Dear Dr. Roach: My mother is 82. About two years ago, she was diagnosed with low iron. All tests came back negative. She can’t tolerate an iron infusion and is allergic to iron pills and/or vitamins with iron. She eats foods that are high in iron, like liver, and drinks a little bit of red wine. Her score was 41 mcg/dL, which is a little bit higher then it was last year. She gets tired easily now, but my mother has always been a very energetic, active person. What else can be done?
C.D.
When iron levels are low, there are three big questions to ask: Is the patient getting iron, are they able to absorb iron, and are they losing too much iron? Inadequate intake isn’t a common problem, but is seen occasionally in clinical practice. Most of the foods that are high in iron are meat. Although there is iron in grape skins, some other compounds in red wine make the iron in wine unable to be absorbed, so don’t ever think of wine as a good source of iron (or really as any kind of health food).
I don’t think your mother’s problem is that she’s not taking in enough iron-rich foods. When it comes to allergic reactions to iron pills, most reactions are not allergies to the iron, but to fillers in the pill. Changing the type of iron pill usually solves that problem. There are also newer formulations of iron by injection, which are sometimes necessary and don’t have near as much potential for a reaction as the old iron dextran injections.
Being unable to absorb iron is also uncommon, but it’s a lot more common than we used to think. Celiac disease is the most common of the conditions that prevent iron absorption. Autoimmune gastric atrophy, a bacterial infection (like H. pylori), bariatric surgery, and medicines that reduce stomach acid (like omeprazole) all reduce iron absorption.
In an 82-year-old, iron loss is a major concern. In a woman who doesn’t menstruate, and in any man over 40, iron deficiency is colon cancer until you prove it isn’t. If your mother hasn’t had a full colonoscopy with good prep and clear visualization of the entire colon, that needs to be done. I sometimes hear that a person is too old for a colonoscopy, but I strongly disagree with that in the vast majority of cases — the exception being someone who is seriously or terminally ill with a different condition. Colon cancer is curable in nearly all cases if it is found early. Even finding incurable colon cancer is worthwhile, because preventing an obstruction avoids a crisis.
There are other places in the body where iron loss is possible, including nosebleeds, intestinal polyps, telangiectasias (easily broken abnormal blood vessels), parasites and stomach ulcers.
With your mother, the next and most important step is to make sure she has had a colon evaluation. If she really has had a thorough colon evaluation, the next steps are to look for possible causes of poor absorption or other places where she might be losing blood.
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 [email protected]
