What is the first line treatment for iron deficiency anemia?

First-Line Treatment for Iron Deficiency Anemia

Oral iron supplementation is the gold standard first-line treatment for iron deficiency anemia, with a recommended dose of 50-100 mg of elemental iron once daily, taken in the fasting state. 1

Oral Iron Therapy Details

Dosing Recommendations

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

Administration

• Take on an empty stomach to maximize absorption
• Consider alternate-day dosing if GI side effects occur
• Different formulations available:
  • Ferrous sulfate (most common and cost-effective)
  • Ferrous gluconate or ferrous fumarate (may be better tolerated) 1, 2

Monitoring Response to Treatment

1. Initial assessment: Check hemoglobin after 2-4 weeks of treatment

   • A hemoglobin increase ≥1.0 g/dL at day 14 strongly predicts successful treatment (sensitivity 90.1%, specificity 79.3%) 1, 3
   • If hemoglobin increase is <1.0 g/dL at day 14, consider switching to IV iron 3

2. Continued monitoring:

   • Monitor every 4 weeks until hemoglobin normalizes
   • Check iron studies (ferritin, TSAT) every 3 months during maintenance phase 1

3. Duration of therapy:

   • Continue treatment for 3-6 months after hemoglobin normalizes to replenish iron stores
   • Premature discontinuation before replenishing stores is a common pitfall 1

Managing Side Effects

• GI side effects (common with oral iron):
  • Try alternate-day dosing
  • Switch to a different iron formulation (ferrous gluconate or ferrous fumarate)
  • Take with a small amount of food if necessary (may reduce absorption) 1

When to Consider IV Iron

Intravenous iron (such as ferric carboxymaltose) should be considered when:

1. Oral iron is not tolerated
2. Malabsorption is present
3. Patient has chronic inflammatory conditions
4. Ongoing blood loss exists
5. Rapid correction of anemia is needed 1, 4

For IV iron administration:

• Ferric carboxymaltose can be given at a maximum single dose of 1000 mg over 15 minutes 1, 4
• Monitor for hypersensitivity reactions during and for at least 30 minutes after administration 4
• Check phosphate levels before repeat treatments, as IV iron can cause hypophosphatemia 4

Common Pitfalls to Avoid

1. Inadequate monitoring of response to treatment
2. Premature discontinuation before iron stores are replenished
3. Overuse of blood transfusion when iron therapy would be sufficient
4. Ignoring non-response to oral iron therapy
5. Failing to identify the underlying cause of iron deficiency
6. Using inappropriate ferritin cutoffs in patients with inflammation 1

Addressing the Underlying Cause

Always investigate and treat the underlying cause of iron deficiency:

• Evaluate for GI blood loss
• Consider non-invasive testing for H. pylori and celiac disease
• Assess menstrual blood loss in premenopausal women
• Evaluate dietary iron intake and absorption issues 1, 5

Remember that iron deficiency anemia is often a symptom of an underlying condition, and treating only the anemia without addressing its cause will lead to recurrence.