Should iron supplementation be increased to ferrous gluconate (iron supplement) three times a day (tid) in a patient with iron deficiency anemia and low ferritin level?

From the Guidelines

The patient's iron supplementation should not be increased to ferrous gluconate three times a day, as the most recent and highest quality study suggests that taking iron more than once a day does not improve absorption but may increase side effects. According to the study published in 2024 1, many formulations of oral iron are available, but there is no substantial evidence that any one product is better than another in terms of effectiveness or tolerance. The study also notes that taking iron with vitamin C may improve absorption, but the evidence is mixed.

The patient is currently taking ferrous gluconate twice a day, and the recent lab results show a ferritin level of 29 ng/mL, which is still low. However, increasing the dosage to three times a day may not be necessary, as the study suggests that taking iron once a day is sufficient.

Instead, the patient could continue taking ferrous gluconate twice a day and have their hemoglobin, ferritin, and iron studies monitored regularly, every 4-8 weeks, to assess response to therapy and adjust treatment as needed. The patient should also be advised to take iron supplements with vitamin C, such as orange juice, to enhance absorption, and avoid calcium-containing foods, tea, coffee, and antacids within two hours of taking iron.

It's also important to note that the patient's GI workup is still pending, and the underlying cause of the iron deficiency anemia should be investigated and addressed. The British Society of Gastroenterology guidelines published in 2021 1 recommend that the initial treatment of iron deficiency anemia should be with one tablet per day of ferrous sulphate, fumarate, or gluconate, and if not tolerated, a reduced dose or alternative oral preparations should be considered.

In this case, the patient's current dosage of ferrous gluconate twice a day could be continued, and the patient's response to therapy should be closely monitored. If the patient's ferritin level and hemoglobin do not improve, alternative treatments, such as parenteral iron, could be considered.

Key points to consider:

• The patient's iron supplementation should not be increased to three times a day
• The patient should continue taking ferrous gluconate twice a day
• The patient's hemoglobin, ferritin, and iron studies should be monitored regularly
• The patient should be advised to take iron supplements with vitamin C and avoid certain foods and drinks that can decrease absorption
• The underlying cause of the iron deficiency anemia should be investigated and addressed.

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 currently taking ferrous gluconate bid (twice a day) and has a low ferritin level, indicating iron deficiency anemia. The drug label suggests an adult serving size of 1 tablet three to four times daily.

• The patient's current dosage is lower than the recommended adult serving size.
• Increasing the iron supplementation to tid (three times a day) may be necessary to improve the patient's iron levels.
• However, it is essential to consult with a physician before making any changes to the patient's medication regimen. The next step would be to consult with a physician to determine if increasing the iron supplementation to tid is appropriate for this patient 2.

From the Research

Patient's Current Condition

The patient is a 21-year-old female with a history of rectal bleeding and is currently undergoing a GI workup. She has been prescribed ferrous gluconate twice a day (bid) and has undergone lab tests to assess her iron levels and complete blood count.

Lab Results

The patient's lab results show:

• Low ferritin level (29 ng/mL)
• Low iron saturation (13%)
• High TIBC (526 mcg/dL)
• Hemoglobin level within the normal range (12.1 g/dL)
• MCV slightly high (100.5 FL)

Considerations for Increasing Iron Supplementation

Given the patient's low ferritin level and iron saturation, increasing iron supplementation may be necessary to address the iron deficiency anemia. However, the decision to increase the dosage should be based on the patient's response to the current treatment and potential side effects.

Evidence from Studies

• A study from 1996 3 found that oral liquid ferrous gluconate was effective and well-tolerated in treating iron-deficiency anemia in pregnant women.
• A 2024 review article 4 discusses the diagnosis and treatment of iron deficiency anemia, including the use of oral iron supplements as the first line of treatment.
• A 2023 study 5 found that taking iron supplements in the morning, away from meals and with ascorbic acid, can increase iron absorption.
• A 2020 review article 6 discusses intravenous iron supplementation therapy, which may be considered for patients with intolerance or unresponsiveness to oral iron.

Next Steps

Based on the patient's lab results and the evidence from studies, the next steps could be:

• Increase the dosage of ferrous gluconate to three times a day (tid) to address the iron deficiency anemia
• Monitor the patient's response to the increased dosage and adjust as needed
• Consider adding ascorbic acid to enhance iron absorption
• Evaluate the patient's GI workup results to determine the underlying cause of the rectal bleeding and iron deficiency anemia

Key Considerations

• The patient's iron levels and complete blood count should be closely monitored to assess the effectiveness of the increased iron supplementation
• Potential side effects of increased iron supplementation, such as gastrointestinal upset, should be monitored and addressed as needed
• The patient's underlying condition and response to treatment should guide the decision to continue or adjust the iron supplementation regimen 3, 4, 5, 6