What is the treatment for a patient with severe iron deficiency (ferritin level of 5)?

Treatment for Severe Iron Deficiency (Ferritin 5)

Oral iron supplementation should be initiated immediately for a patient with severe iron deficiency (ferritin 5), with a recommended dose of ferrous sulfate 200 mg three times daily for at least three months after correction of anemia to replenish iron stores. 1

First-Line Treatment: Oral Iron Therapy

Dosing Options:

• Ferrous sulfate: 200 mg three times daily (preferred) 1
• Ferrous gluconate: 324 mg (38 mg elemental iron) three to four times daily 2
• Ferrous fumarate: Similar efficacy to other oral preparations 1

Optimization Strategies:

• Add ascorbic acid (vitamin C) 250-500 mg with iron to enhance absorption 1, 3
• Liquid preparations may be better tolerated when tablets cause side effects 1
• Consider alternate-day dosing if daily dosing causes significant gastrointestinal side effects 4
• Take on empty stomach if tolerated, or with small amounts of food if necessary for tolerance

Monitoring Response

Initial Follow-up:

• Check hemoglobin and iron studies after 4 weeks of treatment 3
• Expected response: hemoglobin should rise by 2 g/dL after 3-4 weeks 1, 3

Failure to Respond:

Common reasons for inadequate response include:

• Poor compliance due to side effects
• Continued blood loss
• Malabsorption
• Misdiagnosis 1

Duration of Treatment

• Continue iron therapy for three months after correction of anemia 1
• Target ferritin level >100 μg/L to ensure adequate replenishment of iron stores 3
• Monitor iron parameters every 3 months for the first year after normalization 3
• Continue monitoring every 6-12 months if risk factors persist 3

Second-Line Treatment: Intravenous Iron

Consider intravenous iron in the following situations:

• Intolerance to at least two oral preparations
• Non-compliance with oral therapy
• Malabsorption (e.g., celiac disease, post-bariatric surgery)
• Need for rapid iron repletion
• Ongoing blood loss
• Chronic inflammatory conditions (IBD, CKD, heart failure) 1, 4

Addressing Underlying Causes

A ferritin level of 5 indicates severe iron deficiency that requires investigation of potential causes:

Common Causes to Evaluate:

• Gastrointestinal blood loss (upper or lower GI tract)
• Menstrual blood loss in women of reproductive age
• Malabsorption (celiac disease, H. pylori infection)
• Dietary insufficiency
• Pregnancy/recent childbirth 4

Recommended Investigations:

• Upper GI endoscopy with small bowel biopsy
• Colonoscopy or barium enema (for patients >45 years or with GI symptoms)
• Celiac disease screening (tissue transglutaminase antibody)
• Urinalysis to exclude hematuria 1

Important Considerations

• Do not defer iron therapy while awaiting investigations unless colonoscopy is imminent 3
• A ferritin level of 5 is far below the diagnostic threshold of 15-30 μg/L, indicating severe iron deficiency 1, 3
• Patients with severe iron deficiency may experience fatigue, irritability, difficulty concentrating, restless legs syndrome, pica, and exercise intolerance 4
• Resolution of anemia should be achieved in 80% of patients by six months 1

By following this treatment approach, you can effectively address severe iron deficiency, improve patient symptoms, and prevent complications associated with prolonged iron deficiency.