What is the treatment for iron deficiency without anemia?

Treatment for Iron Deficiency Without Anemia

The treatment of iron deficiency without anemia should include oral iron supplementation with ferrous sulfate 200 mg three times daily as first-line therapy to replenish iron stores, particularly in symptomatic patients. 1, 2

Diagnosis Confirmation

• Iron deficiency without anemia is characterized by normal hemoglobin levels but depleted iron stores, typically indicated by serum ferritin <30 μg/L in adults 2
• Transferrin saturation <20% is an additional diagnostic criterion for iron deficiency 2, 3
• In patients with inflammatory conditions, a higher ferritin cut-off of 45 μg/L may be needed for diagnosis 2

Treatment Algorithm

First-Line Therapy: Oral Iron

• Ferrous sulfate 200 mg three times daily (providing approximately 65 mg of elemental iron per tablet) is the simplest, least expensive, and most effective oral iron supplement 1, 4
• Alternative ferrous preparations include ferrous gluconate and ferrous fumarate, which are equally effective but may have different side effect profiles 1
• Liquid preparations may be better tolerated when tablets cause gastrointestinal side effects 1
• Adding ascorbic acid (vitamin C) enhances iron absorption and should be considered when response to iron therapy is poor 1
• Alternate-day dosing may be better tolerated with similar efficacy compared to daily dosing 1, 5

Second-Line Therapy: Intravenous Iron

• Intravenous iron should be considered when there is:
  • 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, 3
  • Chronic inflammatory conditions (IBD, heart failure) 1

Special Populations

Heart Failure Patients

• For heart failure patients with ferritin <100 ng/ml, iron therapy is recommended even without anemia 2
• Target ferritin level should be at least 100 ng/ml 2

Inflammatory Bowel Disease

• The decision to supplement iron in IBD patients without anemia depends on patient history, symptoms, and preferences 1
• Intravenous iron is preferred in patients with clinically active IBD due to compromised absorption 1

Pregnant Women

• Iron supplementation is warranted in pregnant women with iron deficiency even without anemia 2, 3

Monitoring and Follow-up

• Monitor ferritin levels to assess response to therapy 2
• In patients with ongoing risk factors, periodic monitoring of iron status is recommended 3
• Identify and treat the underlying cause of iron deficiency (e.g., occult bleeding, malabsorption) 2, 3

Common Pitfalls to Avoid

• Don't rely solely on ferritin in patients with inflammatory conditions; use transferrin saturation as an additional marker 2
• Don't overlook the need to identify and treat the underlying cause of iron deficiency 2, 3
• Avoid excessive iron supplementation which can cause iron overload, especially in high-risk patients 6
• Don't miss screening for celiac disease, which is found in 3-5% of iron deficiency cases 2

Gastrointestinal Investigation

• GI investigation is generally not warranted in premenopausal women without other risk factors 2
• The threshold for investigation should be low in men, postmenopausal women, and those with GI symptoms 2, 7
• Patients over 45 years with iron deficiency should undergo appropriate gastrointestinal investigations 1