What is the treatment approach for a patient with iron deficiency anemia?

Treatment Approach for Iron Deficiency Anemia

Oral iron supplementation with ferrous sulfate is the first-line treatment for iron deficiency anemia, while intravenous iron should be used for patients who cannot tolerate oral iron, have inadequate response, or have conditions affecting iron absorption. 1

Initial Treatment Strategy

Oral Iron Therapy

• Ferrous sulfate is the preferred oral iron formulation due to its low cost and effectiveness 1
• Administer oral iron once daily rather than multiple times per day to improve tolerance 1
• Add vitamin C to oral iron supplementation to enhance absorption 1
• Consider alternate-day dosing which may improve absorption and reduce gastrointestinal side effects 2
• The hemoglobin concentration should rise by approximately 2 g/dL after 3-4 weeks of treatment 1

When to Use Intravenous Iron

Intravenous iron is indicated in patients with:

• Intolerance to oral iron preparations 1
• Inadequate response to oral iron therapy (hemoglobin increase <1.0 g/dL after 14 days) 3
• Conditions where oral iron is unlikely to be absorbed 1
• Inflammatory bowel disease with active inflammation 1
• Post-bariatric surgery, particularly procedures affecting duodenal absorption 1
• Hemoglobin levels <10 g/dL in inflammatory bowel disease 1

Disease-Specific Approaches

Inflammatory Bowel Disease

• Determine whether iron deficiency is due to inadequate intake/absorption or blood loss 1
• Treat active inflammation to enhance iron absorption and reduce iron depletion 1
• Use intravenous iron in patients with active inflammation and compromised absorption 1

Portal Hypertensive Gastropathy

• Begin with oral iron supplements to replenish iron stores 1
• Switch to intravenous iron for patients with ongoing bleeding who don't respond to oral therapy 1
• Consider nonselective β-blockers to treat portal hypertension in patients without other identified sources of blood loss 4

Celiac Disease

• Ensure strict adherence to a gluten-free diet to improve iron absorption 5
• Use oral iron supplementation based on severity of deficiency and patient tolerance 5
• Switch to intravenous iron if iron stores don't improve despite dietary compliance 5

Gastric Antral Vascular Ectasia

• Provide iron replacement therapy (oral or IV depending on severity) 6
• For inadequate response to iron replacement, consider endoscopic therapy with:
  • Endoscopic band ligation (preferred) 6
  • Thermal methods such as argon plasma coagulation 6

Small Bowel Bleeding/Angioectasias

• Perform deep enteroscopy with distal attachment to improve detection and facilitate treatment 7
• Treat identified angioectasias with ablative thermal therapies or mechanical methods 7
• Provide iron replacement alongside endoscopic treatment 8

Monitoring and Follow-up

• Evaluate hemoglobin response after 14 days of oral therapy; consider switching to IV iron if increase is <1.0 g/dL 3
• Continue treatment until anemia is corrected and iron stores are replenished 1
• Consider further investigation if anemia doesn't resolve within 6 months 1

Intravenous Iron Administration

• Prefer IV iron formulations that can replace iron deficits with 1-2 infusions 1
• Be aware that true anaphylaxis with IV iron is rare; most reactions are infusion-related 1
• For patients requiring IV iron, options include:
  • Ferric gluconate: typically 125 mg per dose 4
  • Iron sucrose: dosing varies by condition (100-200 mg per dose) 6

Common Pitfalls to Avoid

• Failing to diagnose iron deficiency in patients with inflammatory conditions who may have ferritin levels >45 mg/dL (usually <100 mg/dL) 1
• Continuing oral iron therapy despite poor response or intolerance 1
• Not addressing the underlying cause of iron deficiency while treating the anemia 1
• Overlooking the need for multidisciplinary management in complex cases 1