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

Management of Iron Deficiency Anemia

Based on the laboratory values showing low iron saturation (0.12, normal range 0.20-0.50), oral iron supplementation is the first-line treatment for this patient with iron deficiency anemia. 1

Diagnosis Confirmation

• The patient's laboratory values confirm iron deficiency with low iron (7.8 μmol/L) and low iron saturation (0.12), despite normal ferritin (129 μg/L) 1
• Serum ferritin is the most powerful test for iron deficiency, but may be elevated in inflammatory conditions even when iron stores are low 1, 2
• Low transferrin saturation (<20%) is diagnostic of iron deficiency even when ferritin appears normal 2

Treatment Approach

First-Line Therapy

• Administer oral iron supplementation with ferrous sulfate 200 mg three times daily 1, 3
• Alternative formulations include ferrous gluconate and ferrous fumarate, which are equally effective 1
• Consider once-daily dosing to improve tolerance 3
• Add vitamin C (ascorbic acid) to enhance iron absorption 1, 3

Monitoring Response

• Hemoglobin concentration should rise by approximately 2 g/dL after 3-4 weeks of treatment 1, 3
• Failure to respond suggests poor compliance, misdiagnosis, continued blood loss, or malabsorption 1
• Continue iron therapy for three months after correction of anemia to replenish iron stores 1

Follow-Up

• Monitor hemoglobin concentration and red cell indices at three-month intervals for one year, then after another year 1
• Provide additional oral iron if hemoglobin or MCV falls below normal 1
• Further investigation is only necessary if hemoglobin and MCV cannot be maintained with supplementation 1

Alternative Treatment Options

Parenteral Iron Therapy

• Reserve for patients with:
  • Intolerance to at least two oral preparations 1
  • Non-compliance with oral therapy 1
  • Inadequate response to oral iron 3, 4
  • Conditions affecting iron absorption 3, 4
• Note that parenteral iron is more expensive and may cause anaphylactic reactions, though newer formulations are safer 1, 3
• The rise in hemoglobin is no quicker with parenteral than with oral preparations 1

Blood Transfusions

• Reserve only for patients with or at risk of cardiovascular instability due to severe anemia 1

Investigation of Underlying Cause

• All patients with iron deficiency anemia should be investigated for underlying causes 1
• Upper and lower GI investigations should be considered in all postmenopausal females and all male patients 1
• All patients should be screened for celiac disease 1
• Premenopausal women with IDA should be screened for celiac disease, with other investigations based on clinical judgment 1
• Faecal occult blood testing is of no benefit in the investigation of IDA 1

Common Pitfalls to Avoid

• Failing to diagnose iron deficiency in patients with inflammatory conditions who may have elevated ferritin levels 3
• Continuing oral iron therapy despite poor response or intolerance 3
• Not addressing the underlying cause of iron deficiency while treating the anemia 3, 2
• Attributing IDA to medications like aspirin or warfarin without completing GI investigations 1

Quality Standards

• Resolution of anemia should be achieved by six months in 80% of patients 1
• 90% of those not responding to treatment should be considered for further investigation 1