What is the best treatment for iron deficient anemia?

Best Treatment for Iron Deficient Anemia

Oral iron supplementation with ferrous sulfate once daily is the first-line treatment for iron deficiency anemia, while intravenous iron should be reserved for patients who cannot tolerate oral iron, have inadequate response, or have conditions affecting iron absorption. 1, 2

First-Line Treatment: Oral Iron

• Ferrous sulfate is the preferred oral iron formulation due to its effectiveness and low cost 1
• Administer oral iron once daily rather than multiple times per day to improve tolerance 1, 3
• Adding vitamin C to oral iron supplementation enhances absorption 1
• The hemoglobin concentration should rise by approximately 2 g/dL after 3-4 weeks of treatment 1
• Continue iron supplementation for three months after correction of anemia to replenish iron stores 1
• Every-other-day dosing may be better tolerated with similar or equal rates of iron absorption compared to daily dosing 1, 3

When to Consider Intravenous Iron

Intravenous iron should be used in patients who:

• Do not tolerate oral iron despite trying at least two different preparations 1
• Show no improvement in ferritin levels with a trial of oral iron 1
• Have conditions in which oral iron is not likely to be absorbed 1

Specific conditions requiring IV iron:

• Active inflammatory bowel disease with compromised absorption 1, 4
• Post-bariatric surgery patients 1
• Portal hypertensive gastropathy with ongoing bleeding unresponsive to oral iron 1
• Patients with severe anemia requiring rapid correction 4

IV Iron Administration

• IV iron formulations that can replace iron deficits with 1-2 infusions are preferred 1
• For patients weighing ≥50 kg, ferric carboxymaltose can be administered as 750 mg intravenously in two doses separated by at least 7 days 5
• All IV iron formulations have similar risk profiles; true anaphylaxis is rare 1
• Most reactions to IV iron are infusion-related and should be treated accordingly 1

Disease-Specific Approaches

• For inflammatory bowel disease: Treat active inflammation to enhance iron absorption while addressing the anemia 1, 2
• For portal hypertensive gastropathy: Consider treatment with nonselective β-blockers if no other source of chronic blood loss is identified 1
• For gastric antral vascular ectasia: Consider endoscopic therapy with band ligation or thermal methods if iron replacement yields inadequate response 1
• For celiac disease: Ensure adherence to a gluten-free diet to improve iron absorption 1

Monitoring and Follow-up

• Monitor hemoglobin concentration and red cell indices at three-month intervals for one year after normalization, then after another year 1
• Provide additional oral iron if hemoglobin or MCV falls below normal 1
• Consider further investigation if anemia cannot be maintained with supplementation 1
• Check serum phosphate levels in patients requiring repeat IV iron courses, especially within three months of previous treatment 5

Common Pitfalls to Avoid

• Using multiple daily doses of oral iron, which increases side effects without improving efficacy 1, 3
• Continuing with oral iron despite poor response or intolerance 2
• Not addressing the underlying cause of iron deficiency while treating the anemia 1, 2
• Overlooking the need for vitamin C supplementation to enhance iron absorption 1
• Failing to continue treatment long enough to replenish iron stores after anemia correction 1