Iron deficiency anemia in low- and middle-income countries

To the editor:

The paper by Pasricha et al¹  addresses several issues on the control of iron deficiency anemia (IDA) in low- and middle-income countries. When dealing with the topic of iron supplementation or fortification, a major topic is overlooked, which is critical and of concern in developing countries.

Iron is highly effective in treating IDA; this therapy is usually straightforward, simple, and inexpensive, and most of the time the response is predictable and gratifying. The standard preparation for oral use is ferrous sulfate; ferrous gluconate and ferrous fumarate are equally satisfactory and have about the same incidence of side effects.²  However, oral iron hydroxide polymaltose (IP) preparations are ferric compounds that have been licensed as well as heavily promoted in developing countries to treat IDA^2-6 ; interestingly, these preparations are not available in developed countries. Compared with ferrous salts, oral ferric salts are less absorbable but less aggressive to the gastrointestinal tract. The better gastrointestinal tolerability of IP has been widely used as an argument to promote its use in the treatment and prevention of IDA in some countries. However, its ineffectiveness has also been clearly identified.^2-6  As a result of the heavy advertisement campaigns in Mexico, both general practitioners and internists prescribe oral IP as the first choice in the treatment of IDA. In Mexico, oral IP preparations are at least 15% more expensive than ferrous fumarate. Since hemoglobin levels fail to increase in most patients given oral IP,^2-6  selecting adequate iron preparations for either fortification or supplementing food is of particular interest in low- and middle-income countries where IP is being widely distributed.