Iron Supplement (Ferrous Sulfate / Ferrous Ascorbate / Ferrous Fumarate)
Also sold as: Feronia XT, Orofer, Autrin, Dexorange, Fefol, Livogen, Ferium XT, Feriday
Pregnancy
Cat A
Lactation
Safe
Schedule
OTC
Forms
Tablet — ferrous sulfate 200mg (contains 65mg elemental iron) +5
Indications
- Iron deficiency anaemia (IDA)
- Iron deficiency without overt anaemia (low ferritin)
- Prevention of iron deficiency in pregnancy and lactation
- Anaemia of prematurity (premature infants)
- Nutritional iron deficiency in children
- Iron replacement post-GI bleeding, menorrhagia, or surgery
- Pre-operative haemoglobin optimization
- Iron deficiency in inflammatory bowel disease (IBD)
Adult Dosing
Iron deficiency anaemia — treatment
100–200mg elemental iron daily in 1–3 divided doses
Until Hb normalises (6–12 weeks), then continue 3–6 months to replete stores
Take on empty stomach 30–60 minutes before meals for best absorption; can take with food if GI side effects intolerable (reduces absorption by ~30–40%)
Iron deficiency without anaemia (low ferritin)
50–100mg elemental iron daily or alternate-day dosing
3–6 months; alternate-day dosing may improve absorption and reduce GI side effects
Emerging evidence: alternate-day dosing (skip a day) increases absorption by allowing hepcidin reset
Prevention (pregnancy)
60mg elemental iron daily (WHO recommendation) + 400 mcg folic acid
Throughout pregnancy and 3 months postpartum
India's National Iron + Folic Acid Supplementation Programme: daily IFA tablets for all pregnant women
Menorrhagia-related IDA
100–200mg elemental iron daily until stores replete; address underlying cause
Until ferritin >50 ng/mL and Hb normalized
Pediatric Dosing
Give pediatric drops or syrup (not adult tablets). Mix drops with water, juice (NOT milk — reduces absorption). Infants born preterm: start 2 mg/kg/day at 2–4 weeks of life. Formula-fed infants: use iron-fortified formula. Do NOT give cow's milk to children <12 months (low iron, poor absorption, and causes GI blood loss).
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| CKD on EPO therapy | Often requires IV iron (iron sucrose or ferric carboxymaltose) as oral iron is poorly absorbed in CKD and inflammation; target ferritin 200–500 ng/mL and TSAT ≥20% |
| CKD without EPO (non-dialysis) | Oral iron 100–200mg elemental iron/day; IV iron if inadequate response or intolerance |
Hepatic Adjustment
Iron overload conditions associated with liver disease (cirrhosis, hemochromatosis): CONTRAINDICATED supplementation without confirmed deficiency. Serum ferritin is unreliable as iron status marker in liver disease (acute phase reactant).
Pregnancy & Lactation
Pregnancy: Category A
Iron supplementation is essential in pregnancy — physiological demand doubles. 95% of Indian pregnant women are iron-deficient. WHO recommends 60mg elemental iron + 400 mcg folic acid daily from first antenatal contact. Iron deficiency anaemia in pregnancy increases risk of maternal mortality, preterm birth, and low birth weight. Severe anaemia (Hb <7g/dL) in pregnancy requires IV iron or blood transfusion.
Lactation: Safe
Oral iron supplementation is safe during breastfeeding. Negligible transfer to breast milk — maternal iron supplementation does not substantially alter breast milk iron content. Continue supplementation 3 months postpartum (especially after significant postpartum blood loss).
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| Calcium supplements / Dairy products / Antacids | Calcium significantly reduces iron absorption (up to 60%); take iron ≥2 hours apart from calcium, dairy, or antacids | Moderate |
| Fluoroquinolone antibiotics (ciprofloxacin, levofloxacin, norfloxacin) | Iron chelates fluoroquinolones; reduces antibiotic plasma levels by up to 90%; take iron ≥2 hours before or 6 hours after fluoroquinolone | Major |
| Tetracycline / Doxycycline | Iron chelates tetracyclines; severely reduces antibiotic absorption; separate by ≥2–3 hours | Major |
| Levothyroxine (thyroid medication) | Iron reduces levothyroxine absorption by binding in gut; separate by ≥4 hours; take levothyroxine first thing in morning on empty stomach | Major |
| Levodopa / Carbidopa (Parkinson's medication) | Iron reduces levodopa absorption and may form iron-levodopa chelate; take separately by ≥2 hours | Moderate |
| Vitamin C (ascorbic acid) | Vitamin C increases non-haem iron absorption up to 3-fold by reducing ferric Fe3+ to ferrous Fe2+ form; take with iron or use ferrous ascorbate formulation | Minor |
| Proton pump inhibitors / H2-blockers | Reduced gastric acid impairs iron absorption (requires acidic environment); may need higher doses or IV iron | Moderate |
| Antacids (aluminium / magnesium hydroxide) | Reduce iron absorption; take iron 1–2 hours before antacid | Moderate |
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Side Effects
Common
- Dark / Black stools (very common; harmless — iron metabolite; reassure patients)
- Constipation
- Nausea and vomiting
- Abdominal cramping / Pain
- Diarrhea (less common)
- Metallic taste
- Staining of teeth (liquid formulations; use straw and rinse mouth)
Serious / Discontinue If
- Iron overdose / Poisoning (especially in children) — can be FATAL; acute: vomiting blood, metabolic acidosis, liver failure; KEEP OUT OF REACH OF CHILDREN
- Iron overload (hemosiderosis / hemochromatosis) with prolonged unsupervised high-dose supplementation or hereditary hemochromatosis
- Anaphylaxis (IV iron formulations — less common with iron sucrose and ferric carboxymaltose than with older iron dextran)
- Gastrointestinal ulceration / Erosion (with modified-release formulations releasing iron in GI mucosa)
- Exacerbation of inflammatory bowel disease (oral iron — consider IV iron in active IBD)
Contraindications
- Haemochromatosis or other iron overload states
- Haemolytic anaemia (without concurrent iron deficiency)
- Regular blood transfusions (iron overload risk)
- Anaemia NOT due to iron deficiency (confirm diagnosis before prescribing)
- Hypersensitivity to iron formulation (especially IV iron)
- Active gastrointestinal conditions (ulcerative colitis, Crohn's active disease — relative; consider IV iron)
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Feronia XT | Mankind Pharma (ferrous ascorbate + folic acid) | 10 tab ₹35 |
| Orofer XT | Emcure Pharmaceuticals | 10 tab ₹42 |
| Autrin | Pfizer Ltd | 30 cap ₹85 |
| Dexorange | Franco-Indian Pharmaceuticals | 200 mL syrup ₹95 |
| Livogen | MSD India (ferrous fumarate + folic acid) | 30 tab ₹65 |
| Fefol | GlaxoSmithKline (ferrous sulfate + folic acid) | 30 cap ₹75 |
| Ferium XT | Sun Pharmaceutical | 10 tab ₹38 |
Monitoring Required
- Haemoglobin (Hb) at baseline and every 4–6 weeks during treatment; expect rise of 1–2 g/dL per 3–4 weeks
- Serum ferritin (iron stores) — target >50 ng/mL; treatment until ferritin >50–100 ng/mL
- Serum iron and TIBC / transferrin saturation (TSAT)
- Reticulocyte count (rises within 7–10 days of effective iron therapy — earliest response marker)
- Identify and treat underlying cause of iron deficiency (GI bleed, menorrhagia, dietary deficiency)
- In children: Hb every 4 weeks during treatment
- IV iron: monitor for anaphylaxis at 30 minutes post-infusion; check Hb and ferritin at 4 weeks
Patient Counseling Points
- Take iron on an EMPTY STOMACH (30–60 minutes before food) for best absorption — if stomach upset occurs, take with a small amount of food
- Take with a glass of orange juice or vitamin C — it significantly improves iron absorption
- Do NOT take iron with milk, tea, coffee, or calcium tablets — they block iron absorption
- IMPORTANT: Separate iron from thyroid tablets (levothyroxine) by at least 4 hours
- IMPORTANT: Separate from antibiotics (ciprofloxacin, doxycycline) by at least 2 hours
- Black or dark green stools are NORMAL and expected — iron turns stool dark; this is not blood
- Constipation is common — increase water intake, fibre-rich foods, and light exercise
- Liquid iron preparations for children: use measuring dropper; give with juice (not milk); rinse mouth afterwards to prevent tooth staining
- KEEP ALL IRON TABLETS AND DROPS LOCKED AWAY FROM CHILDREN — iron overdose is a medical emergency in children
- Do not stop early — even when Hb normalizes, continue for 3–6 months to replenish iron stores
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Clinically reviewed by: Dr. Rekha Dani, MD (Medicine), DM (Haematology), Tata Memorial Hospital Mumbai
Last reviewed: 2026-04-10
References
- WHO — Daily Iron and Folic Acid Supplementation in Pregnant Women 2012
- ICMR — Iron Supplementation Guidelines India 2020
- Indian Academy of Pediatrics — Iron Deficiency Anaemia Guidelines 2022
- BNF 85 — Ferrous sulfate / Ferrous ascorbate
- UpToDate — Treatment of iron deficiency anaemia in adults
- Lancet — Alternate-day oral iron supplementation, 2017