What is the treatment for Iron Deficiency Anemia (IDA)?

Treatment of Iron Deficiency Anemia (IDA)

Oral iron supplementation is the first-line treatment for most patients with iron deficiency anemia, with ferrous sulfate 200 mg twice daily being the most effective and economical option to correct anemia and replenish iron stores. 1

Initial Treatment Approach

• All patients with IDA should receive iron supplementation to correct anemia and replenish body stores, regardless of the underlying cause 1
• First-line therapy is oral ferrous sulfate 200 mg twice daily (contains approximately 65 mg elemental iron per tablet) 1
• Alternative oral iron formulations may be better tolerated in some patients:
  • Ferrous fumarate or ferrous gluconate may cause fewer gastrointestinal side effects 1
  • Liquid preparations can be used when tablets are not tolerated 1
• Lower doses of oral iron may be as effective and better tolerated than traditional doses 1

Duration of Treatment

• Oral iron should be continued for 3 months after correction of anemia to ensure iron stores are fully replenished 1
• Hemoglobin concentration should rise by approximately 2 g/dL after 3-4 weeks of proper treatment 1
• Failure to respond suggests poor compliance, misdiagnosis, continued blood loss, or malabsorption 1

Adjunctive Therapies

• Ascorbic acid (250-500 mg twice daily) taken with iron supplements may enhance iron absorption when response to iron therapy is poor 1
• Treatment of any underlying cause (e.g., gastrointestinal bleeding, celiac disease) should be addressed simultaneously to prevent further iron loss 1

Intravenous Iron Therapy

Intravenous (IV) iron should be considered in the following situations:

• Intolerance to at least two oral iron preparations 1
• Non-compliance with oral therapy 1
• Patients with inflammatory bowel disease and active inflammation with compromised absorption 1
• Patients with portal hypertensive gastropathy and ongoing bleeding who don't respond to oral iron 1
• Severe iron deficiency requiring rapid repletion 2

Available IV iron preparations include:

• Iron sucrose (Venofer) - can be administered as 200 mg over 10 minutes 1, 3
• Ferric carboxymaltose (Ferinject) - can deliver up to 1000 mg in a single 15-minute infusion 1
• Iron dextran (Cosmofer) - can be given IV or IM, but carries higher risk of serious reactions 1

Special Populations

• Inflammatory Bowel Disease: IV iron therapy is preferred in patients with active inflammation due to compromised absorption of oral iron 1
• Portal Hypertensive Gastropathy: Start with oral iron, but switch to IV iron if there's ongoing bleeding without response to oral therapy 1
• Celiac Disease: Ensure adherence to a gluten-free diet to improve iron absorption; consider IV iron if stores don't improve with oral therapy 1
• Small-bowel Angioectasias: Iron replacement (oral or IV depending on severity) should accompany endoscopic treatment 1

Monitoring and Follow-up

• Monitor hemoglobin concentration and red cell indices at regular intervals:
  • Every 3 months for the first year after correction
  • Then after a further year 1
• Additional oral iron should be given if hemoglobin or MCV falls below normal 1
• Further investigation is only necessary if hemoglobin and MCV cannot be maintained with supplementation 1

Common Pitfalls and Caveats

• Failure to continue iron therapy for 3 months after normalization of hemoglobin leads to inadequate replenishment of iron stores 1
• Accepting upper GI findings like erosions or peptic ulcers as the sole cause of IDA without investigating the lower GI tract (dual pathology occurs in 10-15% of patients) 1
• Overlooking poor compliance due to gastrointestinal side effects of oral iron 1
• Parenteral iron therapy should not be used routinely due to higher cost and risk of adverse reactions, including rare but serious anaphylactic reactions 1
• Transfusions should be avoided in chronically anemic patients due to potential side effects and cost, and reserved only for hemodynamically unstable patients 4