What is the recommended treatment for iron deficiency?

Iron Deficiency Treatment

Oral iron supplementation with ferrous sulfate 324 mg (65 mg elemental iron) once daily is the recommended first-line treatment for iron deficiency, with alternative-day dosing as an option for improved tolerability. 1

Diagnosis and Evaluation

Before initiating treatment, proper diagnosis is essential:

• Iron deficiency is diagnosed by:
  • Low serum ferritin (<30 ng/mL) in individuals without inflammatory conditions
  • Transferrin saturation <20% 1, 2
• Higher ferritin cutoffs (up to 100 μg/L) should be used for diagnosis in patients with inflammatory conditions 1
• For men and postmenopausal women, GI evaluation (endoscopy, colonoscopy) is necessary to rule out underlying causes 1

Treatment Algorithm

First-Line Treatment: Oral Iron

1. Standard Dosing:

   • Ferrous sulfate 324 mg (65 mg elemental iron) once daily 1
   • Alternative-day dosing improves tolerability and may enhance absorption 1, 3
   • Morning administration is preferable (hepcidin levels are lower) 3

2. Optimization Strategies:

   • Take on an empty stomach if tolerated
   • Add vitamin C (500 mg) to enhance absorption
   • Avoid calcium-containing foods, tea, coffee, and antacids during administration 1
   • Continue for 3 months after hemoglobin normalizes to replenish iron stores 1

3. Monitoring Response:

   • Check hemoglobin after 2-4 weeks of therapy
   • Consider alternative approach if hemoglobin increase is <1.0 g/dL at day 14
   • Continue monitoring every 4 weeks until hemoglobin normalizes 1

Second-Line Treatment: Intravenous (IV) Iron

IV iron is indicated for patients with:

• Clinically active inflammatory bowel disease
• Previous intolerance to oral iron
• Hemoglobin below 10 g/dL
• Need for erythropoiesis-stimulating agents 1
• Oral iron intolerance or poor absorption (celiac disease, post-bariatric surgery)
• Chronic inflammatory conditions (CKD, heart failure, IBD, cancer)
• Ongoing blood loss
• Second and third trimesters of pregnancy 2

Modern IV iron formulations have improved safety profiles compared to older preparations, with true anaphylaxis being rare 1

Special Considerations

Dosing Strategy

Recent evidence suggests that alternate-day dosing may be more effective than daily dosing:

• Doses ≥60 mg stimulate hepcidin increase that persists for 24 hours but subsides by 48 hours
• Morning doses are preferable as the circadian increase in plasma hepcidin is augmented by morning iron doses 3
• Total iron absorption is higher when twice the target daily iron dose is given on alternate days 3

Population-Specific Dosing

Recommended daily iron intake varies by population:

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

Common Pitfalls to Avoid

1. Inadequate Evaluation: Accepting upper GI findings without lower GI evaluation can lead to overlooked dual pathology in 10-15% of patients 1

2. Premature Discontinuation: Stopping iron supplementation before iron stores are replenished leads to recurrence 1

3. Excessive Dosing: High doses of oral iron have low fractional absorption and cause more gastrointestinal side effects, reducing compliance 4, 3

4. Inappropriate Monitoring: Failing to check response after 2-4 weeks or ignoring non-response 1

5. Red Cell Transfusion Overuse: Transfusion should be considered only for severe, symptomatic IDA with hemodynamic instability 5

Dietary Recommendations

• Consume foods rich in heme iron (red meat, fish, poultry)
• Include vitamin C-rich foods (citrus fruits, strawberries) with iron-rich meals
• Avoid iron absorption inhibitors (tea, coffee, calcium, phytates) during meals 1