What is the treatment for iron deficiency without anemia?

Treatment of Iron Deficiency Without Anemia

For iron deficiency without anemia, oral iron supplementation with ferrous sulfate 200 mg once daily in the morning, paired with vitamin C, is the recommended first-line treatment when symptoms are present or based on patient preferences. 1

Diagnosis Confirmation

Before initiating treatment, confirm iron deficiency with:

• Serum ferritin < 30 μg/L (primary diagnostic test)
• Transferrin saturation < 20%
• Normal hemoglobin levels (≥ 13 g/dL in men, ≥ 12 g/dL in non-pregnant women)

Treatment Algorithm

First-Line: Oral Iron Therapy

• Dosing: Ferrous sulfate 200 mg once daily in the morning on an empty stomach 1
• Alternative dosing strategy: Every-other-day dosing may improve absorption and reduce side effects 1
• Duration: Continue for 3 months to replenish iron stores 1

Optimization Strategies

1. Enhance absorption:

   • Add vitamin C (500 mg) with iron dose 1
   • Take on an empty stomach in the morning 1
   • Avoid concurrent intake of:
     • Tea, coffee
     • Calcium supplements
     • High-fiber foods
     • Wait at least 1 hour after these substances 1

2. Dietary modifications:

   • Increase intake of iron-rich foods:
     • Heme iron sources (meat, poultry, fish)
     • Non-heme iron sources (leafy greens, legumes)
   • Pair iron-rich foods with vitamin C-rich foods 1
   • Plant-based diets require approximately 1.8 times more dietary iron 1

Second-Line: Intravenous Iron

Consider IV iron when:

• Intolerance to oral iron (after trying at least two oral preparations) 2
• Poor absorption (celiac disease, post-bariatric surgery) 1
• Chronic inflammatory conditions (IBD, chronic kidney disease, heart failure) 2, 3
• Ongoing blood loss exceeds oral replacement capacity 1

Preferred IV formulations:

• Ferric carboxymaltose: Can be administered as 500-1000 mg in a single dose (up to 20 mg/kg) 2, 4
• Other formulations may require multiple administrations

Monitoring and Follow-up

• Check iron studies (ferritin, transferrin saturation) after 3 months of therapy 1
• Target ferritin > 30 μg/L and transferrin saturation > 20% 1
• Continue monitoring periodically, especially in patients with risk factors for recurrent iron deficiency

Special Considerations

Benefits of Treating Iron Deficiency Without Anemia

• May improve symptoms like fatigue, exercise intolerance, and cognitive function 3
• Particularly beneficial in specific conditions:
  • Heart failure (improves exercise capacity) 4
  • Restless legs syndrome 3
  • Chronic fatigue 1

Investigating Underlying Causes

• Essential in men and postmenopausal women (high risk of gastrointestinal malignancy) 2, 1
• Consider upper endoscopy and colonoscopy in high-risk groups 2, 1
• Test for celiac disease (antiendomysial antibodies) 2
• Evaluate menstrual blood loss in premenopausal women 2, 5

Common Pitfalls to Avoid

• Stopping treatment too early before iron stores are replenished 1
• Administering oral iron with absorption inhibitors 1
• Failure to add vitamin C to enhance absorption 1
• Not investigating underlying causes, particularly in men and postmenopausal women 1, 5
• Multiple daily doses of oral iron (increases side effects without improving absorption) 1

While the decision to treat iron deficiency without anemia may be influenced by patient symptoms and preferences, addressing this condition can significantly improve quality of life and prevent progression to iron deficiency anemia.