When should IV be considered over oral copper and how often should serum copper levels be assessed?
The American Society of Metabolic and Bariatric Surgery (ASMBS) recommends treating mild to moderate copper deficiency with 3 to 8 mg/day of oral copper gluconate or sulfate until indices return to normal. In patients with severe deficiency, 2 to 4 mg/day of IV copper is recommended to be given for six days until serum levels return to normal and neurological symptoms resolve. Specific copper levels considered to be ‘mild to moderate’ or ‘severe’ deficiency are not well defined, but ‘mild to moderate’ deficiency has been proposed to be 8-12 μmol/L or 0.5-0.8 mcg/dL. Once copper levels are normal, it is suggested to monitor copper levels every 3 months. Otherwise, copper serum levels should only be assessed in the presence of symptoms compatible with copper deficiency.
According to the American Society for Metabolic and Bariatric Surgery’s (ASMBS) 2016 guideline update on micronutrients, in post-weight loss surgery patients with a copper deficiency, the recommended regimen for repletion of copper varies with the severity of deficiency. For patients with mild to moderate deficiency (including low hematological indices), it is recommended to treat with 3 to 8 mg/day of oral copper gluconate or sulfate until indices return to normal. In patients with severe deficiency, 2 to 4 mg/day of intravenous (IV) copper is recommended to be initiated for six days until serum levels return to normal and neurological symptoms resolve. Once copper levels are normal, it is suggested to monitor copper levels every 3 months.
Early signs/symptoms of copper deficiency may include hypochromic anemia; neutropenia; pancytopenia; hair, skin and nails hypopigmentation; hypercholesterolemia; or impaired biomarkers of bone metabolism. Advanced signs/symptoms can include gait abnormalities; hypopigmentation of skin, hair or nails; peripheral neuropathies; or myelopathies.
Table 1: Algorithm for Diagnosis and Treatment of Copper Deficiency
| Algorithm for Diagnosis and Treatment of Copper Deficiency | |||
| < 0.5 mcg/mL (severe deficit) | 0.5 to < 0.8 mcg/mL (deficit) | 0.8 mcg/mL to 1.0 mcg/mL (gray zone) | 0.8 to 1.2 mcg/mL (normal range) |
| ≤ 0.8 mcg/mL (≤ 12.6 μmol/L) Check ceruloplasmin ≤ 20 mg/dL: IV repletion > 20 mg/dL: Favor PO repletion |
0.8 to 1.0 mcg/mL (12.6 to 15.7 μmol/L) Check ceruloplasmin ≤ 20 mg/dL: Favor PO repletion > 20 mg/dL: Close monitoring (≈ 2 weeks) ≥ 1.0 mcg/mL (≥ 15.7 μmol/L) Inflammation? C-reactive protein ≥ 11 mg/L: Close monitoring (≈ 2 weeks) C-reactive protein < 11 mg/L: Standard screening |
References:
- Altarelli M, Ben-Hamouda N, Schneider A, Berger MM. Copper Deficiency: Causes, Manifestations, and Treatment. Nutr Clin Pract. 2019;34(4):504-513. doi:10.1002/ncp.10328
- Griffith DP, Liff DA, Ziegler TR, Esper GJ, Winton EF. Acquired copper deficiency: a potentially serious and preventable complication following gastric bypass surgery. Obesity (Silver Spring). 2009;17(4):827-31.