What is the appropriate management for a patient with iron deficiency anemia?

Management of Iron Deficiency Anemia

The most appropriate management for this patient with iron deficiency anemia is oral iron supplementation with ferrous sulfate 200 mg three times daily for at least 3 months after correction of anemia to replenish iron stores. 1, 2

Diagnosis Confirmation

The laboratory values clearly indicate iron deficiency anemia:

• Hemoglobin: 99 g/L (low)
• MCV: 68 fL (microcytic)
• MCH: 21 pg (hypochromic)
• Ferritin: 7 μg/L and 12 μg/L (severely depleted iron stores)
• Transferrin saturation: 0.06 (very low)
• Elevated platelets (472 x 10e9/L) and WBC (11.5 x 10e9/L) with mild CRP elevation (10) suggest reactive changes

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, 3
• Alternative options if ferrous sulfate is not tolerated:
  • Ferrous gluconate or ferrous fumarate at equivalent doses 1
  • Liquid preparation if tablets are not tolerated 1
  • Consider lower dose (100 mg daily) if GI side effects occur 2
  • Alternate-day dosing may improve tolerance while maintaining efficacy 2

2. Optimization Strategies

• Add ascorbic acid (vitamin C) to enhance iron absorption 1, 2
• Avoid taking iron with tea, coffee, calcium, or antacids 2
• Take on empty stomach if tolerated 2

3. Monitoring Response

• Expect hemoglobin to rise by 2 g/dL after 3-4 weeks 1, 2
• If no response after 4 weeks, consider:
  • Poor compliance
  • Misdiagnosis
  • Continued blood loss
  • Malabsorption 1

4. Duration of Therapy

• Continue iron supplementation for 3 months after correction of anemia to replenish iron stores 1, 2
• Monitor hemoglobin concentration and red cell indices at 3-month intervals for one year, then after a further year 1

Investigation of Underlying Cause

Based on the patient's age and gender (not specified in the lab values), further investigation may be necessary:

For men and postmenopausal women:

• Upper GI endoscopy with small bowel biopsy
• Colonoscopy or barium enema
• These investigations are essential as GI blood loss is the most common cause 1, 2, 4

For premenopausal women:

• If >45 years: follow same investigation protocol as above
• If <45 years:
  • Upper GI endoscopy and small bowel biopsy only if upper GI symptoms present
  • Test for celiac disease with antiendomysial antibodies
  • Consider menstrual blood loss as a common cause 1, 2

When to Consider IV Iron

Parenteral iron should only be used when:

• Intolerance to at least two oral preparations
• Non-compliance
• Malabsorption conditions
• Chronic inflammatory conditions
• Ongoing blood loss 1, 2

Common Pitfalls to Avoid

1. Inadequate duration of therapy: Continuing iron supplementation for 3 months after normalization of hemoglobin is essential to replenish stores 1
2. Failure to investigate underlying cause: Especially important in men and postmenopausal women 2, 4
3. Overlooking poor absorption factors: Certain medications and foods can impair iron absorption 2
4. Stopping therapy too soon: Monitor hemoglobin and MCV regularly even after correction 1
5. Missing malabsorption: Consider celiac disease and other malabsorption disorders 1, 2

By following this approach, most patients with iron deficiency anemia will achieve normalization of hemoglobin levels and replenishment of iron stores, improving morbidity, mortality, and quality of life.