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

Treatment of Iron Deficiency Anemia (IDA)

The recommended initial treatment for Iron Deficiency Anemia (IDA) is one tablet per day of ferrous sulfate, fumarate, or gluconate, with treatment continued for approximately 3 months after hemoglobin normalization to ensure adequate replenishment of iron stores. 1

First-Line Treatment: Oral Iron Therapy

• Oral iron supplementation should be initiated promptly and not deferred while awaiting investigations unless colonoscopy is imminent 1
• Standard initial dosing is one tablet per day of ferrous sulfate (providing 65mg of elemental iron), ferrous fumarate, or ferrous gluconate 1, 2
• Oral iron should be taken in the morning or fasting state to maximize absorption 3
• Patients should be monitored within the first 4 weeks for hemoglobin response to oral iron therapy 1
• An increase in hemoglobin of at least 10 g/L after 2 weeks of daily oral iron therapy is predictive of subsequent adequate response (sensitivity 90.1%, specificity 79.3%) 1
• Treatment should continue for approximately 3 months after hemoglobin normalization to ensure adequate replenishment of bone marrow iron stores 1, 4

Management of Oral Iron Intolerance

• If standard dosing is not tolerated, consider:
  • Reduced dose of one tablet every other day 1
  • Alternative oral iron preparations such as ferric maltol 1
  • Parenteral iron therapy 1
• Alternate-day dosing may be as effective as daily dosing with fewer gastrointestinal side effects 1, 3
• Morning dosing may be preferable to avoid the circadian increase in hepcidin that can reduce iron absorption 3

Indications for Parenteral Iron Therapy

• Parenteral iron should be considered when oral iron is:
  • Contraindicated
  • Ineffective (inadequate hemoglobin response after 2-4 weeks)
  • Not tolerated due to side effects 1
• Specific conditions where parenteral iron may be preferred:
  • Clinically active inflammatory bowel disease 1, 5
  • Chronic kidney disease with functional iron deficiency 1
  • Chronic heart failure with iron deficiency 1
  • Need for rapid hemoglobin correction 5, 6

Blood Transfusion in IDA

• Blood transfusion should be reserved for patients with severe symptomatic anemia or circulatory compromise 1
• Target hemoglobin of 70-90 g/L (80-100 g/L in those with unstable coronary artery disease) is reasonable 1
• Since a unit of packed red cells contains only about 200mg of elemental iron, iron replacement therapy is still necessary post-transfusion 1

Special Populations

• Elderly patients: Iron deficiency is often multifactorial; carefully consider risks and benefits of invasive investigations 1
• Post-gastrectomy/bariatric surgery: Higher risk of iron deficiency due to malabsorption; may require parenteral iron 1
• Inflammatory bowel disease: Oral iron may be poorly tolerated; parenteral iron often required 1
• Chronic heart failure: Parenteral iron may improve symptoms and quality of life 1
• Chronic kidney disease: Functional iron deficiency is common; refer to specialist guidelines 1

Long-term Monitoring

• After successful treatment, monitor blood counts periodically (perhaps every 6 months initially) to detect recurrent IDA 1
• Long-term iron replacement therapy may be appropriate when the cause of recurrent IDA is unknown or irreversible 1

Common Pitfalls to Avoid

• Failing to investigate the underlying cause of IDA, especially in men and postmenopausal women 1
• Attributing IDA to medications (aspirin, warfarin, proton pump inhibitors) without appropriate GI investigations 1
• Stopping iron therapy too soon after hemoglobin normalization without replenishing iron stores 1
• Not monitoring response to oral iron therapy within the first 4 weeks 1
• Using modified-release iron preparations, which are less well absorbed and more expensive 1