What are the management options for anemia?

Management of Anemia

All patients with iron deficiency anemia should receive oral iron supplementation with ferrous sulfate 200 mg three times daily to correct anemia and replenish iron stores, continuing for three months after hemoglobin normalization. 1, 2

First-Line Oral Iron Therapy

Ferrous sulfate 200 mg three times daily is the preferred initial treatment because it is the most simple, effective, and inexpensive option available. 1, 2 Alternative oral formulations include ferrous gluconate and ferrous fumarate, which are equally effective if ferrous sulfate is not tolerated. 1, 2

Optimizing Oral Iron Absorption

• Add ascorbic acid (vitamin C) when response to oral iron is poor, as it enhances iron absorption. 1, 2
• Consider liquid preparations when tablets are not tolerated. 1
• Recent evidence suggests that lower doses (100 mg daily) or alternate-day dosing may be sufficient for asymptomatic patients, with better tolerability. 3

Expected Response and Monitoring

• Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of treatment. 1, 2
• Continue iron supplementation for three months after correction of anemia to adequately replenish iron stores. 1, 2
• Monitor hemoglobin and red cell indices every three months for the first year, then once more after another year. 1, 2

Failure of Oral Iron Therapy

If hemoglobin fails to rise appropriately after 3-4 weeks, consider:

• Poor compliance (most common cause) 1
• Misdiagnosis 1, 2
• Continued blood loss 1
• Malabsorption 1

Parenteral Iron Therapy

Reserve intravenous iron for specific clinical scenarios only, not as first-line therapy. 1, 2

Clear Indications for Parenteral Iron:

• Intolerance to at least two oral iron preparations 1, 2
• Malabsorption (celiac disease, post-bariatric surgery) 2, 4
• Non-compliance with oral therapy 1, 2
• Chronic inflammatory conditions (CKD, heart failure, IBD, cancer) 2, 4
• Ongoing blood loss exceeding intestinal absorption capacity 5
• Second and third trimesters of pregnancy 4

Important Caveats About Parenteral Iron:

• Parenteral iron carries risk of anaphylactic reactions and is painful when given intramuscularly. 1, 2
• It is more expensive than oral therapy. 1
• The rise in hemoglobin is no quicker than with oral preparations in most cases. 1
• Available intravenous preparations include iron sucrose, ferric carboxymaltose, and iron dextran. 2

Erythropoiesis-Stimulating Agents

Erythropoietin (PROCRIT) is indicated only for specific conditions, not for routine iron deficiency anemia:

• Anemia due to chronic kidney disease 6
• Anemia due to zidovudine in HIV-infected patients 6
• Anemia due to myelosuppressive chemotherapy in cancer patients 6
• Reduction of transfusions in high-risk surgical patients 6

Erythropoietin has NOT been shown to improve quality of life, fatigue, or patient well-being and should not be used as a substitute for addressing iron deficiency. 6

Identifying and Treating Underlying Causes

Treatment of the underlying cause is essential to prevent further iron loss, though all patients still require iron supplementation. 1

Age-Based Investigation Approach:

• Patients >45 years should undergo gastrointestinal investigation due to increasing incidence of serious pathology with age. 1
• Pre-menopausal women (<45 years) with iron deficiency anemia (occurring in 5-10% of this population) should be screened for celiac disease. 1, 2
• Pre-menopausal women require gastrointestinal investigation only if they have GI symptoms, family history of colorectal cancer, or persistent anemia after iron supplementation. 2

Common Causes to Address:

• Menstrual loss, menorrhagia, pregnancy, and breastfeeding in women 1
• Gastrointestinal bleeding 4
• NSAID use 4
• Dietary deficiency 1
• Malabsorption disorders 4

Special Populations

Patients with Severe Co-Morbidity:

Carefully consider whether investigation would influence management before pursuing extensive workup, discussing with patients and caregivers when possible. 1

Transfusion-Dependent Patients:

If iron deficiency anemia is transfusion-dependent, consider enteroscopy to detect and treat small bowel angiodysplasia. 1

Common Pitfalls to Avoid

• Discontinuing iron therapy too early before stores are replenished leads to recurrence. 1, 2
• Failing to investigate underlying causes in patients >45 years can miss serious pathology like malignancy. 1
• Using parenteral iron as first-line therapy exposes patients to unnecessary risks and costs when oral iron would be appropriate. 2
• Not considering malabsorption in patients with poor response to oral iron delays appropriate treatment. 2
• Switching oral formulations unnecessarily rather than trying alternate-day dosing or lower doses to improve tolerability. 3