What treatment approach should be taken for a patient with iron deficiency anemia?

Treatment Approach for Iron Deficiency Anemia in a 37-Year-Old Female

Oral iron supplementation with ferrous sulfate 200 mg (providing 65 mg of elemental iron) daily is the recommended first-line treatment for this patient with iron deficiency anemia and negative stool cards. 1

Diagnostic Workup

Before initiating treatment, complete the following diagnostic workup:

1. Laboratory assessment:

   • Complete blood count with indices
   • Serum ferritin (primary indicator of iron stores)
   • Transferrin saturation
   • C-reactive protein (to exclude inflammation that may affect ferritin interpretation)

2. Diagnostic criteria:

   • Without inflammation: serum ferritin <30 μg/L confirms iron deficiency 1
   • With inflammation: serum ferritin up to 100 μg/L may still indicate iron deficiency 2
   • Transferrin saturation <20% supports diagnosis of iron deficiency 1

3. Etiological investigation:

   • Menstrual history (heavy menstrual bleeding is a common cause in women of reproductive age)
   • Dietary assessment for iron intake
   • Gastrointestinal symptoms (despite negative stool cards, occult bleeding should be considered)
   • Medication review (NSAIDs, anticoagulants)
   • Screening for celiac disease or other malabsorption conditions

Treatment Plan

First-Line Treatment:

• Oral iron therapy: Ferrous sulfate 200 mg daily (providing 65 mg of elemental iron) 1, 3
• Take on an empty stomach (2 hours before or 1 hour after meals) for optimal absorption 1
• Add vitamin C (250-500 mg) with iron to enhance absorption 1
• If gastrointestinal side effects occur, consider:
  • Taking with food (though this reduces absorption by 40-50%)
  • Alternate-day dosing (100 mg ferrous fumarate every other day) 4
  • Switching to a different iron formulation

Optimization Tips:

• Dietary recommendations:
  • Increase intake of iron-rich foods (red meat, poultry, fish, leafy greens, legumes)
  • Consume vitamin C-rich foods with meals
  • Avoid tea, coffee, calcium supplements, and antacids within 2 hours of iron supplements 1

Monitoring Response:

• Check hemoglobin after 2-4 weeks of treatment (expect increase of ~2 g/dL) 1
• Continue treatment for 3 months after hemoglobin normalization to replenish iron stores 1
• Monitor hemoglobin and red cell indices every 3 months for 1 year, then after another year 1
• Target values: hemoglobin >12 g/dL for women, ferritin >100 μg/L, transferrin saturation >20% 1

Consider Intravenous Iron If:

• Poor response to oral therapy after 4 weeks
• Intolerance to oral iron despite adjustments
• Malabsorption conditions
• Hemoglobin <10 g/dL requiring rapid correction 1

Common Pitfalls to Avoid

1. Stopping treatment too early before iron stores are replenished 1
2. Failing to investigate underlying causes of iron deficiency, especially with negative stool cards 5
3. Not adding vitamin C to enhance absorption 1
4. Inadequate monitoring of response to therapy 1
5. Using excessive iron doses leading to unnecessary side effects 4

Special Considerations

In this 37-year-old female with negative stool cards, heavy menstrual bleeding is a likely cause, but other etiologies should be considered. If oral iron therapy fails or if there's no identifiable cause for iron deficiency, further investigation with endoscopy may be warranted, especially if anemia persists or recurs after initial treatment 6.