Kate Street

The use of intravenous (IV) iron among Australian women has increased dramatically over the past decade.1 A recent Australian study reported a 17-fold increase in iron infusion use among women aged 18-44 years between 2013 and 2024, rising from 0.3% to 5.0% of women.1 By 2024, approximately 1 in 20 Australian women of reproductive age received an iron infusion.1 Healthcare expenditure followed a similar trajectory, increasing from $1.1 million to more than $82 million annually.1These figures highlight both the significant medical and financial burden of iron deficiency and the growing role of IV iron in clinical practice. While the rise in iron infusions may partly reflect improved recognition and treatment of iron deficiency, it also points to an opportunity for earlier intervention.1 Identifying declining iron stores, investigating underlying drivers, and optimising management before deficiency progresses may help reduce the need for more intensive treatment approaches.3<h2>A growing clinical challenge
</h2>Iron deficiency remains the most common nutritional deficiency worldwide, affecting up to 25% of the global population.2 Women of reproductive age are particularly vulnerable due to ongoing menstrual blood loss and periods of increased physiological demand such as pregnancy, postpartum recovery, and breastfeeding.1,3Importantly, iron deficiency often develops gradually.2 Iron stores can decline long before haemoglobin falls below the normal range, meaning symptoms may emerge while standard markers for anaemia remain within reference intervals.2 Fatigue, reduced exercise capacity, poor concentration, headaches, hair loss, and diminished quality of life may all occur before iron deficiency anaemia develops.4 Iron studies are therefore key and are best interpreted as a whole, considering ferritin and transferrin saturation (TSAT) alongside haemoglobin and inflammatory markers such as C-reactive protein (CRP).2,4The growing use of iron infusions may in part reflect greater awareness that iron deficiency can be clinically significant even in the absence of anaemia.1 Increased screening and earlier recognition are positive developments, but they also highlight the importance of addressing underlying causes and implementing effective management strategies before iron depletion becomes more severe.
<h2>Understanding the rise in iron infusions
</h2>The rise in IV iron is likely multifactorial, reflecting greater recognition of iron deficiency, increased testing of iron status in people without anaemia, and the need for rapid iron repletion in situations such as pregnancy or pre-operative care.1At the same time, many patients face ongoing challenges that can make restoring and maintaining iron status difficult. Heavy menstrual bleeding (menorrhagia), inadequate dietary intake, gastrointestinal disorders leading to malabsorption, chronic inflammation, frequent blood donation, and increased physiological requirements can all contribute to declining iron stores.4For some individuals, oral iron therapy presents another hurdle. Gastrointestinal side effects such as nausea, abdominal discomfort, and constipation are common reasons for poor adherence.1 However, tolerability can vary between iron formulations. <a href="https://www.blackmoresinstitute.org/articles/iron-absorption-why-form-matters" target="_self">Certain forms, such as iron bisglycinate, have been associated with improved gastrointestinal tolerability compared with some traditional ferrous salts in select populations,5 highlighting the importance of choosing an appropriate formulation and dosing strategy7 before escalating treatment. </a><h2>Important clinical considerations 
</h2>IV iron has become an invaluable treatment option when rapid replenishment is required or when oral therapy is ineffective or inappropriate.1 For many patients, it can restore iron stores quickly and effectively.1 However, increasing reliance on infusions also warrants consideration of potential adverse effects.6Recent media coverage has drawn attention to hypophosphataemia, a condition characterised by low blood phosphate levels that can occur following the administration of some IV iron formulations .6 Symptoms may include fatigue, muscle weakness, bone pain, and myalgia, while repeated or severe cases may rarely contribute to osteomalacia, myopathy, arrhythmias, and cardiomyopathy.6 Evidence highlights that hypophosphataemia may occur more frequently with some IV iron formulations than others, particularly ferric carboxymaltose, reinforcing the need for appropriate patient selection and monitoring.6 Other recognised risks of IV iron therapy include infusion-site skin staining and rare hypersensitivity reactions.1These risks should be considered within the broader context of patient care. Iron infusions remain an important and often necessary intervention, but they should ideally form part of a comprehensive management strategy rather than the sole solution.<h2>Preventing progression to deficiency
</h2>As our understanding of iron regulation evolves, the conversation is shifting from simply replacing iron to optimising how iron is prescribed, absorbed, and utilised. Before progressing to IV therapy, it may also be worth reviewing the oral iron regimen.4<a href="https://www.blackmoresinstitute.org/articles/iron-deficiency-hepcidin-translating-evidence-into-clinical-practice" target="_self"> Emerging evidence suggests that traditional high-dose daily regimens can increase gastrointestinal side effects while also elevating hepcidin, the hormone that regulates iron absorption.7 </a> This has prompted growing interest in lower-dose, alternate-day prescribing strategies7 and forms such as iron bisglycinate, which is thought to be more bioavailable and may improve tolerability in some patients.5Table 1. The six C’s for iron management: A clinical approach to optimising iron status:<table><tbody><tr><td>Opportunity</td><td>Clinical focus</td></tr><tr><td>Cause</td><td>Identify and address the underlying driver of deficiency, such as heavy menstrual bleeding, inadequate dietary intake, malabsorption, gastrointestinal disorders, chronic inflammation, or periods of increased physiological demand.4</td></tr><tr><td>Consume</td><td>Encourage adequate intake of iron-rich foods, including haem iron sources where appropriate, and dietary strategies that enhance non-haem iron absorption.8</td></tr><tr><td>Counteract</td><td>Minimise factors that impair iron absorption, including dietary inhibitors such as phytates, calcium, polyphenols, and tannins,8 <a href="https://www.blackmoresinstitute.org/depletions" target="_self">as well as medications that affect absorption including proton pump inhibitors (PPIs), and H2-blockers. 9</a></td></tr><tr><td>Consider</td><td>Implement evidence-informed supplementation strategies, including hepcidin-aware approaches such as lower-dose or alternate-day dosing where clinically appropriate,7 while selecting formulations that support tolerability and adherence.5</td></tr><tr><td>Cofactors</td><td>Consider nutritional cofactors involved in iron absorption, transport and utilisation, including vitamin C,7 lactoferrin,10 vitamin A/beta-carotene, vitamins B6, B9, and B12, magnesium,11 and adequate protein intake.8</td></tr><tr><td>Check</td><td>Monitor treatment response using appropriate pathology markers, including ferritin, haemoglobin (Hb), transferrin saturation (TSAT), and inflammatory markers such as C-reactive protein (CRP), with reassessment approximately 6-8 weeks after commencing treatment.4</td></tr></tbody></table>This proactive approach shifts the focus from simply correcting iron deficiency to understanding why it developed in the first place and supporting long-term iron health.<h2>Conclusion
</h2>Iron infusions can be transformative for patients with significant iron deficiency, particularly when rapid repletion is needed or oral therapy has not been successful. Their growing use reflects both the substantial burden of iron deficiency and the important role IV iron plays in modern clinical care. However, the significant increase in iron infusion use also highlights an opportunity to intervene earlier. By identifying declining iron stores, investigating underlying causes, and optimising dietary and oral iron strategies, healthcare practitioners may be able to help more patients restore iron status without the need for an infusion. References
1 Kassie GM, Jackson H, Clarke L, Gonete K, Ilomaki J, Whitehead CL, et al. Increasing utilisation of intravenous iron among Australian women of reproductive age, 2013-2024: an Australian population-based study. Intern Med J. 2026;56(9):1536–43. doi:10.1111/imj.704942 Kolarš B, Mijatović Jovin V, Živanović N, Minaković I, Gvozdenović N, Dickov Kokeza I, et al. Iron deficiency and iron deficiency anemia: A comprehensive overview of established and emerging concepts. Pharmaceuticals (Basel). 2025;18(8):1104. doi:10.3390/ph180811043 Petraglia F, Dolmans MM. Iron deficiency anemia: Impact on women’s reproductive health. Fertil Steril. 2022;118(4):605–6. doi:10.1016/j.fertnstert.2022.08.8504 Al-Naseem A, Sallam A, Choudhury S, Thachil J. Iron deficiency without anaemia: a diagnosis that matters. Clin Med. 2021;21(2):107–13. doi:10.7861/clinmed.2020-05825 Fischer JAJ, Cherian AM, Bone JN, Karakochuk CD. The effects of oral ferrous bisglycinate supplementation on hemoglobin and ferritin concentrations in adults and children: a systematic review and meta-analysis of randomized controlled trials. Nutr Rev. 2023;81(8):904–20. doi:10.1093/nutrit/nuac1066 Ta B, Baddock S, Ludington J, Sheu A. Hypophosphataemia following iron infusion: a narrative review of an increasingly recognised complication. Intern Med J. 2026;56(9):1500–9. doi:10.1111/imj.705767 Stoffel NU, von Siebenthal HK, Moretti D, Zimmermann MB. Oral iron supplementation in iron-deficient women: How much and how often? Mol Aspects Med. 2020;75(100865):100865. doi:10.1016/j.mam.2020.1008658 Piskin E, Cianciosi D, Gulec S, Tomas M, Capanoglu E. Iron absorption: Factors, limitations, and improvement methods. ACS Omega. 2022;7(24):20441–56. doi:10.1021/acsomega.2c018339 Blackmores Institute. 2024. Drug-Nutrient Depletions Guide. Available from: https://www.blackmoresinstitute.org/depletions10 Conesa C, Bellés A, Grasa L, Sánchez L. The role of lactoferrin in intestinal health. Pharmaceutics. 2023;15(6):1569. doi:10.3390/pharmaceutics1506156911 Kumar SB, Arnipalli SR, Mehta P, Carrau S, Ziouzenkova O. Iron deficiency anemia: Efficacy and limitations of nutritional and comprehensive mitigation strategies. Nutrients. 2022;14(14):2976. doi:10.3390/nu14142976

<h2>Key highlights
</h2><ul><li>Iron infusion use among Australian women of reproductive age has risen 17-fold over the past decade, reflecting the significant burden of iron deficiency and increased recognition of its clinical impact.</li><li>Iron infusions have an important place in modern clinical care however their increasing use also highlights opportunities for earlier intervention and prevention.</li><li>Many patients may benefit from a proactive approach that identifies declining iron stores before deficiency progresses. </li><li>Optimising oral iron therapy through formulation choice, dosing strategy, and the management of absorption barriers may help to improve treatment success.</li><li>Effective iron management extends beyond iron replacement alone, requiring attention to underlying causes, dietary factors, cofactors, and ongoing monitoring.</li></ul>

Key highlights

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