Management of Iron Deficiency in a 23-year-old with Normal Hemoglobin/Hematocrit
Oral iron supplementation with ferrous sulfate 325 mg (65 mg elemental iron) once daily is recommended for this 23-year-old with iron deficiency despite normal hemoglobin/hematocrit values. 1, 2, 3
Diagnosis Assessment
This patient presents with:
- Normal hemoglobin/hematocrit (129/0.39)
- Low serum iron (8.1)
- Low transferrin saturation (TIBC 0.13)
- Low ferritin (37)
These laboratory values indicate iron deficiency without anemia, as:
- Serum ferritin <45 μg/L suggests depleted iron stores 1
- Low transferrin saturation (TIBC) confirms impaired iron availability 1
- Normal hemoglobin/hematocrit indicates the body has maintained adequate red cell production despite low iron stores
Treatment Approach
Initial Iron Therapy
- Start with ferrous sulfate 325 mg (65 mg elemental iron) once daily 1, 2, 3
- If not tolerated, consider:
- Reduced dosing to one tablet every other day
- Alternative oral iron preparations
- Taking with vitamin C (250-500 mg) to enhance absorption 2
Monitoring Response
- Check hemoglobin and iron studies after 4 weeks of treatment 2
- Expected response: improvement in iron parameters within 4 weeks
- Continue supplementation until ferritin normalizes (>100 μg/L) 2
Follow-up
- After normalization of iron parameters, monitor every 3 months for the first year 2
- Long-term checks of iron parameters every 6-12 months if risk factors persist 2
Additional Considerations
Investigation for Underlying Cause
- While the British Society of Gastroenterology guidelines recommend endoscopic investigation for iron deficiency in men and postmenopausal women 1, this may not be necessary in a 23-year-old unless there are concerning symptoms
- Consider screening for celiac disease with tissue transglutaminase antibody 1
- Assess for potential causes:
- Dietary insufficiency
- Menstrual blood loss (if female)
- NSAID use
- Blood donation history 1
Important Caveats
- Do not defer iron therapy while awaiting investigations unless colonoscopy is imminent 1
- Avoid excessive supplementation as it can lead to iron overload; monitor ferritin levels 2
- Iron deficiency can exist with normal hemoglobin/hematocrit values, making iron studies essential for diagnosis 4
- If no improvement after 4 weeks of oral iron, reassess compliance and consider alternative causes of iron deficiency 2
This approach prioritizes treating the iron deficiency while monitoring for appropriate response, with the goal of preventing progression to iron deficiency anemia and addressing the underlying cause of iron depletion.