What is the first line treatment for iron deficiency anemia?

From the Guidelines

The first line treatment for iron deficiency anemia is oral iron supplementation, specifically one tablet per day of ferrous sulphate, fumarate or gluconate. This recommendation is based on the British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults, as stated in the study published in Gut in 2021 1.

Key Considerations

• The initial treatment should be with one tablet per day, and if not tolerated, a reduced dose of one tablet every other day, alternative oral preparations or parenteral iron should be considered.
• It is essential to address the underlying cause of iron deficiency, which may include dietary changes to increase iron intake from foods like red meat, beans, and leafy greens, as well as investigation to establish the underlying cause, as approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract 1.

Treatment Approach

• Treatment should continue for a sufficient duration to correct the anemia and replenish iron stores.
• Patients should be monitored for common side effects, including constipation, nausea, and black stools, and managed accordingly.
• The importance of investigating the underlying cause of iron deficiency anemia cannot be overstated, as it may lead to the diagnosis of significant gastrointestinal pathologies, including GI malignancies.

From the FDA Drug Label

CONTAINS: Each tablet contains 324 mg of ferrous sulfate, equivalent to 65 mg of elemental iron, providing 362% of the U.S. recommended daily intake (RDI) of iron for adults and children 4 and older. The FDA drug label does not answer the question.

From the Research

Iron Deficiency Anemia Treatment

• The first line treatment for iron deficiency anemia is oral iron supplementation 2, 3, 4, 5.
• Oral iron therapy is usually efficacious in correcting iron-deficiency anemia and replenishing iron stores but causes gastrointestinal side effects that reduce compliance 2.
• The simplest, least expensive, and most commonly prescribed drug is ferrous sulfate, while other ferrous salts and ferric complexes with polysaccharides or succinylated milk proteins are also widely used 2.
• Recent studies suggest that oral iron doses ≥60 mg in iron-deficient women, and doses ≥100 mg in women with IDA, stimulate an acute increase in hepcidin that persists 24 h after the dose, but subsides by 48 h 3.
• To maximize fractional iron absorption, oral doses ≥60 mg should be given on alternate days 3.
• Providing morning doses of 60-120 mg iron as a ferrous salt given with ascorbic acid on alternate days may be an optimal oral dosing regimen for women with iron-deficiency and mild IDA 3.

Intravenous Iron Therapy

• Intravenous iron preparations are indicated for the treatment of iron deficiency when oral preparations are ineffective or cannot be used 6.
• Modern intravenous iron preparations can facilitate rapid iron repletion in one or two doses, both for absolute iron deficiency and, in the presence of inflammation, functional iron deficiency, where oral iron therapy is ineffective or has not worked 6.
• Adverse events occurring with intravenous iron can be anticipated according to when they typically occur, which provides a basis for educating and preparing staff and patients on how iron infusions can be administered safely and efficiently 6.

Treatment Selection

• Iron deficiency treatment selection is driven by several factors, including the presence of inflammation, the time available for iron replenishment, and the anticipated risk of side-effects or intolerance 6.
• An underlying cause should be sought in all patients presenting with iron deficiency: screening for coeliac disease should be considered routinely, and endoscopic investigation to exclude bleeding gastrointestinal lesions is warranted in men and postmenopausal women presenting with iron deficiency anaemia 5.