What is the recommended treatment regimen for iron deficiency anemia?

Treatment Regimen for Iron Deficiency Anemia

For iron deficiency anemia, the recommended first-line treatment is oral ferrous sulfate 324 mg (65 mg elemental iron) once daily, with alternate-day dosing as an option for improved tolerability and absorption. 1

Initial Oral Iron Therapy

Dosing Recommendations:

• First-line treatment: Ferrous sulfate 324 mg (65 mg elemental iron) once daily 1
• Alternative dosing: Consider alternate-day dosing (every other day) which may improve absorption and reduce side effects 1, 2
• Administration: Take on an empty stomach with vitamin C (such as orange juice) to enhance absorption 1
• Duration: Continue treatment for at least 3 months after hemoglobin normalizes to replenish iron stores 1

Monitoring Response:

• Check initial response after 2-4 weeks of treatment 1
• A successful response is indicated by an increase in hemoglobin of at least 10 g/L after 2 weeks 1
• Continue monitoring every 4 weeks until hemoglobin normalizes 1
• Long-term follow-up with iron studies should be repeated every 3 months during the maintenance phase 1

When to Switch to IV Iron Therapy

Switch to intravenous iron when:

• Patient does not tolerate oral iron (gastrointestinal side effects) 1
• No improvement in ferritin levels after an adequate trial of oral iron 1
• Conditions where oral iron absorption is impaired:
  • Inflammatory bowel disease with active inflammation
  • Post-bariatric surgery
  • Celiac disease not responding to gluten-free diet
  • Ongoing blood loss exceeding iron intake 1, 3

IV Iron Administration

Recommended IV Formulation:

• Ferric carboxymaltose is an effective IV option 4
• For patients ≥50 kg: 750 mg IV in two doses separated by at least 7 days (total 1,500 mg) 4
• For patients <50 kg: 15 mg/kg body weight IV in two doses separated by at least 7 days 4
• Single-dose option: 15 mg/kg up to 1,000 mg may be administered as a single dose 4

Common Pitfalls to Avoid

1. Premature discontinuation of therapy: Continue treatment until both clinical symptoms and laboratory parameters normalize 1

2. Inadequate monitoring: Follow hemoglobin and iron studies throughout treatment 1

3. Failure to identify underlying cause: Always determine if iron deficiency is due to inadequate intake/absorption or blood loss 1

   • For men and postmenopausal women: Evaluate for gastrointestinal blood loss
   • For premenopausal women: Assess menstrual blood loss 3

4. Using inappropriate ferritin cutoffs: In patients with inflammation, ferritin may be falsely elevated 1

   • Ferritin <30 μg/L: Definitive iron deficiency
   • Ferritin 30-100 μg/L with transferrin saturation <20%: Possible iron deficiency, especially with inflammation
   • Ferritin >100 μg/L with normal transferrin saturation: Iron deficiency is unlikely 1

5. Overuse of blood transfusion: Reserve for severe anemia or symptomatic patients 1

Special Considerations

• Pregnancy: IV iron may be appropriate during second and third trimesters 3
• Chronic kidney disease: IV iron often preferred due to impaired oral absorption 3
• Heart failure: Iron deficiency treatment improves exercise capacity 4
• Celiac disease: Ensure adherence to gluten-free diet to improve iron absorption 1

By following this treatment algorithm and avoiding common pitfalls, most patients with iron deficiency anemia can achieve successful resolution of anemia and replenishment of iron stores.