What is the first line treatment for iron deficiency anemia?

First-Line Treatment for Iron Deficiency Anemia

The first-line treatment for iron deficiency anemia is oral iron supplementation, most commonly with ferrous sulfate 200 mg three times daily. 1

Oral Iron Therapy

• Oral iron supplementation is the simplest, least expensive, and most effective approach to correct anemia and replenish iron stores 1
• Ferrous sulfate 200 mg three times daily is the most commonly recommended formulation, though ferrous gluconate and ferrous fumarate are equally effective 1
• Treatment should continue for three months after correction of anemia to adequately replenish iron stores 1
• Expected response: Hemoglobin concentration should rise by approximately 2 g/dl after 3-4 weeks of treatment 1
• Alternative formulations may be used if the standard tablet form is not tolerated:
  • Liquid preparations may be better tolerated by some patients 1
  • Adding ascorbic acid (vitamin C) enhances iron absorption and should be considered when response is poor 1

Monitoring and Follow-up

• Hemoglobin concentration and red cell indices should be monitored at regular intervals 1
  • Recommended schedule: Every three months for one year, then after a further year 1
• Additional oral iron should be given if hemoglobin or MCV falls below normal 1
• Failure to respond to oral iron therapy may be due to:
  • Poor compliance
  • Misdiagnosis
  • Continued blood loss
  • Malabsorption 1

Special Considerations

Inflammatory Bowel Disease (IBD)

• For patients with IBD and iron deficiency anemia:
  • Oral iron should be considered first-line for those with mild anemia, clinically inactive disease, and no previous intolerance to oral iron 1
  • Intravenous iron should be considered first-line for patients with:
    • Clinically active IBD
    • Previous intolerance to oral iron
    • Hemoglobin below 100 g/L
    • Need for erythropoiesis-stimulating agents 1

When to Consider Parenteral Iron

• Parenteral iron should only be used when:
  • There is intolerance to at least two oral preparations
  • Non-compliance with oral therapy is an issue
  • Oral therapy is ineffective due to poor absorption
  • Rapid correction of anemia is required 1, 2
• Drawbacks of parenteral iron include:
  • Pain with intramuscular administration
  • Higher cost
  • Risk of anaphylactic reactions 1
  • The rise in hemoglobin is generally no quicker than with oral preparations 1

Common Pitfalls and Caveats

• Excessive dosing: Recent evidence suggests that lower doses (100 mg daily or every other day) may be as effective as traditional higher doses while causing fewer side effects 3, 2
• Gastrointestinal side effects are common with oral iron and may reduce compliance 4
• Failure to treat the underlying cause: While supplementing iron, it's essential to identify and address the source of iron loss or poor absorption 1
• Inadequate duration of therapy: Treatment should continue for three months after normalization of hemoglobin to replenish iron stores 1
• Overlooking inflammation: In patients with inflammatory conditions, serum ferritin up to 100 μg/L may still be consistent with iron deficiency 1

By following these guidelines for oral iron supplementation as first-line therapy for iron deficiency anemia, with appropriate monitoring and consideration of special circumstances, most patients will achieve resolution of their anemia and replenishment of iron stores.