Ask four patients what iron they take and you will often get four different answers: "just Spatone", "the big red pills", "Pregacare Plus", or "the ones the doctor gave me". All of them contain iron. None of them contain the same amount, in the same salt, or absorbed at the same rate. Community pharmacy sees iron deficiency arrive from different directions — pregnancy, heavy menstrual bleeding, coeliac disease, a vegetarian or vegan diet — and the supplement that fits one indication often underserves another.

This piece sits within PharmSee's supplement-evidence series and focuses on how to match product to need.

The three main supplemental iron options

Ferrous fumarate 210 mg (about 65 mg elemental iron per tablet). The workhorse of NHS prescribing. Generic, inexpensive, widely tolerated once dose-fractionated. Equivalent products are stocked by essentially every community pharmacy.

Ferrous sulfate 200 mg (about 65 mg elemental iron per tablet). Similar elemental content. Gastrointestinal tolerance is comparable on a population level but individual patients often prefer one over the other.

Ferrous gluconate 300 mg (about 35 mg elemental iron per tablet). Lower elemental content per tablet, sometimes chosen for patients with troublesome GI side effects — though the effective dose must be adjusted upward to compensate.

Liquid preparations (ferrous sulfate elixir, sodium feredetate) and iron-water products (Spatone) sit outside the tablet comparison and serve specific cases such as paediatric use, pregnancy with severe nausea, or preference.

The alternate-day question

NICE CKS and a body of observational evidence since 2015 now support alternate-day rather than daily dosing of oral iron in many cases of established deficiency. Fractional absorption rises and hepcidin-driven blockade falls when dosing is spaced. Alternate-day dosing is not written into every NHS prescription yet, but it is an increasingly common community pharmacy counselling point — particularly for patients tolerating daily dosing poorly.

Pregnancy

Routine antenatal iron supplementation is not universally offered in the UK; the NICE antenatal care guideline focuses on treating confirmed deficiency rather than mass prophylaxis. Where iron deficiency is diagnosed in pregnancy, first-line treatment is typically ferrous fumarate 210 mg once or twice daily. Second-line is ferrous sulfate. Both have extensive safety data in pregnancy. Iron-containing pregnancy multivitamins (Pregnacare Plus and equivalents) deliver around 14 mg elemental iron per day — useful for general nutritional support, inadequate as treatment for established anaemia. Counsel the difference.

Nausea and vomiting of pregnancy complicate dosing. Moving the dose to bedtime, pairing with vitamin C, or stepping to a liquid preparation all help.

Heavy menstrual bleeding

Heavy menstrual bleeding (HMB) is the leading cause of iron-deficiency anaemia in working-age women. NICE NG88 emphasises investigating the bleeding alongside replacing iron, because high-output loss will outpace oral supplementation. Community pharmacy should recognise that an HMB patient often needs:

• A higher cumulative iron dose than someone recovering from a single bout of deficiency.
• Regular ferritin monitoring (primary-care managed).
• An active conversation with the GP about tranexamic acid, NSAIDs or hormonal options to reduce ongoing loss.

Recommending iron alone to a patient still losing heavy volumes is well-intentioned and frequently insufficient. Signpost to GP review.

Coeliac disease

Coeliac disease is associated with iron malabsorption at the proximal small bowel. NICE NG20 recommends oral iron as first-line where deficiency is documented, but a meaningful minority of patients absorb poorly even on a gluten-free diet and require intravenous iron — dispensed through hospital or specialist pathways, not the community counter. A coeliac patient who is not responding to oral iron after a reasonable trial is a referral, not a higher-dose candidate.

Vegetarian and vegan diets

Plant-based diets contain non-haem iron only. Absorption is lower than for haem iron, but the dietary gap is manageable for most people with attention to intake. Community pharmacy recommendations should reflect that:

• Most vegetarians and vegans are not iron-deficient. Routine supplementation is not needed.
• When deficiency is diagnosed, standard oral iron works. Vitamin C co-administration at the same time as the iron dose is a simple, evidence-supported adjunct.
• Tea and coffee at or near the iron dose reduces absorption — this counselling is cheap and effective.

Matching indication to product

Red flags at the counter

• Persistent fatigue plus a pale or tired appearance with no recent bloods: push for primary-care investigation.
• Heavy menstrual loss described as soaking through products hourly: referral rather than supplementation.
• Melaena or fresh rectal bleeding: urgent referral — iron deficiency can mask GI pathology.
• Unintentional weight loss with anaemia: urgent referral.

Caveats

Recommendations in this article follow NICE CKS and current BNF formulations. Iron preparations change specification occasionally; always work from current BNF data. Community pharmacy OTC recommendation is no substitute for a ferritin result and a diagnosis. For PharmSee's broader coverage of supplement evidence, see the pharmacy blog.

Sources

• NICE CKS: Anaemia - iron deficiency.
• NICE NG88: Heavy menstrual bleeding assessment and management.
• NICE NG20: Coeliac disease recognition, assessment and management.
• BNF treatment summary: Iron deficiency anaemia.