What is the treatment for a 42-year-old female with iron deficiency anemia, elevated Total Iron Binding Capacity (TIBC), normal Unbound Iron Binding Capacity (UIBC), normal iron, low iron saturation, and low ferritin?

Treatment for Iron Deficiency in a 42-Year-Old Female

The initial treatment for iron deficiency in this 42-year-old female should be one tablet per day of ferrous sulfate (providing 65mg of elemental iron), taken on an empty stomach. 1, 2

Diagnosis Confirmation

The patient's laboratory values confirm iron deficiency:

• Ferritin: 9 μg/L (below normal range)
• Iron saturation: 11% (below normal range)
• TIBC: 463 (above normal range)
• Iron: 49 (normal)
• UIBC: 414 (normal)

These values, particularly the low ferritin (<30 μg/L) and low transferrin saturation (<20%), are diagnostic of absolute iron deficiency 2.

Treatment Algorithm

First-Line Treatment:

1. Oral Iron Supplementation

   • Formulation: Ferrous sulfate tablet (324mg, containing 65mg elemental iron) 1, 3
   • Dosing schedule: One tablet daily, preferably on an empty stomach 1
   • Alternative if not tolerated: One tablet every other day 1, 4, 5
   • Duration: Continue for 3 months after normalization of hemoglobin 1, 2

2. Enhancing Absorption

   • Take with 500mg vitamin C (ascorbic acid) to improve absorption 2
   • Take in the morning rather than afternoon/evening 4
   • Avoid taking with tea, coffee, dairy products, or calcium supplements

Monitoring Response:

• Check hemoglobin after 4 weeks to confirm response 2
  • Expected response: Increase in Hb ≥10 g/L within 2-4 weeks 2
• Continue monitoring hemoglobin and red cell indices at 3-month intervals for one year 2

Second-Line Treatment (if oral iron fails):

• Consider parenteral iron if oral iron is:
  • Contraindicated
  • Ineffective after 4 weeks
  • Not tolerated due to side effects 1

Important Considerations

Side Effects Management

• Common side effects include:
  • Constipation (12%)
  • Diarrhea (8%)
  • Nausea (11%) 2
• If side effects occur:
  • Try taking with food (though this reduces absorption by 40-50%)
  • Consider alternate-day dosing which may improve absorption and reduce side effects 4, 5
  • Try different iron formulation if necessary

Investigation of Underlying Cause

• As a 42-year-old female with confirmed iron deficiency, investigation for underlying causes is essential
• Consider:
  • Gastrointestinal evaluation (upper and lower endoscopy) to rule out occult bleeding
  • Celiac disease screening
  • Gynecological evaluation for heavy menstrual bleeding

Evidence Strength and Nuances

The British Society of Gastroenterology guidelines (2021) provide strong recommendations for daily ferrous sulfate as first-line therapy 1. Recent research suggests alternate-day dosing may improve absorption and reduce side effects 4, 5, but guidelines still primarily recommend daily dosing with the option to reduce to alternate-day if not tolerated 1.

While newer iron formulations like ferric maltol are available and may cause fewer GI side effects, traditional ferrous sulfate remains the standard treatment due to its efficacy, good bioavailability, and lower cost 1, 6, 7.

Common Pitfalls to Avoid

• Discontinuing iron therapy too early (before iron stores are replenished)
• Not investigating the underlying cause of iron deficiency
• Failing to monitor response to treatment
• Not considering parenteral iron when oral therapy fails
• Continuing ineffective oral iron therapy for too long