What is the treatment protocol for iron deficiency anemia (IDA) with ferrous sulfate?

Treatment Protocol for Iron Deficiency Anemia with Ferrous Sulfate

The initial treatment of iron deficiency anemia (IDA) should be with one tablet per day of ferrous sulfate (typically 200 mg tablet containing 65 mg of elemental iron), taken in the fasting state. 1

Dosing Regimen

• Start with one ferrous sulfate tablet daily (containing 50-100 mg elemental iron) as the optimal initial treatment approach 1
• If not tolerated, consider alternate day dosing (one tablet every other day) which may provide similar efficacy with fewer side effects 1
• Monitor hemoglobin response within the first 4 weeks of starting therapy 1
• An absence of hemoglobin rise of at least 10 g/L after 2 weeks strongly predicts treatment failure (sensitivity 90.1%, specificity 79.3%) 1

Duration of Treatment

• Continue treatment for approximately 3 months after normalization of hemoglobin levels to ensure adequate replenishment of iron stores 1
• Monitor blood counts periodically (every 6 months initially) after treatment completion to detect recurrent IDA 1

Alternative Approaches for Poor Response or Intolerance

• If ferrous sulfate is not tolerated, consider:
  • Reduced dosing frequency (alternate day dosing) 1
  • Alternative oral iron preparations such as ferric maltol 1
  • Parenteral iron when oral iron is contraindicated, ineffective, or not tolerated 1

Special Considerations

• For moderately severe anemia, consider restricted packed cell transfusion only for those with severe symptomatic and/or circulatory compromise 1
• Target hemoglobin of 70-90 g/L (80-100 g/L in those with unstable coronary artery disease) if transfusion is necessary 1
• Remember that blood transfusion alone will not replenish iron stores and should be followed by adequate iron replacement 1

Common Pitfalls and Caveats

• Modified release preparations of ferrous sulfate are less suitable for prescribing as they may have reduced iron absorption 1
• Failure to respond to oral iron may be due to non-compliance, malabsorption, continued bleeding, or concurrent deficiency of vitamin B12 or folic acid 1
• Traditional practice of switching between different iron salts when side effects occur is not supported by evidence 1
• In patients with chronic inflammatory conditions (IBD, chronic kidney disease, heart failure), parenteral iron may be more effective than continuing oral therapy 1, 2

Monitoring Protocol

• Check hemoglobin every 4 weeks until normalized 1
• After normalization, continue iron for 3 months to replenish stores 1
• After completion of therapy, monitor blood counts every 6 months initially to detect recurrence 1

By following this protocol, most patients with IDA should achieve normalization of hemoglobin levels and replenishment of iron stores, leading to improved quality of life and physiological function 1, 2.