What is the treatment for a patient with severe iron deficiency anemia (ferritin level of 5)?

Treatment of Severe Iron Deficiency Anemia (Ferritin 5)

For a patient with severe iron deficiency anemia with a ferritin level of 5, intravenous iron therapy is the recommended first-line treatment due to the severity of the deficiency and the need for rapid iron repletion. 1

Initial Assessment and Treatment Algorithm

Step 1: Confirm Diagnosis and Evaluate Cause

• Ferritin level of 5 ng/mL confirms severe iron deficiency anemia 1
• Evaluate for underlying causes of iron deficiency:
  • Gastrointestinal blood loss (most common in men and postmenopausal women) 1
  • Menstrual blood loss in premenopausal women 1
  • Malabsorption conditions (celiac disease, post-bariatric surgery) 1
  • Dietary insufficiency 2

Step 2: Treatment Selection

For Severe Iron Deficiency (Ferritin 5):

• Intravenous (IV) iron therapy is preferred due to:

  • Severity of deficiency requiring rapid repletion 1
  • Higher likelihood of poor absorption with oral therapy in severe deficiency 1
  • Need to rapidly improve hemoglobin and replenish iron stores 1, 2

• IV iron formulations that can replace iron deficits with 1-2 infusions are preferred over those requiring multiple infusions 1

• Modern IV iron preparations have significantly lower risk of serious adverse reactions compared to older formulations 1

Alternative if IV Iron Not Available:

• Oral iron therapy with ferrous sulfate 324 mg (65 mg elemental iron) daily or on alternate days 3
• Add vitamin C to enhance absorption 1
• Monitor for response with repeat hemoglobin in 3-4 weeks 1
• Expected hemoglobin rise of 2 g/dL after 3-4 weeks with effective therapy 1

Special Considerations

Specific Conditions Affecting Treatment Choice

• For patients with inflammatory bowel disease and active inflammation: IV iron is strongly recommended 1
• For patients with portal hypertensive gastropathy: Start with oral iron, switch to IV if inadequate response 1
• For patients with celiac disease: Ensure gluten-free diet compliance to improve iron absorption; consider IV iron if oral therapy fails 1
• For patients with gastric antral vascular ectasia: Consider endoscopic therapy alongside iron replacement 1

Duration of Therapy

• Continue iron therapy for three months after correction of anemia to fully replenish iron stores 1
• Monitor hemoglobin and ferritin levels at 8-10 weeks to assess response 1
• Follow up every three months for one year, then after another year 1

Common Pitfalls and Caveats

• Failure to identify and treat the underlying cause will result in recurrent iron deficiency 1, 2
• Inadequate duration of therapy may lead to incomplete replenishment of iron stores 1
• Gastrointestinal side effects of oral iron (constipation, diarrhea, nausea) may reduce compliance 1
• Overtreatment with iron in patients with normal or high ferritin is potentially harmful 4
• Misdiagnosis of iron deficiency in inflammatory states (ferritin may be falsely elevated) 1

Monitoring Response

• Repeat hemoglobin after 3-4 weeks of oral therapy to assess initial response 1
• If using IV iron, wait 8-10 weeks before checking ferritin levels (falsely high immediately after infusion) 1
• Complete blood count and ferritin should normalize with effective treatment 1
• If no improvement after appropriate therapy, consider additional evaluation for ongoing blood loss or malabsorption 1, 2