From the Guidelines
The management of an 84-year-old male with iron deficiency anemia but normal ferritin and TIBC levels requires a comprehensive approach, including further investigation and treatment, as outlined in the 2024 AGA clinical practice update on management of iron deficiency anemia 1. The patient's normal ferritin and TIBC levels are inconsistent with typical iron deficiency anemia, suggesting the need for additional testing, such as serum iron levels, transferrin saturation, and soluble transferrin receptor, to confirm the diagnosis. A gastrointestinal workup is essential, including:
- Upper and lower endoscopy to rule out occult bleeding from conditions like colorectal cancer, gastric ulcers, or angiodysplasia, which are common in elderly patients.
- Evaluation of dietary iron intake and review of menstrual blood losses in premenopausal women, although this may not be relevant in this case.
- Search for gastrointestinal conditions leading to poor iron absorption or blood loss, including Helicobacter pylori infection. If iron deficiency is confirmed despite the normal markers, oral iron supplementation with ferrous sulfate 325 mg once or twice daily between meals would be an appropriate initial treatment, with dose reduction if gastrointestinal side effects occur 1. For patients who cannot tolerate oral iron, intravenous iron formulations like iron sucrose or ferric carboxymaltose may be considered, as they can provide a more efficient and better-tolerated alternative 1. Concurrent vitamin C (250-500 mg) can enhance iron absorption. Monitor hemoglobin levels every 2-4 weeks initially, and continue treatment for 3-6 months after hemoglobin normalizes to replenish iron stores, as recommended by the British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults 1. This approach addresses the inconsistency in laboratory values while ensuring appropriate treatment for the underlying anemia and its potential causes in an elderly patient.
From the Research
Management Approach for Iron Deficiency Anemia
The management approach for an 84-year-old male with iron deficiency anemia, normal ferritin levels, and normal Total Iron-Binding Capacity (TIBC) levels involves several considerations:
- Intravenous Iron Supplementation: Studies have shown that intravenous iron supplementation, such as ferric carboxymaltose, is effective in treating iron deficiency anemia, especially in patients who cannot tolerate oral iron or have a poor response to it 2, 3, 4.
- Ferric Carboxymaltose: Ferric carboxymaltose has been shown to be well-tolerated and effective in rapidly improving hemoglobin levels and replenishing depleted iron stores in patients with iron deficiency anemia 2, 3, 4.
- Oral Iron Supplementation: Oral iron supplementation may not be as effective as intravenous iron supplementation, especially in patients with chronic kidney disease or heart failure 3, 4, 5.
- Investigation of Underlying Causes: It is essential to investigate the underlying causes of iron deficiency anemia, such as gastrointestinal bleeding or chronic kidney disease, and address them accordingly 6.
Treatment Options
Treatment options for iron deficiency anemia in this patient population include:
- Ferric Carboxymaltose: A single dose of 1000 mg of ferric carboxymaltose can be administered intravenously over 15 minutes, with additional doses as needed 2, 3.
- Oral Iron Supplementation: Oral iron supplementation can be considered, but it may not be as effective as intravenous iron supplementation 3, 4.
- Monitoring and Follow-up: Regular monitoring of hemoglobin levels, ferritin levels, and TIBC levels is essential to assess the response to treatment and adjust the treatment plan as needed 2, 3, 4.