Pharmacologic Category

Iron Preparations

Dosing: Adult

Note: Immediate release oral iron products are preferred for treatment of iron deficiency anemia; enteric coated and slow/sustained release preparations are not desired due to poor absorption (Hershko 2014; Liu 2012).

Iron deficiency anemia, prevention/treatment: Oral: One capsule or tablet once daily. Note: Alternate-day dosing (eg, every other day or Monday, Wednesday, Friday) has been shown to result in greater absorption of iron; some experts recommend this dosing schedule in patients who can maintain adherence (Schrier 2019; Stoffel 2017).

Dosing: Geriatric

Refer to adult dosing.

Dosing: Renal Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling.

Use: Labeled Indications

Iron deficiency anemia, prevention/treatment: Prevention and treatment of iron-deficiency anemias and/or nutritional megaloblastic anemias

Dietary Considerations

Dietary sources of iron include beans, cereal (enriched), clams, beef, lentils, liver, oysters, shrimp, and turkey. Foods that enhance dietary absorption of iron include broccoli, grapefruit, orange juice, peppers and strawberries. Foods that decrease dietary absorption of iron include coffee, dairy products, soy products, spinach, and tea.

Storage/Stability

Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).

Poly-Iron 150 Forte: Store at 15°C to 30°C (59°F to 86°F).

Medication Patient Education with HCAHPS Considerations

What is this drug used for?

• It is used to prevent or treat anemia.

Frequently reported side effects of this drug

• Abdominal pain

• Constipation

• Diarrhea

• Stool discoloration

• Nausea

• Vomiting

Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:

• Black, tarry, or bloody stools

• Vomiting blood

• Abdominal cramps

• Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.

Contraindications

Hypersensitivity to any components of the formulation; hemochromatosis; hemosiderosis

Warnings/Precautions

Disease-related concerns:

• Anemia: Not appropriate for with pernicious, aplastic, or normocytic anemias when anemia is present with vitamin B12 deficiency.

• Pernicious anemia: Folate doses >0.1 mg/day may obscure pernicious anemia in that hematologic remission can occur with continuing irreversible nerve damage progression.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Pediatric: Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years of age. Keep this product out of the reach of children. In case of accidental overdose call the poison control center immediately.

Dosage form specific issues:

• Oral iron formulations: Immediate release oral iron products are preferred for treatment of iron deficiency anemia; enteric coated and slow/sustained release preparations are not desired due to poor absorption (Hershko 2014; Liu 2012).

Pregnancy Considerations

Refer to individual monographs

Breast-Feeding Considerations

Refer to individual monographs

Briggs' Drugs in Pregnancy & Lactation

• Folic Acid
• Vitamin B12

Adverse Reactions

Frequency not defined.

Gastrointestinal: Abdominal pain, constipation, dark stools, diarrhea, epigastric pain, GI irritation, nausea, stomach cramping, vomiting

Genitourinary: Discolored urine

Miscellaneous: Hypersensitivity reaction

Allergy and Idiosyncratic Reactions

• Iron Preparation Allergy

Toxicology

• Iron

Metabolism/Transport Effects

None known.

Drug Interactions Open Interactions

Alpha-Lipoic Acid: Iron Preparations may decrease the absorption of Alpha-Lipoic Acid. Alpha-Lipoic Acid may decrease the absorption of Iron Preparations. Risk D: Consider therapy modification

Antacids: May decrease the absorption of Iron Preparations. Management: Separate dosing of oral iron preparations and antacids as much as possible to avoid decreased efficacy of iron preparation. If coadministered with antacids, monitor for decreased therapeutic effects of iron preparations. Risk D: Consider therapy modification

Baloxavir Marboxil: Polyvalent Cation Containing Products may decrease the serum concentration of Baloxavir Marboxil. Risk X: Avoid combination

Bictegravir: Iron Preparations may decrease the serum concentration of Bictegravir. Management: Bictegravir, emtricitabine, and tenofovir alafenamide can be administered with iron preparations under fed conditions, but coadministration with or 2 hours after an iron preparation is not recommended under fasting conditions. Risk D: Consider therapy modification

Bisphosphonate Derivatives: Polyvalent Cation Containing Products may decrease the serum concentration of Bisphosphonate Derivatives. Management: Avoid administration of oral medications containing polyvalent cations within: 2 hours before or after tiludronate/clodronate/etidronate; 60 minutes after oral ibandronate; or 30 minutes after alendronate/risedronate. Exceptions: Pamidronate; Zoledronic Acid. Risk D: Consider therapy modification

Cefdinir: Iron Preparations may decrease the serum concentration of Cefdinir. Red-appearing, non-bloody stools may also develop due to the formation of an insoluble iron-cefdinir complex. Management: Avoid concurrent cefdinir and oral iron when possible. Separating doses by several hours may minimize interaction. Iron-containing infant formulas do not appear to interact with cefdinir. Risk D: Consider therapy modification

Deferiprone: Polyvalent Cation Containing Products may decrease the serum concentration of Deferiprone. Management: Separate administration of deferiprone and oral medications or supplements that contain polyvalent cations by at least 4 hours. Risk D: Consider therapy modification

Dimercaprol: May enhance the nephrotoxic effect of Iron Preparations. Risk X: Avoid combination

Dolutegravir: Iron Preparations may decrease the serum concentration of Dolutegravir. Management: Administer dolutegravir at least 2 hours before or 6 hours after oral iron. Administer dolutegravir/rilpivirine at least 4 hours before or 6 hours after oral iron. Alternatively, dolutegravir and oral iron can be taken together with food. Risk D: Consider therapy modification

Eltrombopag: Polyvalent Cation Containing Products may decrease the serum concentration of Eltrombopag. Management: Administer eltrombopag at least 2 hours before or 4 hours after oral administration of any polyvalent cation containing product. Risk D: Consider therapy modification

Elvitegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Elvitegravir. Management: Administer elvitegravir 2 hours before or 6 hours after the administration of polyvalent cation containing products. Risk D: Consider therapy modification

Entacapone: Iron Preparations may decrease the serum concentration of Entacapone. Management: Consider separating doses of the agents by 2 or more hours to minimize the effects of this interaction. Monitor for decreased therapeutic effects of levodopa during concomitant therapy, particularly if doses cannot be separated. Risk D: Consider therapy modification

Ferric Hydroxide Polymaltose Complex: May decrease the serum concentration of Iron Preparations. Specifically, the absorption of oral iron salts may be reduced. Management: Do not administer intravenous (IV) ferric hydroxide polymaltose complex with other oral iron preparations. Therapy with oral iron preparations should begin 1 week after the last dose of IV ferric hydroxide polymaltose complex. Risk D: Consider therapy modification

Fluorouracil Products: Folic Acid may enhance the adverse/toxic effect of Fluorouracil Products. Risk C: Monitor therapy

Fosphenytoin: Folic Acid may decrease the serum concentration of Fosphenytoin. Risk C: Monitor therapy

Green Tea: May decrease the serum concentration of Folic Acid. Risk C: Monitor therapy

Histamine H2 Receptor Antagonists: May decrease the absorption of Iron Preparations. Risk C: Monitor therapy

Levodopa: Iron Preparations may decrease the serum concentration of Levodopa. Only applies to oral iron preparations. Management: Consider separating doses of the agents by 2 or more hours to minimize the effects of this interaction. Monitor for decreased therapeutic effects of levodopa during concomitant therapy, particularly if doses cannot be separated. Risk D: Consider therapy modification

Levothyroxine: Iron Preparations may decrease the serum concentration of Levothyroxine. Management: Separate oral administration of iron preparations and levothyroxine by at least 4 hours. Separation of doses is not required with parenterally administered iron preparations or levothyroxine. Risk D: Consider therapy modification

Methyldopa: Iron Preparations may decrease the serum concentration of Methyldopa. Management: Consider separating doses of methyldopa and orally administered iron preparation by 2 or more hours. Monitor for decreased efficacy of methyldopa if an oral iron preparation is initiated/dose increase, or increased efficacy if discontinued/dose decreased. Risk D: Consider therapy modification

PenicillAMINE: Polyvalent Cation Containing Products may decrease the serum concentration of PenicillAMINE. Management: Separate the administration of penicillamine and oral polyvalent cation containing products by at least 1 hour. Risk D: Consider therapy modification

PHENobarbital: Folic Acid may decrease the serum concentration of PHENobarbital. Risk C: Monitor therapy

Phenytoin: Folic Acid may decrease the serum concentration of Phenytoin. Risk C: Monitor therapy

Phosphate Supplements: Iron Preparations may decrease the absorption of Phosphate Supplements. Management: Administer oral phosphate supplements as far apart from the administration of an oral iron preparation as possible to minimize the significance of this interaction. Exceptions: Sodium Glycerophosphate Pentahydrate. Risk D: Consider therapy modification

Primidone: Folic Acid may decrease the serum concentration of Primidone. Additionally, folic acid may decrease concentrations of active metabolites of primidone (e.g., phenobarbital). Risk C: Monitor therapy

Proton Pump Inhibitors: May decrease the absorption of Iron Preparations. Risk C: Monitor therapy

Pyrimethamine: Folic Acid may diminish the therapeutic effect of Pyrimethamine. Management: Folic acid doses greater than 2.5 mg per day should be avoided due to the potential for sulfadoxine/pyrimethamine treatment failure. Consider limiting folic acid use to no more than 0.4 mg per day for women of child-bearing age. Risk D: Consider therapy modification

Quinolones: Iron Preparations may decrease the serum concentration of Quinolones. Management: Give oral quinolones at least several hours before (4 h for moxi- and sparfloxacin, 2 h for others) or after (8 h for moxi-, 6 h for cipro/dela-, 4 h for lome-, 3 h for gemi-, and 2 h for levo-, nor-, oflox-, pefloxacin, or nalidixic acid) oral iron. Exceptions: LevoFLOXacin (Oral Inhalation). Risk D: Consider therapy modification

Raltegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Raltegravir. Management: Administer raltegravir 2 hours before or 6 hours after administration of the polyvalent cations. Dose separation may not adequately minimize the significance of this interaction. Risk D: Consider therapy modification

Raltitrexed: Folic Acid may diminish the therapeutic effect of Raltitrexed. Risk X: Avoid combination

Sulfadoxine: Folic Acid may diminish the therapeutic effect of Sulfadoxine. Management: Folic acid doses greater than 2.5 mg per day should be avoided due to the potential for sulfadoxine/pyrimethamine treatment failure. Consider limiting folic acid use to no more than 0.4 mg per day for women of child-bearing age. Risk D: Consider therapy modification

SulfaSALAzine: May decrease the serum concentration of Folic Acid. Risk C: Monitor therapy

Tetracyclines: May decrease the absorption of Iron Preparations. Iron Preparations may decrease the serum concentration of Tetracyclines. Management: Avoid this combination if possible. Administer oral iron preparations at least 2 hours before, or 4 hours after, the dose of the oral tetracycline derivative. Monitor for decreased therapeutic effect of oral tetracycline derivatives. Exceptions: Eravacycline. Risk D: Consider therapy modification

Trientine: Polyvalent Cation Containing Products may decrease the serum concentration of Trientine. Management: Avoid concomitant administration of trientine and oral products that contain polyvalent cations. If oral iron supplements are required, separate the administration by 2 hours. If other oral polyvalent cations are needed, separate administration by 1 hour. Risk D: Consider therapy modification

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Capsule, Oral:

IFerex 150 Forte: Elemental iron 150 mg, cyanocobalamin 25 mcg, and folic acid 1 mg [contains brilliant blue fcf (fd&c blue #1), fd&c yellow #10 (quinoline yellow)]

Myferon 150 Forte: Elemental iron 150 mg, cyanocobalamin 25 mcg, and folic acid 1 mg [contains fd&c blue #1 aluminum lake, fd&c red #40 aluminum lake]

Poly-Iron 150 Forte: Elemental iron 150 mg, cyanocobalamin 25 mcg, and folic acid 1 mg [contains fd&c blue #1 aluminum lake, fd&c red #40 aluminum lake]

Tablet, Oral:

BiferaRx: Iron as polysaccharide iron complex 22 mg, iron as heme iron polypeptide 6 mg, cyanocobalamin 25 mcg, and folic acid 1 mg [DSC] [scored; contains fd&c blue #2 aluminum lake, fd&c red #40 aluminum lake]

Irofol: Elemental iron 150 mg, cyanocobalamin 25 mcg, and folic acid 1 mg

Anatomic Therapeutic Chemical (ATC) Classification

• B03AE01

Generic Available (US)

May be product dependent

Pricing: US

Capsules (IFerex 150 Forte Oral)

150-25-1 mg-mcg-mg (per each): $0.34

Tablets (Irofol Oral)

150-0.025-1 mg (per each): $0.45

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

Effects on Dental Treatment

No significant effects or complications reported

Effects on Bleeding

No information available to require special precautions

Index Terms

Iron Polysaccharide Complex, Vitamin B12, and Folic Acid; Iron-Polysaccharide Complex, Vitamin B12, and Folic Acid

References

BiferaRx (Polysaccharide-Iron Complex, Vitamin B12, and Folic Acid) [prescribing information]. Somerset, NJ: Meda Pharmaceuticals; November 2015.

Hershko C and Camaschella C. How I treat unexplained refractory iron deficiency anemia. Blood. 2014;123(3):326-333. doi: 10.1182/blood-2013-10-512624.[PubMed 24215034]

IOM (Institute of Medicine), Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc, Washington, DC: National Academy Press, 2001.

Liu K and Kaffes AJ. Iron deficiency anaemia: a review of diagnosis, investigation and management. Eur J Gastroenterol Hepatol. 2012;24(2):109-116. doi: 10.1097/MEG.0b013e32834f3140.[PubMed 22157204]

“Recommendations to Prevent and Control Iron Deficiency in the United States. Centers for Disease Control and Prevention,” MMWR Recomm Rep, 1998, 47(RR-3):1-29.[PubMed 9563847]

Schrier SL, Auerbach M. Treatment of iron deficiency anemia in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed March 25, 2019.

Stoffel NU, Cercamondi CI, Brittenham G. Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing in iron-depleted women: two open-label, randomised controlled trials. Lancet Haematol. 2017;4(11):e524-e533. doi: 10.1016/S2352-3026(17)30182-5.[PubMed 29032957]

Last Updated 3/28/20