What is the treatment for severe iron deficiency anemia?

Treatment for Severe Iron Deficiency Anemia

For severe iron deficiency anemia with iron 36 μg/dL, iron binding capacity 461 μg/dL, saturation 8%, and ferritin 5 μg/L, the recommended treatment is oral iron supplementation at a dose of 60-120 mg of elemental iron daily for 2-3 months after hemoglobin normalizes to replenish iron stores. 1

Initial Treatment Approach

• Oral Iron Therapy (First-line):

  • Recommended daily dose: 60-120 mg of elemental iron for adults 1
  • Formulation options:
    • Ferrous sulfate 325 mg tablet (provides 65 mg elemental iron)
    • Ferrous gluconate or ferrous fumarate (equally effective alternatives) 1
    • Can be given as a single daily dose with vitamin C to enhance absorption 1
  • Duration: Continue for 2-3 months after hemoglobin normalizes to replenish iron stores 1

• Expected Response:

  • Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of therapy 1
  • Target values:
    • Hemoglobin >12 g/dL for women, >13 g/dL for men
    • Ferritin >100 μg/L
    • Transferrin saturation >20% 1

When to Consider IV Iron Therapy

IV iron should be considered in the following situations:

1. Intolerance to oral iron
2. Poor absorption of oral iron
3. Hemoglobin <10 g/dL requiring rapid correction
4. Active infection
5. Specific conditions:
   • Inflammatory bowel disease
   • Post-bariatric surgery
   • Chronic kidney disease (if ferritin >100 ng/mL) 1

IV Iron Dosing Based on Weight and Hemoglobin Level:

Hemoglobin g/dL	Body weight <70 kg	Body weight ≥70 kg
10-12 [women]	1000 mg	1500 mg
10-13 [men]	1500 mg	1500 mg
7-10	1500 mg	2000 mg

• IV Iron Options:
  • Ferric carboxymaltose: Preferred due to ability to administer up to 1000 mg in a single 15-minute infusion 1
  • Iron sucrose: 200 mg over 10 minutes 1
  • Iron dextran: 20 mg/kg over 6 hours 1

Diagnostic Workup

Given the severe iron deficiency in this case (ferritin 5 μg/L), investigation of the underlying cause is essential:

• For patients under 45 years without GI symptoms: Test for celiac disease (antiendomysial antibodies) 1
• For males and postmenopausal females: Bidirectional endoscopy (colonoscopy and upper endoscopy) is mandatory 1

Common causes to investigate:

• Gastrointestinal blood loss (peptic ulcer, cancer, inflammatory bowel disease)
• Menstrual blood loss
• Malabsorption (celiac disease, gastric atrophy)
• NSAID use
• Inadequate dietary intake 1

Lifestyle Modifications

• Increase intake of iron-rich foods:
  • Heme iron: Red meat, poultry, fish
  • Non-heme iron: Leafy greens, legumes, fortified cereals
• Consume vitamin C-rich foods with meals to enhance iron absorption 1
• For plant-based diets: Increase iron intake by approximately 1.8 times due to lower bioavailability 1

Common Pitfalls to Avoid

1. Stopping treatment too early: Continue therapy for 2-3 months after hemoglobin normalizes to replenish iron stores 1
2. Inadequate dosing: Ensure sufficient elemental iron is provided 1
3. Not enhancing absorption: Add vitamin C to improve iron absorption 1
4. Inappropriate use of IV iron: Reserve for specific indications rather than first-line therapy 1
5. Delaying treatment: Don't wait for underlying condition to resolve before treating iron deficiency 1

The laboratory values provided (iron 36 μg/dL, iron binding capacity 461 μg/dL, saturation 8%, ferritin 5 μg/L) indicate severe iron deficiency anemia requiring prompt treatment and investigation of the underlying cause.