What is the treatment for iron deficiency?

Treatment of Iron Deficiency

The initial treatment for iron deficiency should be oral iron supplementation with one tablet per day of ferrous sulfate, fumarate, or gluconate, which should be continued for approximately 3 months after normalization of hemoglobin levels to ensure adequate repletion of iron stores. 1

First-Line Treatment: Oral Iron Therapy

• Ferrous sulfate 200 mg once daily (containing approximately 65 mg of elemental iron) is the most simple, effective, and cost-efficient oral iron preparation 1
• Alternative ferrous salt preparations like ferrous gluconate and ferrous fumarate are equally effective and may be better tolerated by some patients 1
• Treatment should be monitored within the first 4 weeks for hemoglobin response, with an expected rise of approximately 2 g/dL after 3-4 weeks 1
• Continue iron therapy for approximately 3 months after normalization of hemoglobin to adequately replenish iron stores 1

Optimizing Oral Iron Therapy

• If standard dosing is not tolerated, consider reduced dosing of one tablet every other day, which may improve absorption while reducing side effects 1
• Liquid preparations may be better tolerated when tablets cause gastrointestinal distress 1
• Adding ascorbic acid (vitamin C) enhances iron absorption and should be considered when response to iron therapy is poor 1
• Take iron supplements on an empty stomach to maximize absorption 1

When to Consider Parenteral Iron Therapy

• Parenteral iron should be reserved for patients with:

  • Intolerance to at least two oral iron preparations 1
  • Poor compliance with oral therapy 1
  • Conditions with impaired iron absorption (celiac disease, post-bariatric surgery) 1, 2
  • Chronic inflammatory conditions (inflammatory bowel disease, chronic kidney disease, heart failure) 1
  • Ongoing blood loss exceeding the intestinal ability to absorb iron 3

• Available parenteral iron options include:

  • Iron sucrose (Venofer) 4
  • Ferric carboxymaltose (Injectafer) 5

Special Considerations

• For patients with moderately severe anemia, limited transfusion of packed red cells may be required alongside iron therapy 1
• Athletes and menstruating women may require higher iron intake (18-22 mg/day) to maintain adequate iron stores 1
• For patients with inflammatory bowel disease, determine whether iron deficiency is due to inadequate intake/absorption or blood loss, and treat the underlying inflammation 1

Monitoring and Follow-up

• Monitor hemoglobin levels in the first 4 weeks to assess response to therapy 1
• After restoration of hemoglobin and iron stores, monitor blood counts periodically (approximately every 6 months initially) to detect recurrent iron deficiency 1
• Failure to respond to oral iron therapy may indicate:
  • Poor compliance
  • Misdiagnosis
  • Continued blood loss
  • Malabsorption 1

Common Pitfalls to Avoid

• Delaying iron therapy while awaiting investigations (unless colonoscopy is imminent) 1
• Using parenteral iron as first-line therapy when oral iron would be effective 1
• Discontinuing iron therapy too early (before iron stores are replenished) 1
• Overlooking the underlying cause of iron deficiency, which should be identified and treated 2
• Prescribing excessive iron doses, as recent evidence suggests lower doses may be equally effective with fewer side effects 6