What is the recommended oral treatment for iron deficiency anemia?

Oral Treatment of Iron Deficiency Anemia

The recommended first-line oral treatment for iron deficiency anemia is ferrous sulfate 50-100 mg of elemental iron once daily, taken in the morning on an empty stomach, continued for 3 months after hemoglobin normalization. 1, 2

Recommended Oral Iron Regimen

First-line therapy:

• Ferrous sulfate: 1 tablet daily (contains 65mg elemental iron) 1, 3
  • Take in the morning on an empty stomach
  • Can be taken with vitamin C (500mg) to enhance absorption 2
  • Avoid taking with tea, coffee, calcium supplements, or high-fiber foods 2

Alternative dosing strategies:

• If daily dosing causes side effects:
  • Alternate-day dosing (one tablet every other day) 1, 4
  • This approach may actually improve absorption while reducing side effects 2, 4

Alternative oral preparations:

• Ferrous fumarate or ferrous gluconate if sulfate not tolerated 1
• Ferric maltol for patients with inflammatory bowel disease or previous intolerance to iron salts 1

Monitoring and Duration

1. Monitor hemoglobin response within first 4 weeks of starting therapy 1, 2
2. Continue treatment for approximately 3 months after hemoglobin normalizes to replenish iron stores 1, 2
3. Target ferritin >100 μg/L to ensure adequate iron stores 2
4. Monitor blood count periodically (every 6 months initially) to detect recurrent IDA 1, 2

When to Consider Parenteral Iron

Intravenous iron should be considered when:

• Oral iron is contraindicated
• Oral iron is ineffective despite good adherence
• Oral iron is not tolerated due to side effects
• Rapid correction of anemia is required
• Patient has conditions impairing oral iron absorption (active IBD, post-bariatric surgery, etc.) 1, 2, 5

Common Pitfalls to Avoid

1. Excessive dosing: Higher doses (200mg elemental iron 3x daily) don't improve absorption and increase side effects 6, 4
2. Modified-release preparations: Less effective due to reduced absorption in small intestine 2
3. Multiple daily doses: May not improve absorption due to hepcidin elevation 2, 4
4. Stopping treatment too early: Failure to continue for 3 months after hemoglobin normalization 2
5. Neglecting to investigate underlying cause: The cause of iron deficiency must be identified and addressed 2, 7

Special Considerations

• Recent research suggests that morning doses on alternate days may maximize absorption while minimizing side effects 4
• Oral iron protein succinylate (Ferplex®) may have comparable efficacy to ferrous sulfate with potentially better tolerability 8
• Lower doses (50-100mg elemental iron) are as effective as higher doses while causing fewer side effects 4, 8

For patients with severe symptomatic anemia, consider restricted packed cell transfusion alongside oral iron therapy 1.