What is the treatment for iron deficiency?

Treatment of Iron Deficiency

The first-line treatment for iron deficiency is oral iron supplementation with ferrous sulfate 200 mg three times daily, while intravenous iron should be reserved for patients who cannot tolerate oral iron, have inadequate response, or have conditions affecting iron absorption. 1, 2

Oral Iron Therapy

• Ferrous sulfate is the preferred oral iron formulation due to its effectiveness and low cost (each tablet contains 324 mg ferrous sulfate, equivalent to 65 mg elemental iron) 3
• Alternative oral preparations include ferrous gluconate and ferrous fumarate, which are equally effective 1
• Liquid preparations may be better tolerated when tablets cause side effects 1
• Treatment should continue for approximately 3 months after normalization of hemoglobin levels to ensure adequate repletion of iron stores 1
• Monitor hemoglobin response within the first 4 weeks of treatment; hemoglobin should rise by approximately 2 g/dL after 3-4 weeks 1, 2

Dosing Strategies to Improve Tolerance

• Consider once-daily dosing rather than multiple daily doses to improve tolerance and compliance 2, 4
• If standard dosing is not tolerated, try reduced dosing of one tablet every other day 1
• Adding vitamin C (ascorbic acid) enhances iron absorption and should be considered when response is poor 1, 2

When to Use Intravenous Iron

Intravenous iron should be considered in the following situations:

• Intolerance to at least two oral iron preparations 1
• Poor compliance with oral therapy 1
• Inadequate response to oral iron 1, 2
• Conditions affecting iron absorption:
  • Active inflammation in inflammatory bowel disease 1
  • After bariatric surgery 5
  • Celiac disease (though oral iron with strict gluten-free diet should be tried first) 1
• Ongoing blood loss exceeding the intestinal ability to absorb iron 6
• Portal hypertensive gastropathy with ongoing bleeding unresponsive to oral iron 1

Disease-Specific Approaches

Inflammatory Bowel Disease

• Use intravenous iron in patients with active inflammation and compromised absorption 1
• Treat underlying inflammation to enhance iron absorption 2

Portal Hypertensive Gastropathy

• Begin with oral iron supplements to replenish iron stores 1
• Consider treatment with nonselective β-blockers if no other source of chronic blood loss is identified 1
• Switch to intravenous iron for patients with ongoing bleeding who don't respond to oral therapy 1

Celiac Disease

• Ensure adherence to a gluten-free diet to improve iron absorption 1
• Consider oral iron supplementation based on severity of deficiency and tolerance 1
• Use intravenous iron if iron stores don't improve despite dietary compliance 1

Monitoring and Follow-up

• Continue treatment until anemia is corrected and iron stores are replenished 2
• After restoration of hemoglobin and iron stores, monitor blood count periodically (perhaps every 6 months initially) to detect recurrent iron deficiency anemia 1
• Consider further investigation if anemia doesn't resolve within 6 months 2

Common Pitfalls to Avoid

• Failing to diagnose iron deficiency in patients with inflammatory conditions who may have ferritin levels >45 mg/dL (usually <100 mg/dL) 1, 2
• Continuing oral iron therapy despite poor response or intolerance 2
• Not addressing the underlying cause of iron deficiency while treating the anemia 5
• Overlooking the need for multidisciplinary management in complex cases 1
• Using parenteral iron when oral preparations would be effective 1
• Transfusing packed red cells when iron therapy alone would suffice (transfusion should be limited to symptomatic severe anemia) 1