What is the treatment for a patient with iron deficiency anemia, indicated by low iron levels and ferritin?

Treatment for Iron Deficiency Anemia

Oral iron supplementation with ferrous sulfate 324 mg (65 mg elemental iron) daily is the first-line treatment for this patient with iron deficiency anemia, as indicated by low serum iron (39 μg/dL) and low iron saturation (14%). 1, 2

Diagnosis Confirmation

The laboratory values show:

• Ferritin: 67 ng/mL (normal range: 12-300 ng/mL)
• Iron: 39 μg/dL (low; normal range: 59-158 μg/dL)
• Iron saturation: 14% (low; normal range: 20-55%)
• TIBC: 282 μg/dL (normal range: 228-428 μg/dL)

These values confirm iron deficiency anemia with:

• Low serum iron
• Low transferrin saturation (<20%)
• Normal TIBC
• Ferritin in normal range (may be falsely elevated in inflammatory conditions)

Treatment Algorithm

1. Initial Treatment:

   • Oral iron supplementation: Ferrous sulfate 324 mg daily (provides 65 mg elemental iron) 1, 2
   • Consider alternate-day dosing to improve absorption and reduce side effects 3

2. For patients with poor tolerance to oral iron:

   • Try taking with food (though may reduce absorption)
   • Consider lower doses or alternate-day dosing
   • Switch to a different iron formulation

3. Consider IV iron if:

   • Intolerance to oral iron
   • Malabsorption conditions
   • Ongoing blood loss exceeding oral absorption capacity
   • Inflammatory bowel disease
   • Hemoglobin below 10 g/dL 3, 1

Monitoring Response

• Check hemoglobin after 4 weeks of therapy to assess response 1
  • Adequate response: Increase in hemoglobin of at least 1 g/dL
• Monitor ferritin and hemoglobin after 8-10 weeks of treatment 3, 1
• Once normalized, monitor every 3 months for one year, then annually 1

Important Considerations

• Investigate underlying cause: The most common causes of iron deficiency are blood loss (menstrual, gastrointestinal), impaired iron absorption (atrophic gastritis, celiac disease), and inadequate dietary intake 1, 4
• Endoscopic evaluation: Consider bidirectional endoscopy (EGD and colonoscopy) to identify potential sources of blood loss, particularly in men and postmenopausal women 1
• Dietary recommendations: Increase consumption of iron-rich foods and vitamin C to enhance absorption; avoid tea, coffee, and calcium supplements with meals 1

Potential Pitfalls

• Misinterpreting ferritin levels: Normal ferritin (as in this case) doesn't exclude iron deficiency, especially in inflammatory conditions where ferritin can be falsely elevated up to 100 μg/L 3, 1
• Inadequate dosing or duration: Ensure sufficient elemental iron and treatment duration 1
• Overlooking compliance issues: GI side effects from oral iron can lead to poor adherence 1
• Failing to investigate underlying cause: Identifying and addressing the source of iron loss or malabsorption is crucial 1, 4

Special Situations

• For severe anemia (Hgb <7 g/dL): Consider IV iron therapy 1
• For inflammatory conditions: IV iron may be more effective than oral supplementation 3, 5
• For pregnancy: Higher iron requirements may necessitate increased dosing 4