What is the best treatment for a patient with chronic iron deficiency, normal Hemoglobin (Hgb) levels, cold hands and feet, and pale skin?

Treatment of Iron Deficiency with Normal Hemoglobin

Oral iron supplementation is the first-line treatment for patients with chronic iron deficiency, normal hemoglobin levels, and symptoms such as cold hands and feet and pale skin.

Diagnosis Confirmation

Iron deficiency without anemia is characterized by:

• Normal hemoglobin levels
• Low serum ferritin (<30 μg/L without inflammation, <100 μg/L with inflammation) 1
• Low transferrin saturation (<20%) 1
• Symptoms may include:
  • Cold extremities
  • Pale skin
  • Fatigue
  • Difficulty concentrating
  • Restless legs syndrome (in 32-40% of cases) 2

Treatment Algorithm

First-Line Therapy

• Oral iron supplementation:
  • Ferrous sulfate 50-100 mg elemental iron daily 1
  • Alternative dosing: 200 mg elemental iron daily (e.g., ferrous sulfate 200 mg three times daily) 1
  • Continue for at least 3 months after symptom resolution to replenish iron stores 1

Optimizing Oral Iron Absorption

• Take on an empty stomach if tolerated
• Take with 80 mg vitamin C to enhance absorption 1
• Avoid taking with:
  • Tea or coffee (wait at least 1 hour) 1
  • Proton pump inhibitors (reduce absorption by 70-80%) 1
• Consider alternate-day dosing if experiencing gastrointestinal side effects 1

Monitoring Response

• Reassess after 2-4 weeks of therapy 1
• Expected response: improvement in symptoms (reduced coldness in extremities, improved skin color)
• Monitor ferritin and transferrin saturation until normalized
• Continue supplementation for 3 months after normalization of iron stores 1

When to Consider IV Iron

Consider intravenous iron in the following situations:

• Poor response to oral iron after 4 weeks
• Intolerance to oral iron (gastrointestinal side effects) 1
• Malabsorption disorders
• Need for rapid correction of iron deficiency 1

Special Considerations

Managing Side Effects of Oral Iron

Common side effects include:

• Constipation (12% of patients)
• Diarrhea (8% of patients)
• Nausea (11% of patients) 1

Management strategies:

• Take with food (may reduce absorption but improves tolerance)
• Alternate-day dosing
• Try different iron formulations (ferrous gluconate may be better tolerated than ferrous sulfate)

Investigating Underlying Causes

While treating iron deficiency, investigate potential causes:

• Menstrual blood loss in women
• Gastrointestinal blood loss
• Malabsorption disorders
• Inadequate dietary intake
• Pregnancy 2

Follow-up

• Reassess iron status after 3 months of therapy
• Monitor for recurrent iron deficiency every 3-6 months for the first year 1
• If iron deficiency recurs, further investigation for underlying causes is warranted

Iron deficiency, even without anemia, can cause significant symptoms and should be treated promptly. Oral iron supplementation is effective for most patients, but treatment should be continued long enough to replenish iron stores, not just resolve symptoms.