What is the appropriate management for a patient with severe iron deficiency anemia?

Management of Severe Iron Deficiency Anemia

For a 41-year-old male with severe iron deficiency anemia (hemoglobin 6.5 g/dL, ferritin 5 ng/mL), oral iron supplementation with ferrous sulfate 200 mg three times daily should be initiated immediately to correct anemia and replenish iron stores. 1

Initial Treatment Approach

• Start oral iron therapy with ferrous sulfate 200 mg three times daily (provides approximately 65 mg elemental iron per tablet) as the most cost-effective first-line treatment 1
• Alternative oral preparations include ferrous gluconate or ferrous fumarate if ferrous sulfate is not tolerated 1
• Consider adding ascorbic acid (vitamin C) to enhance iron absorption if response to therapy is poor 1
• Expect hemoglobin to rise by approximately 2 g/dL after 3-4 weeks of proper therapy 1
• Continue iron supplementation for 3 months after hemoglobin normalizes to adequately replenish iron stores 1

Monitoring Response

• Check hemoglobin after 4 weeks to assess response to oral iron therapy 1
• If no improvement in hemoglobin is seen, evaluate for:
  • Poor compliance with medication 1
  • Misdiagnosis of iron deficiency 1
  • Ongoing blood loss 1
  • Malabsorption of iron 1

Diagnostic Evaluation

Given the severity of anemia in this 41-year-old male patient:

• Upper GI endoscopy with small bowel biopsy and colonoscopy are strongly recommended to identify the underlying cause 1
• Screen for celiac disease with transglutaminase antibody (IgA type) and IgA testing 2
• Consider additional small intestine investigation (capsule endoscopy, CT, or MRI enterography) if initial endoscopic evaluation is negative but clinical suspicion for ongoing blood loss remains high 2

Parenteral Iron Considerations

• Reserve parenteral iron for cases where:

  • Intolerance to at least two oral iron preparations 1
  • Poor compliance with oral therapy 1
  • Documented malabsorption 1, 3
  • Ongoing blood loss 3

• Available parenteral options include:

  • Iron sucrose (Venofer): 200 mg IV administered as slow injection or infusion 4
  • Ferric gluconate (Ferrlecit): 125 mg IV administered as slow injection or infusion 5

Follow-up Recommendations

• Monitor hemoglobin and red cell indices at three-month intervals for the first year after normalization, then after another year 1
• Provide additional oral iron if hemoglobin or MCV falls below normal during follow-up 1
• Consider further investigation only if hemoglobin and MCV cannot be maintained with supplementation 1

Common Pitfalls to Avoid

• Failing to investigate the underlying cause of iron deficiency in a male patient (gastrointestinal blood loss is the most common cause) 2, 3
• Discontinuing iron therapy too early (before iron stores are replenished) 1
• Using parenteral iron as first-line therapy when oral iron is appropriate 1
• Neglecting to monitor response to therapy at appropriate intervals 1
• Missing malabsorption conditions like celiac disease that may prevent adequate response to oral iron 2