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

Management of Iron Deficiency Anemia

Oral iron supplementation with ferrous sulfate 200 mg three times daily is the first-line treatment for iron deficiency anemia, while identifying and treating the underlying cause is essential for long-term resolution. 1, 2

Diagnosis Confirmation

• The patient's laboratory values (hemoglobin 12.6 g/dL, ferritin 42.8, transferrin 196, transferrin saturation 31%, TIBC 218) suggest iron deficiency anemia 3
• Iron deficiency is typically diagnosed by low serum ferritin (<30 ng/mL) or transferrin saturation <20% 3

Treatment Algorithm

First-Line Therapy

• Initiate oral iron supplementation with ferrous sulfate 200 mg three times daily (equivalent to 65 mg elemental iron per tablet) 2, 4
• Alternative formulations like ferrous gluconate and ferrous fumarate are equally effective if ferrous sulfate is not tolerated 2
• Consider liquid preparations for patients who cannot tolerate tablets 2
• Add ascorbic acid (vitamin C) to enhance iron absorption when response is poor 2, 1

Monitoring Response

• Expect hemoglobin concentration to rise by approximately 2 g/dL after 3-4 weeks of treatment 2, 1
• Failure to respond may indicate:
  • Poor compliance
  • Misdiagnosis
  • Continued blood loss
  • Malabsorption 2
• Continue iron therapy for three months after anemia correction to replenish iron stores 2

Follow-up Schedule

• Monitor hemoglobin concentration and red cell indices at 3-month intervals for one year, then after another year 2
• Provide additional oral iron if hemoglobin or MCV falls below normal 2

Alternative Approaches

• Recent evidence suggests that lower doses (100 mg ferrous fumarate once daily) may be sufficient for asymptomatic patients with mild anemia 5
• Alternate-day dosing may improve tolerance while maintaining efficacy 1, 5

Parenteral Iron Therapy

• Reserve for patients with:
  • Intolerance to at least two oral preparations
  • Non-compliance
  • Malabsorption
  • Ongoing blood loss 2, 1
• Be aware that parenteral iron:
  • Can be painful (intramuscular)
  • Is more expensive
  • May cause anaphylactic reactions
  • Does not correct anemia faster than oral preparations 2

Investigation of Underlying Cause

• For patients >45 years: perform both upper GI endoscopy with small bowel biopsy and either colonoscopy or barium enema 2
• For patients <45 years:
  • If upper GI symptoms present: perform endoscopy and small bowel biopsy
  • If no GI symptoms: test for celiac disease with antiendomysial antibody determinations 2
• For premenopausal women: evaluate for menorrhagia, which affects 5-10% of menstruating women 2

Common Pitfalls to Avoid

• Failing to continue treatment until iron stores are fully replenished 1
• Not investigating the underlying cause, especially in men and postmenopausal women 3, 6
• Overlooking poor compliance or continued blood loss in patients who don't respond to therapy 2
• Using parenteral iron as first-line therapy when oral iron would be effective 1

Special Considerations

• Resolution of anemia should be achieved by six months in 80% of patients 2
• Consider further investigation if anemia persists despite appropriate therapy 2, 1
• For severe anemia or patients with symptoms, higher doses (200 mg/day) may be appropriate 5