What is the recommended treatment for iron deficiency?

Treatment of Iron Deficiency

The gold standard treatment for iron deficiency is oral iron supplementation with 50-100 mg of elemental iron once daily, taken in the fasting state (morning), with continuation for 3 months after hemoglobin normalization to replenish iron stores. 1

Oral Iron Therapy: First-Line Treatment

Dosing Recommendations

• Optimal dosing strategy:
  • 60-120 mg of elemental iron as a single morning dose on alternate days 1, 2
  • Take with vitamin C to improve absorption 1
  • Take between meals to maximize absorption 1

Population-Specific Dosing (CDC Recommendations)

• Nonpregnant women and adolescent girls: 60-120 mg daily
• School-age children: 60 mg daily
• Adolescent boys: 120 mg daily
• Pregnant women (preventive): 30 mg daily
• Pregnant women (treatment): 60-120 mg daily 1

Formulations

• Ferrous sulfate (65 mg elemental iron per tablet) is the simplest, least expensive, and most commonly prescribed form 1, 3
• Other options include ferrous salts and ferric complexes with polysaccharides 3
• Extended-release formulations may reduce gastrointestinal side effects 4

Monitoring Response

1. Check hemoglobin after 2-4 weeks of treatment
   • Critical decision point: Increase in hemoglobin of ≥10 g/L after 2 weeks strongly predicts successful treatment (sensitivity 90.1%, specificity 79.3%) 1
2. Continue monitoring every 4 weeks until hemoglobin normalizes
3. After normalization, continue iron for 3 months to replenish stores
4. Long-term follow-up with iron studies every 3 months during maintenance phase 1

When to Consider Intravenous Iron

Intravenous iron should be used when:

• Oral iron is not tolerated
• No hemoglobin increase of at least 10 g/L after 2 weeks of oral therapy
• Malabsorption conditions present (celiac disease, post-bariatric surgery)
• Chronic inflammatory conditions (IBD, CKD, heart failure, cancer)
• Ongoing blood loss exceeding oral replacement capacity
• Second and third trimesters of pregnancy when rapid repletion needed 1, 5

IV Iron Options

• Ferric carboxymaltose: Maximum single dose 1000 mg, infused over 15 minutes 1
• Iron sucrose: 200 mg per injection over 10-30 minutes 1
• Iron dextran: Can replenish iron in a single infusion but carries risk of serious reactions (0.6-0.7%) 1

Identifying and Addressing Underlying Causes

Essential evaluations based on patient demographics:

• Men and postmenopausal women: Evaluate for gastrointestinal blood loss with upper GI endoscopy and colonoscopy 1
• Premenopausal women: Assess for heavy menstrual bleeding 1
• All patients: Screen for malabsorption conditions and evaluate dietary intake patterns 1
• Consider testing for H. pylori 1
• Screen for celiac disease with tTG antibodies, especially in premenopausal women 1

Common Pitfalls to Avoid

1. Inadequate monitoring: Failing to check hemoglobin response after 2 weeks may delay recognition of treatment failure 1
2. Premature discontinuation: Stopping iron once hemoglobin normalizes without continuing for 3 months to replenish stores 1
3. Overuse of blood transfusion: Should be reserved for severe symptomatic anemia or circulatory compromise 1
4. Ignoring non-response: May indicate non-compliance, malabsorption, continued bleeding, or concurrent deficiencies 1
5. Using inappropriate ferritin cutoffs in patients with inflammation (should use transferrin saturation <20% when ferritin is 30-100 μg/L) 1
6. Excessive dosing: Traditional high-dose daily regimens (150-200 mg) lead to lower fractional absorption and more side effects; alternate-day dosing may improve absorption and reduce side effects 2, 6