What is the recommended treatment for iron deficiency?

Treatment of Iron Deficiency Anemia

The initial treatment for iron deficiency anemia should be with one tablet per day of ferrous sulfate (200 mg, providing approximately 60-65 mg elemental iron), with treatment continuing for 3 months after normalization of hemoglobin levels to ensure adequate repletion of iron stores. 1, 2

First-Line Treatment: Oral Iron Therapy

Recommended Oral Iron Regimen

• Dosage: Ferrous sulfate 200 mg once daily (providing 60-65 mg elemental iron) 1, 2
• Duration: Continue for 3 months after hemoglobin normalizes 1, 2
• Expected response: Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of treatment 1, 2
• Monitoring: Check hemoglobin within 4 weeks to assess initial response 2

Managing Side Effects

If standard dosing is not tolerated due to gastrointestinal side effects:

1. Reduce dose to one tablet every other day 1, 2
2. Consider alternative oral preparations (ferrous fumarate, ferrous gluconate) 1
3. Consider adding ascorbic acid (vitamin C) to enhance absorption when response is poor 1

Second-Line Treatment: Parenteral Iron

Indications for Parenteral Iron

Parenteral iron should be considered when:

• Oral iron is contraindicated
• Oral iron is ineffective despite adequate trial
• Oral iron is not tolerated after trying at least two different preparations
• Patient has inflammatory bowel disease with active inflammation 1
• Patient has non-dialysis dependent chronic kidney disease 3

Parenteral Iron Options

For patients ≥50 kg, ferric carboxymaltose can be administered as:

• 750 mg intravenously in two doses separated by at least 7 days (total 1,500 mg) 3
• Alternatively, 15 mg/kg body weight up to 1,000 mg as a single dose 3

For patients <50 kg:

• 15 mg/kg body weight intravenously in two doses separated by at least 7 days 3

Special Populations

Portal Hypertensive Gastropathy

• Begin with oral iron supplements
• Switch to intravenous iron if there is ongoing bleeding with inadequate response to oral therapy 1
• Consider treatment of portal hypertension with non-selective β-blockers 1

Celiac Disease

• Ensure adherence to a gluten-free diet to improve iron absorption
• Add oral iron supplementation based on severity of deficiency 1

Premenopausal Women

• Women <45 years without GI symptoms should have antiendomysial antibody testing to exclude celiac disease 1
• Consider evaluation for menorrhagia using pictorial blood loss assessment charts 2

Monitoring and Follow-up

Short-term Monitoring

• Check hemoglobin within 4 weeks to assess initial response 2
• Repeat iron studies (ferritin, transferrin saturation) after 4-8 weeks of treatment 2

Long-term Monitoring

• Monitor blood count periodically (every 6 months initially) to detect recurrent IDA 1
• Target ferritin level >50 ng/mL in the absence of inflammation 2

Common Pitfalls to Avoid

1. Premature discontinuation: Stopping iron supplementation before iron stores are fully replenished can lead to recurrence 2
2. Excessive dosing: High doses (e.g., 200 mg three times daily) may not improve absorption and can increase side effects 4
3. Poor timing: Taking iron with meals containing calcium, tannins, or phytates reduces absorption 2
4. Inadequate investigation: Failing to identify and address the underlying cause of iron deficiency 1, 2
5. Inappropriate use of blood transfusion: Transfusion should be reserved for severe, symptomatic anemia with hemodynamic instability 5

Recent evidence suggests that alternate-day dosing may improve absorption and reduce side effects compared to daily dosing, as it avoids the hepcidin spike that occurs 24 hours after an iron dose 4. However, the most recent guidelines still recommend daily dosing with dose reduction if side effects occur 1, 2.