What is the treatment plan for a 19-year-old female with chronic iron deficiency anemia, vitamin B12 deficiency, and vitamin D deficiency, with a ferritin level of 5, iron saturation of 5%, and hemoglobin of 9.2?

Treatment Plan for a 19-Year-Old Female with Chronic Iron Deficiency Anemia, Low B12, and Vitamin D Deficiency

The patient requires immediate oral iron supplementation with ferrous sulfate 200 mg twice daily, intramuscular vitamin B12 injections, and vitamin D supplementation to address her severe deficiencies and improve her hemoglobin level of 9.2 g/dL. 1, 2

Iron Deficiency Treatment

Initial Management

• Start ferrous sulfate 200 mg twice daily (providing approximately 60-80 mg of elemental iron per day) 1
• Consider alternate-day dosing (200 mg every other day) if gastrointestinal side effects occur 3
• Take iron supplements in the morning with vitamin C (250-500 mg) to enhance absorption 1
• Continue iron supplementation for at least 3 months after hemoglobin normalizes to replenish iron stores 1

Monitoring Response

• Check hemoglobin after 3-4 weeks of treatment; expect a rise of approximately 2 g/dL 1
• Monitor hemoglobin and red cell indices at 3-month intervals for the first year, then after another year 1
• If no response to oral iron (hemoglobin increase <1 g/dL after 4 weeks), consider:
  • Evaluating compliance
  • Investigating ongoing blood loss
  • Considering parenteral iron therapy 1

Parenteral Iron Considerations

• Consider intravenous iron if oral therapy fails, is not tolerated, or if rapid correction is needed 1
• Options include iron sucrose, ferric carboxymaltose, or iron dextran 1
• Ensure resuscitation facilities are available when administering IV iron due to rare risk of anaphylaxis 1

Vitamin B12 Deficiency Treatment

• Initiate intramuscular vitamin B12 injections at 100 mcg daily for 6-7 days 2
• Follow with 100 mcg on alternate days for 7 doses 2
• Then administer 100 mcg every 3-4 weeks for 2-3 weeks 2
• After normalization of hematologic values, continue with 100 mcg monthly injections 2
• Monitor B12 levels after initial treatment course 2

Vitamin D Deficiency Treatment

• Start vitamin D supplementation with 50,000 IU weekly for 8 weeks to correct severe deficiency (level of 13) 1
• After initial repletion, transition to maintenance dose of 1000-2000 IU daily 1
• Recheck vitamin D level after 3 months of therapy 1

Additional Considerations

Dietary Recommendations

• Encourage consumption of iron-rich foods (red meat, poultry, fish, beans, leafy greens) 1
• Include vitamin C-rich foods with meals to enhance iron absorption 1
• Recommend vitamin B12-rich foods (meat, fish, dairy, eggs) 2
• Suggest calcium-rich foods, but advise taking calcium supplements at different times than iron supplements 1

Further Evaluation

• Investigate potential causes of iron deficiency, particularly heavy menstrual bleeding given the patient's age and gender 4, 5
• Consider screening for celiac disease with anti-tissue transglutaminase antibodies 1
• Evaluate for other causes of B12 deficiency (atrophic gastritis, malabsorption) 2

Common Pitfalls to Avoid

• Do not exceed 100 mg of elemental iron daily as higher doses may not improve absorption and can increase side effects 1
• Avoid administering calcium supplements simultaneously with iron as calcium impairs iron absorption 1
• Do not rely solely on ferritin for monitoring response; use hemoglobin and MCV 1
• Do not discontinue iron therapy prematurely; continue for 3 months after normalization of hemoglobin 1
• Do not substitute folic acid for vitamin B12, as this may mask B12 deficiency while allowing neurologic damage to progress 2

By following this comprehensive treatment plan, the patient's iron deficiency anemia, vitamin B12 deficiency, and vitamin D deficiency should improve significantly, leading to better overall health outcomes and quality of life.