What is the first line treatment for iron deficiency?

First-Line Treatment for Iron Deficiency

Oral iron supplementation is the first-line treatment for iron deficiency in patients with mild anemia, whose disease is clinically inactive, and who have not been previously intolerant to oral iron. 1, 2

Diagnostic Criteria for Iron Deficiency

Before initiating treatment, proper diagnosis is essential:

• Without inflammation: Serum ferritin <30 μg/L is diagnostic of iron deficiency 1, 2
• With inflammation: Serum ferritin up to 100 μg/L may still indicate iron deficiency 1
• Mixed picture: If ferritin is between 30-100 μg/L with inflammation, a combination of iron deficiency and anemia of chronic disease is likely 1

Treatment Algorithm

First-Line Treatment: Oral Iron

• Standard dosing: Ferrous sulfate 324 mg daily (providing 65 mg of elemental iron) 2, 3
• Administration: Take once daily in the morning with vitamin C to enhance absorption 2
• Duration: Continue for 2 months to normalize hemoglobin, then 2-3 additional months to replenish iron stores 4
• Monitoring: Check hemoglobin after 3-4 weeks of treatment; expect increase of 1-2 g/dL 2

When to Use Intravenous Iron (First-Line)

IV iron should be considered as first-line treatment in specific situations:

1. Clinically active inflammatory disease 1
2. Previous intolerance to oral iron 1, 2
3. Hemoglobin below 100 g/L (severe anemia) 1
4. Patients requiring erythropoiesis-stimulating agents 1
5. Conditions with impaired oral iron absorption 2, 5

Dosing Considerations

Oral Iron Dosing

• Traditional approach: Daily dosing of 60-120 mg elemental iron 2
• Alternative approach: Every-other-day dosing may improve absorption and reduce gastrointestinal side effects 6, 7

IV Iron Dosing

For patients requiring IV iron, dosing is typically based on hemoglobin and body weight:

• Hemoglobin 100-120 g/L (women) or 100-130 g/L (men):
  • <70 kg: 1000 mg
  • ≥70 kg: 1500 mg 1
• Hemoglobin 70-100 g/L:
  • <70 kg: 1500 mg
  • ≥70 kg: 2000 mg 1

Common Pitfalls to Avoid

1. Inadequate dosing: Ensure sufficient elemental iron content (typically 60-65 mg per dose) 2, 4
2. Premature discontinuation: Complete the full treatment course (2 months for hemoglobin correction + 2-3 months for iron store repletion) 2, 4
3. Overlooking the underlying cause: Identify and address the source of iron deficiency 2, 5
4. Poor patient education: Explain the importance of adherence and potential side effects 1, 4
5. Ignoring follow-up: Monitor response with appropriate timing of lab tests (avoid checking iron studies within 4 weeks of IV iron) 2

Special Considerations

• Target values: Aim for ferritin ≥100 μg/L and hemoglobin 12-13 g/dL (gender-specific) 2
• Side effects management: Common gastrointestinal side effects with oral iron include nausea, constipation, and abdominal discomfort 6, 7
• Recurrence prevention: After successful treatment, monitor iron status periodically, especially in high-risk patients 1

By following this evidence-based approach to iron deficiency treatment, clinicians can effectively improve patient outcomes while minimizing potential complications.