What is the first line treatment for iron deficiency anemia?

First-Line Treatment for Iron Deficiency Anemia

Oral iron supplementation should be considered as first-line treatment for iron deficiency anemia in patients with mild anemia, whose underlying condition is clinically inactive, and who have not been previously intolerant to oral iron. 1, 2

Treatment Algorithm Based on Patient Characteristics

First-Line Therapy: Oral Iron

• Preferred agent: Ferrous sulfate (65mg elemental iron per tablet daily) 2
• Dosing: 60-120mg of elemental iron daily 2
• Duration: Continue for 3 months after normalization of hemoglobin to replenish iron stores 2
• Monitoring: Check hemoglobin within 4 weeks; expect increase of at least 1-2 g/dL 1, 2

When to Use Intravenous Iron (First-Line)

Intravenous iron should be considered as first-line treatment in specific situations:

1. Patients with clinically active inflammatory bowel disease 1
2. Previous intolerance to oral iron 1
3. Hemoglobin below 10 g/dL 1, 2
4. Patients requiring erythropoiesis-stimulating agents 1
5. Conditions impairing iron absorption (post-bariatric surgery, celiac disease) 2, 3
6. Ongoing blood loss exceeding absorption capacity 4, 3

Dosing Considerations

Oral Iron Dosing

• Standard dosing: One tablet of ferrous sulfate daily (providing approximately 65mg of elemental iron) 2
• Alternative approach: Alternate-day dosing may improve absorption and reduce side effects 3
• Goal: Normalize hemoglobin levels and replenish iron stores 1

IV Iron Dosing

For patients requiring IV iron, dosing is based on hemoglobin level and body weight:

• Hemoglobin 10-12 g/dL (women) or 10-13 g/dL (men):
  • Body weight <70kg: 1000mg
  • Body weight ≥70kg: 1500mg
• Hemoglobin 7-10 g/dL:
  • Body weight <70kg: 1500mg
  • Body weight ≥70kg: 2000mg 1

Monitoring Response to Treatment

• Check hemoglobin within 4 weeks of starting therapy 2
• Acceptable response: Increase in hemoglobin of at least 2 g/dL within 4 weeks 1
• If no response to oral iron after 4 weeks despite compliance, further evaluation is needed 2
• For patients treated with IV iron, re-treatment should be initiated when serum ferritin drops below 100 μg/L or hemoglobin falls below gender-specific thresholds (12 g/dL for women, 13 g/dL for men) 1

Common Pitfalls to Avoid

• Failing to identify underlying cause: Always investigate the cause of iron deficiency while initiating treatment 2, 3
• Inadequate treatment duration: Continuing treatment for only until hemoglobin normalizes without replenishing iron stores 2, 5
• Overlooking poor compliance: Gastrointestinal side effects from oral iron often lead to poor adherence; consider alternate-day dosing or different formulations if side effects occur 6, 5
• Delaying IV iron when indicated: Patients with severe anemia or conditions affecting absorption may experience continued deterioration if IV iron is delayed 4, 3
• Ignoring recurrence risk: Iron deficiency often recurs after successful treatment, requiring ongoing monitoring 1

By following this algorithm and understanding the specific indications for oral versus intravenous iron therapy, clinicians can effectively manage iron deficiency anemia while minimizing complications and improving patient outcomes.