding of the distinction.
 
For Dr Byrne, this is not helping GPs to treat iron deficiency, which he describes as a ‘very common’ reason for presentations.
 
He was an early advocate for making iron infusion treatments accessible on the Pharmaceutical Benefits Scheme, and also believes GPs have a critical part to play in addressing confusion around taking oral iron, which is the first-line treatment for iron deficiency.
 
‘It’s the role of the GP to explain to the patient that you need 100 to 200 milligrams and write down on a piece of paper the exact dose like we do for other drugs,’ he said.
 
‘It’s just that you don’t do a prescription, so you have got to write it down on a piece of paper – or you just write it as a prescription in your software and write “over the counter” in big letters on it.’
 
However, that does not address the issue of patients who self-diagnose and try to treat their own symptoms – a trend that particularly worries Ms Gailer.
 
‘This is the difficulty with some of the low-dose iron products being available outside of community pharmacy, if they are re-presenting repeatedly with ongoing symptoms that may be iron deficiency, trying to self-manage without that being investigated, that is a huge risk,’ she said.
 
Messaging on some products about being gentle on the stomach is another issue, Ms Gailer believes.
 
‘It’s so much more around the tolerability rather than the efficacy, that is what I have noticed more than anything else,’ she said.
 
‘Many people are already primed that they may not tolerate oral iron, and it can be an incredibly effective intervention.’
 
Ms Gailer says a nuanced conversation is needed to get oral iron treatments right, as does Dr Byrne who says there are a ‘whole suite of ways to cope with oral iron’.
 
‘Pre-empt the side-effects, have a discussion with the patient,’ he said.
 
‘Reflux, constipation … I often think if patients are made aware in the first place, they will manage with advice, rather than it becoming a surprise to them.’
 
And following the TGA’s focus on vitamin B6, and its links to neuropathy, Dr Byrne said GPs ‘have to become that much more aware and alert of what our patients are actually taking’.
 
‘We’ve all been totally surprised by the B6 toxicity,’ he said.
 
‘Now taking at face value the patient saying, “yeah, I’m taking an iron tablet”, but finding out it’s only five milligrams, and that’s the reason they haven’t responded.
 
‘It’s never-ending.’
 
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