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00:10
Hey everyone, it's Mikki here. You're listening to Mini Mikkipedia. And today I wanna chat about the risk of hypophosphatemia and an iron infusion. So this has come up a couple of times actually in my clinic and the first I heard about it was when a friend of mine posted on her social media channel that after having an iron infusion where she expected to feel really great in a week's time, she felt even worse. And then

00:40
Upon further investigation, it was revealed that due to the iron infusion, she now had dangerously low phosphate levels. So first of all, I just want to chat a little bit about who gets or what criteria sort of determines who might get an iron infusion and how to get it. And then I want to chat about what are normal phosphate levels, what some of the symptoms are of hypophosphatemia. I think I've got that right. And then also how doctors miss it.

01:09
and then what can be done about it. So in New Zealand, the eligibility criteria for receiving a funded iron infusion, which is specifically ferric carboxymaltose, the brand name of that is Ferrinject, is determined based on specific special authority criteria. So the funding applies to patients who meet certain conditions related to iron deficiency anemia and can be accessed in both community and hospital settings.

01:37
Generally speaking, patients with iron deficiency anemia and a serum ferritin level of less than or equal to 20 micrograms per litre can apply for an initial special authority approval, which is valid for three months. If they have been complied with oral iron treatment, such as just typical iron supplements, and that's been proven ineffective, or if that iron treatment has resulted in dose limiting intolerance. So you have really bad GI issues.

02:07
you cannot tolerate the iron supplements, they will look for an alternative. Also, someone may be considered eligible if there is real need for a rapid correction of anemia. This is in the guidelines and in my head I'm like, who wouldn't be in need of that? Because life is just so much better when you're not anemic. Anyway, not only better, but better for you. There are also specific conditions for that special authority approval. So for patients with a serum ferritin above,

02:34
20 micrograms per liter, subsidized treatment can be recommended by an internal medicine doctor or an obstetrician or a gynecologist or an anesthetist. And this just allows for that broader access under specific clinical circumstances. This might be someone with symptomatic heart failure, chronic kidney disease, stage three or more, or active inflammatory bowel disease, where clearly oral iron supplementation is unlikely to be successful.

03:00
And so the cost of the iron infusion appointment might be around $175, which includes the initial consult and the infusion itself. If the patient meets the funding criteria for fair inject, the medication can be obtained from the pharmacy with a funded prescription. But if the patient doesn't meet the criteria, it could be cost an additional $300 or $400.

03:21
So you can see that it's not that easy to get an iron infusion. And in fact, iron infusion does come with certain risks as we're about to talk about, or just considerations, not risks, I think considerations. So when someone does receive an iron infusion, there's the possibility for the condition known as hypophosphatemia. And this is when the phosphate levels in the blood drop to dangerously low levels. And in New Zealand,

03:47
The normal phosphate levels in the blood expressed in mmol per liter does vary by age group, but for adults 18 and older, the normal range is 0.75 to 1.5 mmol per liter. Levels below this range would indicate low phosphate levels, and low phosphate levels can happen for a few reasons, and it's related to how iron and phosphate metabolism are interconnected in the body. So you get increased erythropoiesis.

04:14
which is when the iron infusions stimulate the production of red blood cells. And this process, erythropoiesis, requires phosphate. So as the body ramps up red blood cell production in response to newly available iron, it can consume phosphate at a higher rate than usual. This potentially leads to that decrease in those phosphate levels in the blood, which would be lower. Certain types of intravenous iron preparations, such as the ferrin inject, which is a ferric carboxymaltose,

04:43
can interact with phosphate in the blood, leading to the formation of insoluble complexes. These complexes are then removed from circulation, effectively lowering the available phosphate in the blood. And also there may be a shift in phosphate distribution. So the iron infusion can alter the balance of various hormones and factors that regulate mineral and bone metabolism, including phosphate. So it can lead to a temporary shift of phosphate from the blood into cells or bone, reducing its plasma concentration.

05:11
So low phosphate levels can range from mild to severe and maybe asymptomatic or present with various symptoms depending on the severity of the phosphate depletion. And I have to say that the most recent presentation of it for someone I've been working with, it sounded horrendous. She said that she expected to feel so much better and she felt a thousand times worse. So those symptoms of severe hypophosphatemia include muscle weakness and pain, bone pain and fragility,

05:41
respiratory failure, irregular heartbeats, i.e. arrhythmias, numbness and neurological disorders and immune dysfunction. And you can see actually that these do seem very similar to anemia, particularly that muscle weakness, the fatigue, the respiratory failure or problems with being out of breath. So you can understand why if this occurs to someone after an iron infusion, you might even be thinking, gosh, did that even work for me?

06:10
In cases where the phosphate levels do drop to dangerously low levels, it's important to monitor and manage the levels carefully. Treatment may involve oral or intravenous phosphate supplementation depending on the severity of the low phosphate levels. And also, of course, close monitoring of the patient's response to the therapy. In the case of my client, she went back to her doctor after a week to tell her what had happened and the doctor was like, I'm not sure.

06:38
what's going on. She had googled it and said, I think it's my phosphate. And the doctor was like, I don't know. And then when they got the results and saw that it was, she sent her immediately to hospital. Interestingly, when you look on the interwebs with recommendations from the worldwide web and all of its genius, there is a recommendation to drink Coca Cola or other cola beverages for resolving these low phosphate levels, because these drinks contain phosphoric acid, which can increase phosphate levels in the body.

07:07
Albeit remember, you're likely on some phosphate supplements as well. So, colas are often suggested as a quick and accessible source of phosphate for people experiencing mild cases of low phosphate, especially when medical treatment isn't immediately necessary or is a supplementary measure. But it is important to remember that the actual amount of phosphate in cola drinks may not be sufficient to correct significant phosphate deficiencies, especially in the case of low phosphate levels.

07:35
And the bioavailability of phosphate from cola is also not as well defined as that from dietary sources or supplements designed for medical use. So understandably, this would not be my first choice for anyone who had this issue. Thankfully though, I mean, this is a medical condition and I think doctors who are in the know will be well versed with what they should be doing. Also another sort of risk is obviously sugar and calories. So cola drinks.

08:02
can be high in sugar and calories, which may not be suitable for everyone, especially people who have metabolic concerns and all the things that occur with fluctuating blood sugars because you've mainlined sugar into your bloodstream. Now, apparently Coke Zero Diet Coke do have measurable amounts of phosphoric acid in them as well, just not quite as much as your Coca-Cola. And if you go looking on the interwebs, it'll tell you that a 12 ounce,

08:31
fluid ounce, can of cola contains about 37 milligrams of phosphorus, or the same size serving of a diet cola contains 32 milligrams. Not that different. And just so you have an appreciation for foods containing phosphorus, we're talking predominantly like your meats, like chicken and turkey. So an 85 gram serving might have 194 to 196 milligrams of phosphorus, actually much more than that cola.

08:59
Pork contains around 230 milligrams. Organ meats have quite a bit of additional available phosphorus, as does seafood. So this gives you an appreciation for the fact that all these real foods also contain highly bioavailable phosphorus, which is actually preserved when you cook it. So you don't necessarily need to go running for that cola. One thing to be mindful of, and the reason why you want to closely monitor phosphate

09:27
is because you need a sweet spot in the body, and the body does regulate its minerals really quite well. So if you're taking on board quite a bit of phosphate or too much phosphate, it can also be problematic. So high levels of phosphate can lead to an imbalance between calcium and phosphate in the body, which causes calcium to precipitate out of the blood and deposit in soft tissues, leading to calcification in areas such as kidneys, blood vessels, and the heart.

09:56
bone and mineral disorders because you've got that leaching of calcium, and it can also disrupt the regulation of the parathyroid hormone vitamin D and calcium, potentially leading to secondary conditions. And while mildly high phosphate levels may not cause immediate symptoms, if you get severe elevations, it can lead to muscle cramps, irritability, and other related conditions. So

10:22
The body is very good and works very hard to regulate our minerals and our electrolytes. So this is just a really good example of it. So you might be wondering why didn't the doctor mention it or pick it up? And there are several pretty legitimate reasons really. So there is a low incidence. So whilst I've had a handful of cases of this over the last couple of years, it's not a common side effect for all types of ion infusions or for all patients. So the physicians may not be able to do this.

10:51
they might just prioritize discussing more common or severe side effects and risks. There are time constraints. So, you know, appointments are what 15, 20 minutes, and it can limit the amount of information they're able to convey. Doctors will just probably assume that the person in front of them is low risk. And so they're likely not to bring up something to sort of of concern if the patient is going to get overly anxious about something that might not happen. Or the doctor

11:18
themselves may already have in place protocols to assess for risk of this happening after the procedure. So, you know, they may get them back in within five days or seven days to measure phosphate levels particularly to see if anything is amiss there. And then it would come up if something was. And of course, you know, clinicians often have to balance that need for informing patients of the risk versus overwhelming them with information that might even be unnecessary. So...

11:47
they may choose to focus on what the patient needs to know to follow through with the treatment and aftercare instructions effectively. But of course, you know, it's important for everyone to feel empowered when they're sitting in their doctor's office. So, you know, if you're in the position where you may need or be wondering whether an iron infusion is right for you, then absolutely bring this up with your doctor to ensure that there is monitoring in place. And there are a few things which may give

12:15
insight into who might be at risk of developing these low phosphate levels following an iron infusion. Baseline phosphate levels, so checking a patient's baseline phosphate levels before administering it, can help identify individuals who may already have low phosphate levels or those who are at the lower end of the normal range, making them more susceptible to developing the condition. As I said, the type of iron preparation, so some are more likely to cause

12:44
The iron carboxymaltose and ferric derisomaltose have been associated with higher incidence compared to other formulations. And this is the one the ferre injector in New Zealand is the carboxymaltose. Patients with conditions that affect phosphate absorption or utilization, such as chronic kidney disease, malabsorption syndromes like inflammatory bowel or celiac, or previous history of low phosphate, might be at an increased risk.

13:13
nutritional status or specific dietary deficiencies may have lower baseline levels of phosphate, making them more vulnerable to developing the condition. I was just talking about where we find high amounts of absorbable phosphate in the diet, which is of course from animal protein, organ meats, seafood, things like that. So that's something to consider. Certain medications can affect phosphate levels, including diuretics and tassids.

13:40
and insulin. So patients taking these medications may have an altered risk profile. And the risk might also depend on the total dose of the iron administered and the frequency of infusions. So it makes sense that the higher the doses or the more frequent administration, you're going to get that increased risk of those low phosphate levels. So to mitigate these risks, you want that pre-treatment assessment where you assess these things and you evaluate the patient's medical history, current medications, nutritional status.

14:10
Where possible, you select an ion formulation with the lower risk of causing low phosphate levels. And then, of course, you have close monitoring of these levels before and after the infusion, particularly in patients identified as being higher risk, which can help catch and address these low phosphate levels. So, I just thought it was really interesting because I had the conversation about ion infusion with several clients over the years.

14:39
that GPs don't discuss it, which is probably not necessarily a bad thing, but it's just good to be aware that this can happen because you can get a real fright, not only a fright, you can get quite severely sick when this occurs. So being forward with the conversation initially, if this is you going in for an iron infusion, understanding your risk and then just keeping an eye on it post your infusion, I think would be quite a good idea.

15:07
Alright team, so that is low phosphate levels and hypo phosphatemia. Hypo phosphatemia. So bad with my words. Anyway, that's alright though. If you have any questions or concerns or just anything really, why don't you hit me up? I'm on Instagram, Twitter and threads @mikkiwilliden. I'm on Facebook @mikkiwillidenNutrition or

15:36
head to my website mikkiwilliden.com and book a one-on-one call with me and we can discuss this or anything related to your nutrition. All right team, you have a great day.