Treatment for Microcytic Anemia with Iron Deficiency
Oral iron supplementation is the first-line treatment for this patient with microcytic anemia (MCV 62) and iron deficiency (iron 38, TIBC 210, ferritin 323).
Diagnosis Assessment
The laboratory values show:
- MCV 62 (low, indicating microcytic anemia)
- Iron 38 (low)
- TIBC 210 (low)
- Ferritin 323 (elevated)
This pattern suggests iron deficiency anemia complicated by an inflammatory condition. The elevated ferritin despite low iron and low TIBC indicates an acute phase reaction, as ferritin is an acute phase reactant that can be elevated in inflammatory states despite iron deficiency 1.
Treatment Algorithm
Step 1: Initial Oral Iron Therapy
- Begin with oral iron supplementation: ferrous sulfate 200 mg twice daily 2
- Continue for 3 months after hemoglobin normalizes to replenish iron stores 2, 1
- Consider adding ascorbic acid (250-500 mg twice daily) to enhance iron absorption 2
- Alternative dosing strategy: 60-120 mg elemental iron on alternate days in the morning may improve absorption and reduce side effects 3, 4
Step 2: Monitor Response
- Check complete blood count in 2-4 weeks to assess response 1
- Expect hemoglobin rise of ≥1 g/dL within 2 weeks for adequate response 5
- Monitor iron studies monthly 1
Step 3: If Inadequate Response or Intolerance
Consider intravenous iron if:
- Hemoglobin increase is <1.0 g/dL after 14 days of oral therapy 5
- Patient cannot tolerate oral iron due to side effects 2, 1
- Patient has inflammatory bowel disease or other conditions affecting absorption 1
Step 4: IV Iron Options
Ferric carboxymaltose (Injectafer) 6:
- For patients ≥50 kg: 750 mg IV in two doses separated by at least 7 days
- For patients <50 kg: 15 mg/kg IV in two doses separated by at least 7 days
Iron dextran (INFeD) 7:
- Dose calculated based on: 0.0442 (Desired Hb - Observed Hb) × LBW + (0.26 × LBW)
- Administered as a single infusion or divided doses
Special Considerations
For Iron-Refractory Iron Deficiency Anemia (IRIDA)
- Consider IRIDA if there is poor response to oral iron 2
- IRIDA patients typically have low TSAT with normal or low ferritin (unlike this patient) 2
- For confirmed IRIDA, intravenous iron is the treatment of choice 2
Monitoring for Complications
- Monitor serum ferritin levels during IV therapy; avoid exceeding 500 μg/L to prevent iron overload 2
- For IV iron, watch for hypersensitivity reactions during and for 30 minutes after administration 6
- Monitor phosphate levels with repeated IV iron courses due to risk of hypophosphatemia 6
Common Pitfalls to Avoid
- Relying solely on ferritin for diagnosis without considering inflammatory status 1
- Failing to investigate underlying causes of iron deficiency 8, 9
- Continuing ineffective oral iron therapy beyond 2 weeks when response is inadequate 5
- Providing iron doses too frequently (daily vs. alternate day), which can increase hepcidin and reduce absorption 3, 4
This patient's elevated ferritin with low iron and TIBC suggests an underlying inflammatory condition that should be investigated while initiating iron therapy.