Comparative Study of Ferrous Fumarate, Ferrous Ascorbate, and Polysaccharide Iron for Treating Iron Deficiency Anemia in Adults

Authors

  • Anil Gupta, MD, CCFP, FCFP Albion Finch Medical Centre, Toronto, ON, Canada, William Osler Health Centre, Clinical Instructor, Toronto Metropolitan University, Toronto, ON, Canada
  • Amisha Gandhi, Ind. Elec. Eng. Albion Finch Medical Centre, Toronto, ON, Canada
  • Vishwas Kini, MD, CCFP 4515 Ebenezer Road, Brampton, ON, Canada
  • Kira Gupta-Baltazar, BSc (Hons) Albion Finch Medical Centre, Toronto, ON, Canada
  • Karen Tu, MD, CCFP, FCFP Toronto Western Family Health Team, University Health Network, Toronto, ON Canada; Department of Family and Community Medicine, Institute of Health Policy and Evaluation, University of Toronto, Toronto, ON, Canada

DOI:

https://doi.org/10.58931/cpct.2025.3243

Abstract

Iron deficiency anemia (IDA) is a highly prevalent condition encountered in clinical practice and represents a major global health concern, affecting an estimated 1.92 billion individuals worldwide. Despite its prevalence and the availability of various oral iron formulations with wide cost variations, comparative data on their efficacy and tolerability remain limited.

This randomized, open-label trial conducted across two centres evaluated the efficacy, tolerability, and adherence of three oral iron supplements in improving hemoglobin and ferritin levels in adults with IDA. The study compared ferrous fumarate (Eurofer, 100 mg elemental iron, $15.87 for 90 tablets), ferrous ascorbate (EBMfer, 100 mg elemental iron, $68.97 for 90 tablets), and polysaccharide iron (FeraMAX, 150 mg elemental iron, $77.97 for 90 tablets). A total of 111 participants aged ≥18 years were randomly assigned into one of three treatment groups and monitored over a 12-week period.

Both ferrous fumarate (p=0.001) and ferrous ascorbate (p<0.001) demonstrated significantly greater hemoglobin and ferritin levels compared to polysaccharide iron. Specifically, ferrous fumarate led to mean increases in hemoglobin and ferritin of 11.59 g/L (95% confidence interval [CI]: 7.87–15.3, standard deviation [SD]: 10.7) and 19.21 µg/L (95% CI: 7.82–28.6, SD: 29.8), respectively. Ferrous ascorbate showed mean increases in hemoglobin and ferritin levels of 17.14 g/L (95% CI: 13.5–20.8, SD: 10.7) and 23.51 µg/L (95% CI: 16.5–30.5, SD: 20.3), respectively. Polysaccharide iron showed mean increases in hemoglobin and ferritin of 3.56 g/L (95% CI: -0.06–7.18, SD: 10.4) and 3.21 µg/L (95% CI: -0.07–6.48, SD: 9.39), respectively.

Adverse events occurred more frequently with ferrous fumarate (13 events) compared with ferrous ascorbate (8 events) and polysaccharide iron (6 events). The most commonly reported side effects across all groups were constipation and bloating, well-documented side effects of iron supplements.

These findings demonstrate that ferrous fumarate and ferrous ascorbate significantly outperformed polysaccharide iron in improving hemoglobin and ferritin levels. Given its lower cost and comparable efficacy, ferrous fumarate may be the most cost-effective option and warrants consideration in updates to Canadian treatment guidelines.

Author Biographies

Anil Gupta, MD, CCFP, FCFP, Albion Finch Medical Centre, Toronto, ON, Canada, William Osler Health Centre, Clinical Instructor, Toronto Metropolitan University, Toronto, ON, Canada

Dr. Anil Gupta, a graduate of the University of Toronto’s Faculty of Medicine, is a primary care physician, researcher, and author with over 19 years of experience as a principal investigator in more than 150 clinical trials. His passion for clinical research led him to play a key role in groundbreaking studies on COVID-19 treatments during the pandemic. Dr. Gupta was the lead author of two major publications in the New England Journal of Medicine (NEJM) and Journal of the American Medical Association (JAMA), focusing on the efficacy and safety of the SARS-CoV-2 neutralizing antibody, sotrovimab. Additionally, he contributed as a lead collaborator to the KidCOVE study evaluating the mRNA-1273 vaccine for children aged 6–11. His extensive research background includes a trial on Vitamin B-12 deficiency in South Asians published in CFPC May,2004. Reflecting on his work, Dr. Gupta takes pride in demonstrating that family doctors can make significant contributions to clinical research, proving that groundbreaking studies are not limited to specialists.

Amisha Gandhi, Ind. Elec. Eng., Albion Finch Medical Centre, Toronto, ON, Canada

Amisha Gandhi is a Clinical Research Coordinator at Albion Finch Medical Centre in Toronto, ON, Canada. Since December 2013, she has been actively involved in conducting Phase 2, 3, and 4 clinical trials alongside Dr. Gupta. Originally trained in Industrial Electronics Engineering (1995), Amisha transitioned into healthcare by managing a pharmacy and medical clinic before specializing in clinical research. She played a key role in the largest pediatric mRNA vaccine trial conducted to date and contributed to the emergency use authorization of mRNA-1273 (COVID-19 vaccine) for children aged 6 months to 11 years. She also contributed to the conduct of the pivotal sotrovimab COVID-19 trial with Dr. Gupta.

Vishwas Kini, MD, CCFP, 4515 Ebenezer Road, Brampton, ON, Canada

Dr. Vishwas M. Kini is a family physician based in Ontario, Canada, with broad clinical and leadership experience. He completed his Family Medicine Residency at St. Vincent Mercy Medical Center, Toledo, Ohio, following an Ophthalmology Residency at Dr. R.P. Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India. He earned his medical degree from Karnataka Institute of Medical Sciences, Hubli, India. In addition to his clinical practice, Dr. Kini has held multiple leadership positions within the Central West Ontario Health Team, contributing to healthcare system improvement and pandemic response initiatives. His research background includes thesis work in ophthalmology at AIIMS and presentations on diabetes management, chronic kidney disease, and primary care operations. Dr. Kini holds certifications from the College of Physicians and Surgeons of Ontario, Medical Council of Canada, American Board of Family Medicine, and Medical Council of India. He is a member of the College of Family Physicians of Canada.

Kira Gupta-Baltazar, BSc (Hons), Albion Finch Medical Centre, Toronto, ON, Canada

Kira Gupta-Baltazar holds a BSc Honors from the University of San Francisco and is currently pursuing a master’s in health economics at Texas Christian University. She is a highly accomplished triathlete, winning the 2021 NCAA Division I Individual National Championship. Her interest includes health economics and policy, particularly in optimizing healthcare access for athletes and general populations.

Karen Tu, MD, CCFP, FCFP, Toronto Western Family Health Team, University Health Network, Toronto, ON Canada; Department of Family and Community Medicine, Institute of Health Policy and Evaluation, University of Toronto, Toronto, ON, Canada

Dr. Karen Tu is a Professor in the Department of Family and Community Medicine-Temerty Faculty of Medicine with a cross appointment in the Institute of Health Policy, Management and Evaluation-Dalla Lana School of Public Health at the University of Toronto, Canada and an Adjunct Professor in the International Centre for Future Health Systems-UNSW Medicine, University of New South Wales, Australia. She holds a Chair in Family and Community Medicine Research in Primary Care at UHN, is a Research Scientist and Family Medicine Research Lead at North York General Hospital and a family physician at University Health Network-Toronto Western Hospital Family Health Team. She is one of Canada’s leading primary care researchers in the secondary use of primary care EMR data and administrative data. Triggered by the COVID-19 pandemic and the understanding of common challenges worldwide, Dr. Tu developed the International Consortium of Primary Care Big Data Researchers‑INTRePID (www.intrepidprimarycare.org). INTRePID joins together primary care researchers currently in 15 countries spanning six continents and includes visits to primary care on over 150 million patients around the world. INTRePID fosters and facilitates international collaboration, networking, knowledge exchange, mentorship and education for primary care big data research worldwide.

References

Institute for Health Metrics and Evaluation. Anemia - level 1 impairment [Internet]. Seattle (WA): IHME; [cited 2025 Jun 9]. Available from: https://www.healthdata.org/research-analysis/diseases-injuries-risks/factsheets/2021-anemia-level-1-impairment

World Health Organization. Anaemia [Internet]. Geneva: WHO; [cited 2025 Jun 9]. Available from: https://www.who.int/health-topics/anaemia#tab=tab_1

Liu TC, Lin SF, Chang CS, Yang WC, Chen TP. Comparison of a combination ferrous fumarate product and a polysaccharide iron complex as oral treatments of iron deficiency anemia: a Taiwanese study. Int J Hematol. 2004;80(5):416–420. doi:10.1532/ijh97.a10409 DOI: https://doi.org/10.1532/IJH97.A10409

Powers JM, Buchanan GR, Adix L, Zhang S, Gao A, McCavit TL. Effect of low-dose ferrous sulfate vs iron polysaccharide complex on hemoglobin concentration in young children with nutritional iron-deficiency anemia: a randomized clinical trial. JAMA. 2017;317(22):2297–2304. doi:10.1001/jama.2017.6846 DOI: https://doi.org/10.1001/jama.2017.6846

BC Guidelines. Iron deficiency – diagnosis and management [Internet]. Victoria (BC): Government of British Columbia; 2023 [updated 2023 November 2, cited 2025 Jun 9]. Available from: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/iron-deficiency

Association of Ontario Midwives. Iron deficiency anemia and you [Internet]. Toronto: AOM; 2016 [cited 2025 Jun 9]. Available from: https://www.ontariomidwives.ca/sites/default/files/2022-02/Iron-deficiency-anemia-and-you-2022-English.pdf

Association of Ontario Midwives. Iron supplements guide for midwives [Internet]. Toronto: AOM; 2024 [cited 2025 Jun 9]. Available from: https://www.ontariomidwives.ca/sites/default/files/IDA-Iron-supplements-guide-for-midwives-2024.pdf

Hamilton Health Sciences. Choosing an iron pill [Internet]. Hamilton (ON): HHS; 2020 [updated January 2020, cited 2025 Jun 9]. Available from: https://www.hamiltonhealthsciences.ca/wp-content/uploads/2019/08/Choosing-an-Iron-Pill.pdf

Alberta Medical Association. Iron deficiency anemia (IDA) clinical practice guideline [Internet]. Edmonton (AB): AMA; 2018 [cited 2025 Jun 9]. Available from: https://www.albertadoctors.org/media/atabokv2/iron-deficiency-anemia-guideline.pdf

The jamovi project. jamovi (Version 2.3) [Computer software]. 2022. Available from: https://www.jamovi.org

R Core Team. R: A language and environment for statistical computing (Version 4.1) [Computer software]. Vienna: R Foundation for Statistical Computing; 2021. Available from: https://cran.r-project.org

Downloads

Published

2025-08-26

How to Cite

1.
Gupta A, Gandhi A, Kini V, Gupta-Baltazar K, Tu K. Comparative Study of Ferrous Fumarate, Ferrous Ascorbate, and Polysaccharide Iron for Treating Iron Deficiency Anemia in Adults. Can Prim Care Today [Internet]. 2025 Aug. 26 [cited 2025 Sep. 6];3(2):5–13. Available from: https://canadianprimarycaretoday.com/article/view/3-2-Gupta_et_al

Issue

Volume 3, Issue 2, Summer 2025

Section

Articles

License

Copyright (c) 2025 Canadian Primary Care Today

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.