What is the management plan for a patient with decreased percent iron saturation percentage?

From the Guidelines

The management plan for a patient with decreased percent iron saturation percentage should focus on replenishing iron stores through oral iron supplementation as the first-line treatment, with parenteral iron reserved for those who cannot tolerate oral preparations, as recommended by the guidelines for the management of iron deficiency anaemia 1. The goal of treatment is to correct the underlying cause of iron deficiency while restoring normal iron parameters and hemoglobin levels. Initial evaluation should include a complete blood count, serum ferritin, and assessment for sources of blood loss through stool occult blood testing, endoscopy, or gynecological evaluation as appropriate.

• Oral iron supplementation is typically administered with ferrous sulfate 325 mg (containing 65 mg elemental iron) taken 1-3 times daily between meals with vitamin C to enhance absorption.
• Side effects like constipation, nausea, and abdominal discomfort can be managed by taking iron with food, though this reduces absorption by 40-50%.
• For patients who cannot tolerate oral iron or have malabsorption, intravenous iron formulations such as iron sucrose (100-200 mg per session) or ferric carboxymaltose (up to 1000 mg per dose) may be necessary, as supported by the guidelines for anemia of chronic kidney disease 1. Treatment should continue until iron saturation normalizes (typically 20-50%) and ferritin reaches adequate levels (>50 ng/mL), usually requiring 3-6 months of therapy.
• Dietary counseling to increase iron-rich foods (red meat, spinach, beans) should complement supplementation.
• Blood transfusions should be reserved for patients with or at risk of cardiovascular instability due to the degree of their anaemia, as recommended by the guidelines for the management of iron deficiency anaemia 1.

From the Research

Management Plan for Decreased Percent Iron Saturation Percentage

• The management plan for a patient with decreased percent iron saturation percentage involves diagnosing and treating iron deficiency, which can be absolute or functional 2.
• 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% 3.
• The causes of iron deficiency should be identified and treated, and oral iron therapy is usually the first step in treatment 4, 3.
• Counselling and oral iron therapy are usually combined, and integrating haem and free iron regularly into the diet, looking for enhancers and avoiding inhibitors of iron uptake is beneficial 4.
• To prevent reduced compliance, mainly as a result of gastrointestinal side effects of oral treatment, the use of preparations with reasonable but not excessive elemental iron content (28-50 mg) seems appropriate 4.
• In exceptional cases, intravenous iron injection may be necessary, such as concomitant disease needing urgent treatment, repeated failure of first-step therapy, or certain chronic inflammatory conditions (CKD, HF, IBD, cancer) 4, 3, 2.
• The success of treatment should be measured by repeating basic blood tests after 8 to 10 weeks, and patients with repeatedly low ferritin will benefit from intermittent oral substitution to preserve iron stores and from long-term follow-up 4.

Special Considerations

• In patients with chronic kidney disease (CKD), iron deficiency anemia is a common complication, and all CKD patients should be screened for anemia during the initial evaluation for CKD 2.
• In CKD patients, absolute iron deficiency is defined when the transferrin saturation (TSAT) is ≤20% and the serum ferritin concentration is ≤100 ng/mL among predialysis and peritoneal dialysis patients or ≤200 ng/mL among hemodialysis patients 2.
• Intravenous iron supplementation is the preferred method for CKD patients on dialysis, and either intravenous or oral iron is recommended for patients with CKD not on dialysis 2.
• In patients with inflammatory bowel disease (IBD), such as ulcerative colitis (UC), iron deficiency anemia is often unrecognized and undertreated, and testing for iron deficiency and subsequent treatment with iron replacement therapy should be considered among the quality process indicators in UC 5.