What is the appropriate treatment plan for a patient with suspected iron deficiency anemia?

Treatment Plan for Suspected Iron Deficiency Anemia

All patients with suspected iron deficiency anemia should receive oral iron supplementation with ferrous sulfate 200 mg three times daily to correct anemia and replenish body stores. 1

Diagnostic Confirmation

Before initiating treatment, confirm iron deficiency with:

• Serum ferritin (<15 μg/L indicates absent iron stores)
• Hemoglobin level (below normal range)
• MCV (<76 fl in iron deficiency)

Oral Iron Therapy

First-line Treatment

• Ferrous sulfate 200 mg three times daily 1
• Alternative options if not tolerated:
  • Ferrous gluconate or ferrous fumarate (equally effective) 1
  • Liquid preparation if tablets are not tolerated 1
  • Lower doses (100-200 mg/day) may be better tolerated with similar efficacy 2
  • Consider alternate-day dosing if side effects occur 2

Duration of Treatment

• Continue for 3 months after normalization of hemoglobin to replenish iron stores 1
• Expected response: Hemoglobin should rise by 2 g/dL after 3-4 weeks 1

Enhancing Absorption

• Add ascorbic acid (vitamin C) 250-500 mg twice daily with iron if response is poor 1
• Take iron between meals or at bedtime for better absorption 1

Monitoring Response

1. Check hemoglobin weekly until stable, then every 2-4 weeks 3
2. Monitor hemoglobin and red cell indices at 3-month intervals for one year, then after another year 1
3. If hemoglobin or MCV falls below normal, provide additional oral iron 1
4. Target for resolution: Achieve normal hemoglobin within 6 months in 80% of patients 1

Parenteral Iron Therapy

Indications

• Intolerance to at least two oral iron preparations 1
• Non-compliance with oral therapy 1
• Poor absorption (celiac disease, post-bariatric surgery) 4
• Chronic inflammatory conditions (IBD, CKD, heart failure) 2, 4
• Ongoing blood loss 4

Available Options

1. Iron sucrose (Venofer): 200 mg over 10 minutes
2. Ferric carboxymaltose (Ferinject): 1000 mg over 15 minutes
3. Iron dextran (Cosmofer): 20 mg/kg over 6 hours (can also be given IM)

Cautions

• Parenteral iron therapy can cause anaphylactic reactions (0.6-0.7% with iron dextran) 1
• Resuscitation facilities should be available for all intravenous iron administrations 1
• More expensive than oral therapy 1

Investigation of Underlying Cause

While treating the anemia, investigate the underlying cause:

For patients >45 years:

• Upper GI endoscopy with small bowel biopsy
• Colonoscopy or barium enema 1

For patients <45 years:

• If upper GI symptoms: endoscopy and small bowel biopsy
• Test for celiac disease with antiendomysial antibodies and IgA measurement
• Colonic investigation only if specific indications 1

Common Pitfalls to Avoid

1. Accepting dietary history as sole cause without GI investigation 3
2. Inadequate duration of iron therapy 3
3. Deferring iron replacement while awaiting investigations 3
4. Misinterpreting ferritin levels in presence of inflammation (may be falsely elevated) 3
5. Failing to investigate non-responsive anemia (may indicate continued blood loss, malabsorption, or misdiagnosis) 1

Follow-up for Non-responders

If hemoglobin fails to rise by 2 g/dL after 3-4 weeks, consider:

• Poor compliance
• Misdiagnosis
• Continued blood loss
• Malabsorption 1

90% of those not responding to treatment should be considered for further investigation 1