What treatment is recommended for a patient with iron deficiency anemia?

Treatment for Iron Deficiency Anemia

Oral iron supplementation is the first-line treatment for most patients with iron deficiency anemia, typically with ferrous sulfate 200 mg (65 mg elemental iron) three times daily, while intravenous iron therapy should be reserved for specific indications such as intolerance to oral iron, inflammatory conditions, or ongoing blood loss. 1

Diagnosis Confirmation

• Iron deficiency anemia is diagnosed by:
  • Serum ferritin <30 ng/mL in patients without inflammatory conditions 1, 2
  • Transferrin saturation <20% 1, 2
  • Low hemoglobin levels (<12 g/dL for women, <13 g/dL for men) 1

First-Line Treatment: Oral Iron

Dosing Options

• Standard dosing: Ferrous sulfate 324 mg (65 mg elemental iron) three times daily 1, 3
• Alternative dosing:
  • Ferrous gluconate 300 mg (37 mg elemental iron) three times daily 1
  • Ferrous fumarate 210 mg (69 mg elemental iron) three times daily 1
  • Lower dose option: 100 mg ferrous fumarate once daily for asymptomatic patients 4
  • Alternate-day dosing if side effects occur 4

Administration Tips

• Take on empty stomach (1 hour before or 2 hours after meals)
• Pair with vitamin C (orange juice) to enhance absorption 1
• Avoid taking with calcium, dairy, tea, coffee, or antacids

Monitoring Response

• Check hemoglobin after 3-4 weeks of treatment 1
• Expected response: Hemoglobin rise of approximately 2 g/dL 1
• Early predictor: Hemoglobin increase of ≥1.0 g/dL at day 14 1
• Continue treatment for 3-6 months after hemoglobin normalizes to replenish iron stores

Second-Line Treatment: Intravenous Iron

Indications for IV Iron

1. Intolerance to at least two oral iron preparations 1
2. Poor absorption (celiac disease, post-bariatric surgery) 1, 2
3. Inflammatory bowel disease with active inflammation 5
4. Ongoing blood loss 1
5. Need for rapid correction of severe anemia 4
6. Chronic kidney disease 4, 6
7. Heart failure 2, 4

Risks of IV Iron

• Hypersensitivity reactions
• Infusion reactions
• Potential iron overload with repeated infusions
• Hypophosphatemia (particularly with certain formulations) 1

Special Clinical Scenarios

Inflammatory Bowel Disease

• Determine if anemia is due to inadequate intake/absorption or iron loss from GI bleeding 5
• Treat active inflammation to enhance iron absorption 5
• Use IV iron in patients with active inflammation and compromised absorption 5

Portal Hypertensive Gastropathy

• Start with oral iron supplements 5
• Switch to IV iron if ongoing bleeding persists or no response to oral therapy 5
• Consider nonselective β-blockers to treat portal hypertension 5

Celiac Disease

• Ensure adherence to gluten-free diet to improve iron absorption 5
• Start with oral iron based on severity and tolerance 5
• Use IV iron if stores don't improve despite dietary compliance 5

Post-Bariatric Surgery

• IV iron therapy is recommended, particularly after procedures that disrupt duodenal iron absorption 5

Common Pitfalls to Avoid

• Inadequate follow-up
• Premature discontinuation of therapy
• Overlooking underlying cause of iron deficiency
• Inappropriate parenteral iron use
• Missing concomitant conditions 1

When to Consider Erythropoietic Therapy

• When anemia doesn't improve despite IV iron therapy and control of inflammation 5
• Should be combined with IV iron supplementation for optimal effect 5
• Target hemoglobin should be 11-13 g/dL to minimize thrombosis risk 5

Blood Transfusions

• Reserve for acute severe anemia with hemodynamic instability 5
• Not a first-line treatment for chronic iron deficiency anemia