What is the recommended treatment for iron deficiency or insufficiency?

Iron Deficiency Treatment Guidelines

The recommended first-line treatment for iron deficiency or insufficiency is oral iron supplementation with ferrous sulfate 200 mg (providing 65 mg elemental iron) once daily, which should be continued for 3 months after hemoglobin normalization to replenish iron stores. 1

Diagnosis and Assessment

• Iron deficiency is diagnosed by:
  • Low serum ferritin (<30 ng/mL) in individuals without inflammatory conditions
  • Transferrin saturation <20% in those with inflammatory conditions 2
  • Hemoglobin <11.5 g/dL indicates iron deficiency anemia 3

Treatment Algorithm

Oral Iron Therapy (First-Line)

1. Initial Treatment:

   • Ferrous sulfate 200 mg (65 mg elemental iron) once daily 1, 4
   • Take on an empty stomach (2 hours before or 1 hour after meals) 1
   • Take with vitamin C (250-500 mg) to enhance absorption 1

2. If not tolerated:

   • Reduce to alternate-day dosing 3, 5
   • Consider morning dosing to maximize absorption 5
   • Try different formulations (ferrous gluconate or ferrous fumarate) 1

3. Duration:

   • Continue for 3 months after hemoglobin normalization 3, 1, 6
   • This ensures adequate repletion of marrow iron stores 3

4. Monitoring:

   • Check hemoglobin after 2-4 weeks of treatment (expect ~2 g/dL increase) 1
   • Monitor blood count periodically (every 6 months initially) to detect recurrent IDA 3

Parenteral Iron Therapy (Second-Line)

Consider intravenous iron when oral iron is:

• Contraindicated
• Ineffective
• Not tolerated 3, 1

Particularly indicated for:

• Patients with chronic inflammatory conditions (IBD, CKD, heart failure)
• Those with impaired absorption
• Ongoing blood loss
• Need for rapid correction (Hb <10 g/dL) 1, 2

Recent Evidence on Dosing

Recent studies suggest that alternate-day dosing may be more effective than daily dosing:

• Doses ≥60 mg stimulate hepcidin, which reduces subsequent iron absorption
• Alternate-day dosing leads to significantly increased fractional iron absorption
• Morning doses are better absorbed than afternoon/evening doses 5

Special Considerations

• Inflammatory conditions: Standard iron markers may be misleading; hepcidin may be a more reliable indicator of iron deficiency 3
• Athletes and active women: May require higher daily iron intake (22 mg/day) 3
• Pregnancy: Higher risk of iron deficiency, especially in third trimester 2

Common Pitfalls to Avoid

1. Stopping treatment too early before iron stores are replenished
2. Failing to add vitamin C to enhance absorption
3. Administering iron with absorption inhibitors (calcium, tea, coffee, dairy)
4. Using divided doses when a single daily dose may be better tolerated
5. Failing to investigate underlying causes of iron deficiency, especially in men and postmenopausal women 1

Dietary Recommendations

While supplementation is necessary for treatment, dietary modifications can help maintain iron status:

• Increase intake of heme iron (red meat, poultry, fish)
• Include non-heme iron sources (leafy greens, legumes, fortified cereals)
• Consume vitamin C-rich foods with meals to enhance absorption 1