What treatment is recommended for a patient with hypochromic microcytic anemia (low hemoglobin), low ferritin, and normal iron levels?

From the Guidelines

The recommended treatment for a patient with hypochromic microcytic anemia, low ferritin, and normal iron levels is oral iron supplementation, as indicated by the most recent and highest quality study 1. This treatment approach is based on the understanding that low ferritin levels are a sensitive marker for iron deficiency, despite normal serum iron levels. According to the British Society of Gastroenterology guidelines 1, serum ferritin is the most specific test for iron deficiency in the absence of inflammation, and an SF level of <15 μg/L is indicative of absent iron stores.

The treatment should include ferrous sulfate 325 mg (containing 65 mg of elemental iron) taken once or twice daily between meals, with alternative formulations such as ferrous gluconate 300 mg or ferrous fumarate 200 mg if ferrous sulfate is not tolerated. It is essential to continue treatment for 3-6 months to replenish iron stores completely, even after hemoglobin normalizes.

Some key points to consider when administering oral iron supplementation include:

• Taking iron with vitamin C (such as orange juice) enhances absorption
• Calcium, dairy products, tea, coffee, and antacids should be avoided within 2 hours of iron intake as they reduce absorption
• Patients should be monitored with repeat complete blood counts and ferritin levels after 4-8 weeks of therapy to assess response
• Side effects may include gastrointestinal discomfort, constipation, or dark stools, which are normal and not concerning

It is also important to note that intravenous iron administration may be considered in patients who do not respond to oral supplementation or require rapid iron replacement, as suggested by the ESPEN micronutrient guideline 1. However, this approach should be reserved for patients who meet specific criteria, such as those with repeated failure of first-step oral therapy or requiring a fast supplementation before elective surgery.

From the Research

Treatment for Hypochromic Microcytic Anemia

For a patient with hypochromic microcytic anemia, low ferritin, and normal iron levels, the following treatment options are recommended:

• Oral iron therapy, as it is the most common strategy used to control iron deficiency 2
• Counselling on integrating haem and free iron regularly into the diet, looking for enhancers and avoiding inhibitors of iron uptake 3
• Monitoring of iron deficiency through blood tests, including haemoglobin concentration, haematocrit, mean cellular volume, mean cellular haemoglobin, percentage of hypochromic erythrocytes, and serum ferritin levels 3

Dosage and Administration

• The dosage of oral iron therapy can range from 60 to 120 mg per day, depending on the severity of iron-deficiency anaemia 2
• Preparations with reasonable but not excessive elemental iron content (28-50 mg) seem appropriate to prevent reduced compliance due to gastrointestinal side effects 3
• Intravenous iron therapy may be necessary in exceptional cases, such as concomitant disease needing urgent treatment or repeated failure of first-step therapy 3, 4

Monitoring and Follow-up

• The basic blood tests should be repeated after 8 to 10 weeks to measure the success of treatment 3
• Patients with repeatedly low ferritin will benefit from intermittent oral substitution to preserve iron stores and from long-term follow-up, with the basic blood tests repeated every 6 or 12 months to monitor iron stores 3