What is the appropriate treatment for a 69-year-old female diagnosed with iron deficiency anemia?

Treatment for Iron Deficiency Anemia in a 69-Year-Old Female

The most appropriate treatment for this 69-year-old female with iron deficiency anemia is oral ferrous sulfate 200 mg three times daily, which should be continued for three months after correction of anemia to replenish iron stores. 1, 2

Diagnosis Confirmation

The patient's laboratory values clearly indicate iron deficiency anemia:

• Low iron (57 μg/dL)
• Normal iron binding capacity (377 μg/dL)
• Low % saturation (15%)
• Low ferritin (9 μg/dL)
• Low MCH (25.8 pg)
• Low MCHC (30.1 g/dL)
• High RDW (18.3%)

These findings are consistent with absolute iron deficiency anemia, with the ferritin level below 15 μg/dL being particularly diagnostic 1.

Treatment Algorithm

1. Oral Iron Supplementation

• First-line therapy: Ferrous sulfate 200 mg three times daily (providing approximately 65 mg elemental iron per tablet) 1, 2
• Alternative formulations if ferrous sulfate is not tolerated:
  • Ferrous gluconate or ferrous fumarate (equally effective) 1
  • Liquid preparation if tablets are not tolerated 1

2. Optimization of Iron Absorption

• Add ascorbic acid (vitamin C) to enhance iron absorption 1, 2
• Take iron supplements on an empty stomach for maximum absorption 2
• Consider once-daily morning dosing if three times daily dosing causes intolerance 2

3. Expected Response and Monitoring

• Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of therapy 1, 2
• If no response after 2-4 weeks (hemoglobin rise <10 g/L), consider:
  • Poor compliance
  • Ongoing blood loss
  • Malabsorption
  • Incorrect diagnosis
  • Need for parenteral iron 1, 2

4. Duration of Treatment

• Continue iron supplementation for three months after correction of anemia to replenish iron stores 1
• Monitor hemoglobin concentration and red cell indices at three-monthly intervals for one year, then after a further year 1

Investigation of Underlying Cause

Given the patient's age (69 years), it is crucial to investigate the underlying cause of iron deficiency anemia:

• Upper GI endoscopy with small bowel biopsy to rule out upper GI sources of bleeding and malabsorptive conditions like celiac disease 1, 2
• Colonoscopy (or barium enema as an alternative) to evaluate for colonic sources of blood loss, particularly neoplasms 1, 2

When to Consider Parenteral Iron

Parenteral iron should only be used when:

• There is intolerance to at least two oral preparations
• Non-compliance is an issue
• Patient has conditions affecting iron absorption
• Oral therapy fails despite adjustments 1, 2

Common Pitfalls and Caveats

• Failure to investigate the underlying cause: In a 69-year-old female, iron deficiency anemia could indicate serious underlying pathology, particularly gastrointestinal malignancy 1, 2, 3
• Inadequate duration of treatment: Treatment should continue for three months after normalization of hemoglobin to replenish iron stores 1
• Poor monitoring: Regular follow-up is essential to ensure response to treatment and detect recurrence 1
• Overlooking gastrointestinal side effects: GI side effects are common with oral iron and can reduce compliance; adjusting dosing schedule or changing formulation may improve tolerance 4
• Missing malabsorption: Conditions like celiac disease can impair iron absorption and should be ruled out with small bowel biopsy during upper endoscopy 1, 2

Treatment Goals

• Restore hemoglobin levels and MCV to normal
• Replenish body iron stores
• Identify and treat the underlying cause
• Resolution of anemia should be achieved by six months in 80% of patients 1, 2