Tox in The Land: Iron Toxicity

The Case

A 16-year-old female presents to the emergency department for an intentional overdose of iron pills after a fight with her boyfriend. She notes that she has taken 40 pills of her mom’s iron tablets. Should you be concerned?

Well it depends…

Iron Toxicity

To better discern whether our patient has a potentially lethal ingestion of iron, we need a little more information.

  • Iron supplements come in a variety of forms, all of which have different concentrations of elemental iron.

  • This information is vital for us to ascertain, as it can guide our expected clinical course for the patient.

  • There are three forms of supplemental iron: Iron Fumarate, Iron Sulfate, and Iron Gluconate.

    • I use the following mnemonic to remember the concentration of elemental iron in each (shoutout to our friends at OHSU Tox for this one)

  • A 357 Magnum is a Fast Shooting Gun

    • Iron Fumarate: 1/3 elemental iron

    • Iron Sulfate: 1/5 elemental iron

    • Iron Gluconate 1/7 elemental iron

Our Patient

  • When talking with our patient’s mother, she is able to show us her medication list and demonstrate that she is taking Iron Gluconate 300 mg once daily.

  • Based on this information, we can calculate out to see that the patient has taken about 1.7 grams of elemental iron.

  • A 357 Magnum is a Fast Shooting Gun

    • Iron Fumarate: 1/3 elemental iron

    • Iron Sulfate: 1/5 elemental iron

    • Iron Gluconate 1/7 elemental iron

  • (300 mg iron gluconate) x (1/7) x (40 tablets) = 1.7 grams

Stages of Toxicity

Emergency Evaluation

  • The usuals

    • EKG, metabolic panel, CBC, coagulation screen, liver function testing, and acetaminophen/salicylate levels.

  • The extras

    • With an unclear story a KUB can be useful to evaluate for radio-opaque tablets in the stomach

      • It however does not rule out or rule in ingestions reliably on its own

    • Serum Iron level between 4-6 hours post ingestion

      • When serum concentrations will be the highest

  • If you don’t have the information for weight-based ingestion, this level can help guide your expected course as well:



Treatment

  • Symptomatic management.

    • Utilize antiemetics (keeping in mind QTc based on possible co-ingestions

    • Resuscitate with IV fluids despite our current shortage

  • Antidote therapy

    • Deferoxamine for chelation therapy

  • Additional therapies

    • WBI

    • FFP/Vitamin K

    • Hemodialysis




Deferoxamine

  • When to use your antidote?

    • If a patient develops hypotension or metabolic acidosis, just give it.

    • If they have a confirmed severe ingestion… just give it.

    • If they have severe toxicity based on blood iron levels, you can use this as well.

  • Side effects

    • It can worsen a vasodilatory state & hypotension---why it’s started at 15mg/kg/hr and increased as tolerated to 45mg/kg/hr

      • Supplement with IVF/Vasopressors as needed

    • Pulmonary edema

    • Yersinia infections

  • Dosing

    • Maximum of 8 grams in the first 24-hour period.

    • This should be stopped after 24 hours or 8 grams (whichever comes first).




Disposition

  • 3 decision points to consider

    • Asymptomatic at 6 hours

      • Medically clear for DC vs psychiatry evaluation

    • Submassive ingestions with isolated GI symptoms

      • Regular nursing floor

    • Requiring antidote or adjunctive therapies

      • ICU level of care due to high risk of decompensation.

  • For our patient, her ingestion resulted in moderate GI symptoms requiring 24 hours of regular nursing floor care for IV fluids and antiemetic therapy.

  • She was able to be discharged home after psychiatry evaluation.

AUTHORED BY: MATTHEW MULLINS, MD

FACULTY EDITING BY: LAUREN PORTER, DO

References

  • Yuen HW, Becker W. Iron Toxicity. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459224/

  • Baranwal AK, Singhi SC. Acute iron poisoning: management guidelines. Indian Pediatr. 2003 Jun;40(6):534-40.

  • Singhi SC, Baranwal AK, M J. Acute iron poisoning: clinical picture, intensive care needs and outcome. Indian Pediatr. 2003 Dec;40(12):1177-82.

  • Nickson DC. Iron Overdose • LITFL • CCC Toxicology. Life in the Fast Lane • LITFL • Medical Blog. Published January 4, 2019. https://litfl.com/iron-overdose/

    OHSU Tox. OHSU Tox Shorts: Iron Toxicity. YouTube. Published January 22, 2016. Accessed November 14, 2024. https://www.youtube.com/watch?v=mAEKdZFoAjk

ToxLauren McCaffertytox, toxicology, iron toxicity, iron, deferoxamine