What is the recommended treatment for a patient with iron deficiency anemia?

Treatment of Iron Deficiency Anemia

Oral iron supplementation with ferrous sulfate 200 mg three times daily is the recommended first-line treatment for iron deficiency anemia to correct anemia and replenish body iron stores. 1

Initial Treatment Approach

• Ferrous sulfate 200 mg three times daily (providing approximately 65 mg of elemental iron per tablet) is the most simple, effective, and cost-efficient oral iron therapy 1, 2
• Alternative oral iron preparations such as ferrous gluconate and ferrous fumarate are equally effective and can be used if ferrous sulfate is not tolerated 1, 3
• Oral iron therapy should be continued for three months after hemoglobin normalization to ensure adequate replenishment of iron stores 1
• The hemoglobin concentration should rise by approximately 2 g/dL after 3-4 weeks of oral iron therapy 1

Monitoring Response to Treatment

• Hemoglobin response should be monitored at 4 weeks after initiating oral iron therapy 1
• A hemoglobin increase of ≥1.0 g/dL at day 14 of treatment is predictive of satisfactory overall response by day 42/56 4
• After normalization of hemoglobin, monitor levels at three-month intervals for one year and then after a further year 1
• Additional oral iron should be given if hemoglobin or MCV falls below normal during follow-up 1

Strategies to Improve Oral Iron Absorption and Tolerance

• Liquid preparations may be better tolerated when tablets cause gastrointestinal side effects 1
• Adding ascorbic acid (vitamin C) enhances iron absorption and should be considered when response to iron therapy is poor 1
• For patients experiencing gastrointestinal side effects, consider alternate-day dosing which may improve tolerance while maintaining efficacy 1, 5
• Taking iron supplements with meals may reduce gastrointestinal side effects but can decrease absorption by 40-50% 6

When to Consider Parenteral Iron Therapy

Parenteral (intravenous) iron should be considered in the following situations:

• Intolerance to at least two oral iron preparations 1
• Poor compliance with oral therapy 1
• Ongoing blood loss not adequately compensated by oral iron 1
• Conditions with impaired iron absorption:
  • Inflammatory bowel disease with active inflammation 1
  • Post-bariatric surgery 1
  • Celiac disease not responding to gluten-free diet and oral iron 1

Special Considerations for Specific Conditions

• Inflammatory Bowel Disease: Treat active inflammation to enhance iron absorption; consider IV iron when inflammation compromises absorption 1
• Celiac Disease: Ensure adherence to a gluten-free diet to improve iron absorption; start with oral iron and progress to IV iron if stores don't improve 1
• Portal Hypertensive Gastropathy: Begin with oral iron supplements; use IV iron for ongoing bleeding not responding to oral therapy 1
• Chronic Kidney Disease or Heart Failure: Refer to specialist guidelines for management of iron deficiency in these conditions 1

Common Pitfalls and Caveats

• Failure to respond to oral iron therapy may be due to:
  • Poor compliance 1
  • Misdiagnosis of the type of anemia 1
  • Continued blood loss 1
  • Malabsorption 1
  • Concomitant inflammatory condition 6
• Parenteral iron, while effective, can cause pain (when given intramuscularly), is expensive, and may cause anaphylactic reactions 1
• The rise in hemoglobin with parenteral iron is not quicker than with oral preparations 1
• Failure to continue iron therapy for sufficient duration after hemoglobin normalization may result in recurrence of iron deficiency 1

Treatment Duration

• Iron therapy should be continued for a total of 3 months after hemoglobin normalization to ensure adequate replenishment of iron stores 1
• Long-term iron replacement therapy may be appropriate when the cause of recurrent iron deficiency anemia is unknown or irreversible 1