What is the diagnosis for a 62-year-old female (F) with hypertension (HTN), iron deficiency anemia, taking ferrous glyconate (Iron), with elevated Total Iron-Binding Capacity (TIBC) and low iron saturation?

From the Guidelines

This patient's lab values show iron deficiency with low serum iron (26 mcg/dL), high TIBC (486 mcg/dL), and low iron saturation (5%), despite being on ferrous glyconate, and I recommend switching to ferrous sulfate 325 mg orally three times daily, taken between meals with vitamin C (orange juice or 250 mg vitamin C supplement) to enhance absorption, as suggested by the British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults 1. The current treatment appears ineffective as iron studies show persistent deficiency despite supplementation, suggesting either poor absorption, inadequate dosing, medication interactions, or ongoing blood loss that requires identification and management. Some key points to consider in the management of this patient's iron deficiency anaemia include:

• Avoid taking iron with calcium, dairy, coffee, tea, or antacids as these reduce absorption 1
• Continue treatment for 3-6 months to replenish iron stores, then reassess labs 1
• Consider IV iron (ferric carboxymaltose or iron sucrose) if oral therapy fails after 4-6 weeks or if symptoms are severe 1
• Investigate the cause of iron deficiency through colonoscopy, upper endoscopy, or gynecological evaluation as appropriate for this 62-year-old female, as IDA may be the first presenting manifestation of colonic or oesophago-gastric carcinoma 1 The British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults suggest that the optimal drug, dosage and timing of oral IRT for adults with IDA are not clearly defined, but a once daily dose of 50–100 mg of elemental iron (eg, one ferrous sulfate 200 mg tablet a day) taken in the fasting state may be the best compromise option for initial treatment 1. Regular Hb monitoring is recommended to ensure an ultimately satisfactory response, with the optimal interval being every 4 weeks until the Hb is in the normal range 1. In patients with chronic disease, continuing blood loss, impaired absorption or GI inflammatory pathology, parenteral iron is more effective than continuing traditional oral therapy 1.

From the FDA Drug Label

Each tablet contains 324 mg of ferrous gluconate, equivalent to 38 mg of elemental iron, providing 211% of the U.S. recommended daily intake (RDI) of iron for adults and children 4 and older. Adult Serving Size: 1 tablet three to four times daily.

The patient is taking ferrous glyconate 37 - 145 mcg/dL, but the label recommends 1 tablet three to four times daily, which is equivalent to 38 mg of elemental iron per tablet.

• The patient's iron saturation is low at 5% and 17%, and TIBC is high at 410, 448, and 566.
• The label does not provide information on adjusting the dose based on the patient's iron levels or TIBC.
• Given the patient's low iron saturation and high TIBC, it is likely that the patient is not receiving enough iron, but the label does not provide guidance on how to adjust the dose in this situation 2.

From the Research

Patient's Iron Deficiency Status

The patient is a 62-year-old female with hypertension (HTN) and iron deficiency, currently taking ferrous glyconate. Her iron levels are as follows:

• Iron: 37 - 145 mcg/dL, with a high value of 205 and low values of 74,124, and 26
• TIBC (Total Iron Binding Capacity): 228 - 428 mcg/dL, with high values of 410,448,566, and 486
• Iron Saturation: 20 - 55%, with low values of 50,17,22, and 5

Diagnosis and Treatment of Iron Deficiency

According to 3, iron deficiency is diagnosed by low serum ferritin (typically <30 ng/mL) in individuals without inflammatory conditions or by transferrin saturation (iron/total iron binding capacity × 100) less than 20%. The patient's iron saturation levels are below the normal range, indicating iron deficiency.

• Causes of iron deficiency include bleeding, impaired iron absorption, inadequate dietary iron intake, and pregnancy 3.
• Treatment options for iron deficiency include oral iron supplements, such as ferrous sulfate, and intravenous iron therapy 3, 4.
• A study comparing ferrous sulfate and ferrous glycinate chelate found that ferrous sulfate was more effective in treating iron deficiency anemia in gastrectomized patients 5.
• Another study found that lactoferrin supplementation had better effects on serum iron, ferritin, and hemoglobin concentration compared to ferrous sulfate 6.

Interpretation of Biochemical and Haematological Findings

The interpretation of biochemical and haematological findings in iron deficiency is crucial for diagnosis and treatment 7.

• Ferritin measurement is the most important analysis in the study of iron deficiency, but there is no consensus on the diagnostic cut-off 7.
• The level of transferrin receptor in plasma increases with iron deficiency without being influenced by inflammation and is therefore a good supplement to ferritin measurement 7.
• Measurement of iron, transferrin, and transferrin saturation provides little information additional to that provided by ferritin in iron deficiency studies 7.

Key Points to Consider

• The patient's iron deficiency status and treatment options should be evaluated in the context of her underlying medical conditions, such as hypertension 3.
• The choice of iron supplement and treatment regimen should be based on the patient's individual needs and response to therapy 3, 4, 5, 6.
• Regular monitoring of iron levels and haematological parameters is essential to assess the effectiveness of treatment and adjust the treatment plan as needed 3, 7.