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Iron, anaemia and inflammation

The following information is not intended to be medical advice. As always, please consult your doctor before starting a new supplement, or changing it, since there can be interactions with medications, toxic effects from too-high a dose and side-effects.

It’s an often overlooked fact that many people with acute or chronic inflammation have anaemia. According to Wikipedia anaemia is “a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of haemoglobin. When anaemia comes on slowly, the symptoms are often vague, such as tiredness, weakness, shortness of breath, headaches, and a reduced ability to exercise.”


Inflammation triggers a number of significant changes in the metabolism of iron. When inflammatory cytokines are produced iron is removed from the blood and stored inside cells, thus reducing the concentration of iron in serum [1]. Adding to this effect, iron absorption from the gut decreases, and the enzymes that normally make stored iron available are degraded - this is particularly severe in women, due to the effects of sex hormones [1]. These changes in metabolism are a strategy for fighting infections, since the removal of iron starves invading bacteria of that essential nutrient they need for growth, but unfortunately, it also starves our body in the process. To make matters worse, red blood cells (that carry oxygen) die more quickly, have reduced capacity, and new red blood cells are made more slowly in anaemic people [1].


Around 30% of adults who are planning surgery have preoperative anaemia [2]. If you’re planning surgery, or have recently had surgery, you should have your iron levels checked, and people with long-term arthrofibrosis should also have regular blood tests to check serum iron levels.

In addition to its important role in transporting oxygen around the body, iron is crucial for a host of biochemical pathways, including the production of energy, DNA and hormones. Therefore, iron deficiency and anaemia are serious health problems that should be corrected [1]. Anaemia is prevalent in people with chronic low-level inflammation and in many medical conditions, even aging, and pre and post-operative anaemia increases the risk of adverse surgical outcomes [2]. In addition, many healthy people (especially women) also have an iron deficiency, often without anaemia.


Iron replacement therapy is usually the first-line treatment for anaemia, and this can be in oral or intravenous form. Oral forms are usually adequate unless there is gut inflammation (reducing absorption). Milk, tea and proton pump inhibitors (for gastritis) decrease iron bioavailability, while overnight fasting and vitamin C increase iron absorption [1]. Where anaemia is diagnosed prior to surgery, intravenous or injected iron is often the preferred treatment, since it rapidly corrects the deficiency compared to oral iron.


Interestingly, research indicates that oral iron should only be taken once a day in the morning, since taking it more frequently reduces iron uptake [1]. When oral forms of iron are not properly absorbed there can be gastrointestinal side effects, but stomach upsets can be reduced by taking iron with food – but unfortunately, this reduces the amount of iron that is absorbed. Oral iron bis-glycinate is often better tolerated than iron sulphate. Please note that too much iron can be toxic, and more is not necessarily better.


Folic acid, vitamin B12 and vitamin D deficiencies are often also involved in anaemia, and contribute to it, so blood tests to check the levels of these are advisable. Lactoferrrin, a natural compound found in milk, increases iron uptake and has interesting therapeutic potential for arthrofibrosis, with studies showing anti-inflammatory [3] and anti-fibrotic effects in animal models [4]. In addition, when anaemia results from inflammation, anti-inflammatory treatments such as IL-1 and TNF-α inhibitors can successfully treat it [1].



References

  1. Lanser, L., Fuchs, D., Kurz, K. & Weiss, G. Physiology and Inflammation Driven Pathophysiology of Iron Homeostasis-Mechanistic Insights into Anemia of Inflammation and Its Treatment. Nutrients 13, doi:10 [3].390/nu13113732 (2021).

  2. Kaufner, L. et al. Erythropoietin plus iron versus control treatment including placebo or iron for preoperative anaemic adults undergoing non-cardiac surgery. Cochrane Database Syst Rev 8, CD012451, doi:10 [1].002/14651858.CD012451.pub2 (2020).

  3. Kell, D. B., Heyden, E. L. & Pretorius, E. The Biology of Lactoferrin, an Iron-Binding Protein That Can Help Defend Against Viruses and Bacteria. Front Immunol 11, 1221, doi:10 [3].389/fimmu [2].020.01221 (2020).

  4. Al-Najjar, A. H., Ayob, A. R. & Awad, A. S. Role of Lactoferrin in Treatment of Bile Duct Ligation-Induced Hepatic Fibrosis in Rats: Impact on Inflammation and TGF-β1/Smad2/α SMA Signaling Pathway. Journal of Clinical and Experimental Hepatology, doi:10 [1].016/j.jceh [2].022 [1] [2]..014 (2022).



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