What is the treatment for iron deficiency?

Treatment of Iron Deficiency

The first-line treatment for iron deficiency is oral iron supplementation with ferrous sulfate 200-325 mg (containing 65 mg elemental iron) once daily, while intravenous iron should be reserved for patients who cannot tolerate oral iron, have inadequate response, or have conditions affecting iron absorption. 1, 2

Oral Iron Therapy

First-Line Treatment

• Ferrous sulfate is the preferred oral iron formulation due to its effectiveness, widespread availability, and low cost 1, 2
• Standard dosing is one tablet daily of ferrous sulfate (324 mg, providing 65 mg of elemental iron) 3
• Alternative oral preparations include ferrous fumarate and ferrous gluconate, which are equally effective 1, 4
• Liquid preparations may be better tolerated when tablets cause side effects 1

Optimizing Oral Iron Therapy

• Adding vitamin C (ascorbic acid) enhances iron absorption and should be considered when response is poor 1, 2
• If daily dosing is not tolerated, alternate-day dosing can improve absorption and reduce side effects 1, 5
• Monitor hemoglobin response within the first 4 weeks of treatment; expect a rise of approximately 2 g/dL after 3-4 weeks 1
• Continue treatment for approximately 3 months after hemoglobin normalization to ensure adequate replenishment of iron stores 1

When to Consider Intravenous Iron

Intravenous iron should be considered in the following situations:

• Intolerance to at least two oral iron preparations 1
• Poor compliance with oral therapy 1
• Inadequate response to oral iron 1, 2
• Conditions affecting iron absorption:
  • Active inflammatory bowel disease with inflammation 1, 2
  • Celiac disease not responding to gluten-free diet 1
  • Post-bariatric surgery 6
• Ongoing blood loss exceeding the capacity for oral iron absorption 1
• Portal hypertensive gastropathy with continued bleeding despite oral iron 1

Special Populations and Considerations

Inflammatory Bowel Disease

• Use intravenous iron in patients with active inflammation and compromised absorption 1, 2
• Treat the underlying inflammation to improve iron absorption 1, 2

Portal Hypertension

• Start with oral iron supplements to replenish iron stores 1
• Consider treatment of portal hypertension with nonselective β-blockers 1
• Switch to intravenous iron for patients with ongoing bleeding who don't respond to oral therapy 1

Celiac Disease

• Ensure adherence to a gluten-free diet to improve iron absorption 1
• Consider oral iron supplementation based on severity of deficiency 1
• Use intravenous iron if iron stores don't improve despite dietary compliance 1

Heart Failure

• Intravenous iron (ferric carboxymaltose) is recommended for patients with heart failure with reduced ejection fraction and iron deficiency 1
• Contraindications for IV iron include hypersensitivity to the active substance, evidence of iron overload, or hemoglobin >15 g/dL 1

Monitoring and Follow-up

• Monitor hemoglobin response within 4 weeks of starting treatment 1
• Continue treatment until anemia is corrected and iron stores are replenished (typically 3 months after hemoglobin normalization) 1, 2
• After successful treatment, monitor blood count periodically (perhaps every 6 months initially) to detect recurrent iron deficiency anemia 1
• If anemia doesn't resolve within 6 months, consider further investigation 1, 2

Common Pitfalls to Avoid

• Failing to diagnose iron deficiency in patients with inflammatory conditions who may have ferritin levels >45 mg/dL (usually <100 mg/dL) 1, 2
• Continuing oral iron therapy despite poor response or intolerance 2
• Not addressing the underlying cause of iron deficiency while treating the anemia 2, 6
• Using parenteral iron as first-line therapy when oral iron would be effective 1
• Overlooking the need for multidisciplinary management in complex cases 1