What is the treatment protocol for severe iron deficiency in India?

Treatment Protocol for Severe Iron Deficiency in India

For severe iron deficiency anemia in India, oral iron therapy with ferrous sulfate 200 mg three times daily should be the first-line treatment, continued for three months after correction of anemia to replenish iron stores. 1

Diagnosis Criteria

• Hemoglobin < 8 g/dL
• MCV < 76 fl
• Ferritin < 15 μg/dL
• Transferrin saturation < 20%

Treatment Algorithm

First-Line: Oral Iron Therapy

• Dosage: Ferrous sulfate 200 mg three times daily (providing 65 mg elemental iron per tablet) 1
• Duration: Continue for 3 months after normalization of hemoglobin to replenish iron stores 1
• Administration: Take on empty stomach for optimal absorption 2
• Adjunct: Add ascorbic acid (vitamin C) to enhance iron absorption 1, 2

Alternative Oral Regimens (if standard dosing not tolerated)

• Once daily dose of 50-100 mg elemental iron (one ferrous sulfate 200 mg tablet daily) 1
• Alternate-day dosing (one tablet every other day) may improve absorption and reduce side effects 2, 3
• Morning dosing is preferable to afternoon/evening dosing 3

Monitoring Response

• Expected hemoglobin rise: 2 g/dL after 3-4 weeks 1, 2
• Check hemoglobin after 2 weeks - absence of at least 10 g/L rise strongly predicts treatment failure 1
• Monitor hemoglobin and red cell indices at 3-month intervals for 1 year, then after a further year 1, 2

Indications for Parenteral Iron (IV Iron Sucrose)

1. Intolerance to at least two oral iron preparations 1
2. Non-compliance with oral therapy 1
3. Malabsorption conditions 2, 4
4. Ongoing blood loss 4
5. Need for rapid correction in severe symptomatic anemia 1
6. Severe anemia in pregnancy (particularly in second and third trimesters) 4, 5

IV Iron Sucrose Protocol

• Calculation: Total iron deficit (mg) = [Target Hb - Actual Hb] × Weight (kg) × 2.4 + 500 mg (for stores) 6
• Administration: 200 mg on alternate days until calculated iron deficit is met 2, 6
• Test dose: Recommended for patients with drug allergies 2
• Contraindication: Active infection 2

Special Considerations

Pregnancy

• IV iron sucrose may be considered for moderate-to-severe anemia (Hb 5-9 g/dL) in second and third trimesters 5
• However, a large Indian randomized controlled trial showed no significant difference in maternal outcomes between IV iron sucrose and standard oral iron therapy in pregnant women 5

Blood Transfusion

• Rarely required for iron deficiency anemia 1
• Reserve for severe symptomatic anemia with circulatory compromise 1
• Target Hb: 70-90 g/L (80-100 g/L in unstable coronary artery disease) 1
• Must be followed by adequate iron replacement 1

Common Pitfalls to Avoid

1. Discontinuing therapy prematurely before iron stores are replenished 2
2. Not investigating underlying cause of iron deficiency 2
3. Failing to monitor response to treatment 1, 2
4. Using modified-release iron preparations (less suitable and more expensive) 1
5. Excessive dosing (>100 mg elemental iron daily) which increases side effects without improving efficacy 2, 3

Dietary Counseling

• Increase consumption of iron-rich foods (red meat, fish, poultry, beans, lentils, spinach) 2
• Include vitamin C-rich foods with meals to enhance iron absorption 2
• Limit cow's milk intake to prevent displacement of iron-rich foods 2

The evidence strongly supports oral iron as first-line therapy for severe iron deficiency in India, with IV iron reserved for specific indications. The British Society of Gastroenterology guidelines provide the most comprehensive approach, and recent research supports potentially lower, alternate-day dosing to improve absorption and reduce side effects.