What is the appropriate treatment for iron deficiency anemia with hypoferritinemia and hypoironemia?

Treatment of Iron Deficiency Anemia

Start oral ferrous sulfate 200 mg once or twice daily, as this is the most cost-effective first-line treatment that will correct your severe iron deficiency (ferritin 10 ng/mL, iron saturation 9%). 1

Initial Treatment Approach

Your laboratory values confirm severe iron deficiency anemia with:

• Ferritin 10 ng/mL (severely depleted stores, normal >30 ng/mL)
• Iron saturation 9% (severely low, normal >20%)
• High TIBC (428) and low iron (40) indicating true iron deficiency 1

Oral Iron Therapy (First-Line)

Recommended regimen:

• Ferrous sulfate 200 mg once daily or twice daily (provides 65 mg elemental iron per dose) 1
• Alternative preparations include ferrous fumarate or ferrous gluconate, which are equally effective 1
• Continue for 3 months after hemoglobin normalizes to replenish iron stores 1

Dosing considerations based on recent evidence:

• Recent data shows 60 mg elemental iron twice daily produces faster hemoglobin rise than alternate-day dosing, though alternate-day dosing (120 mg every other day) achieves similar results with fewer gastrointestinal side effects 1
• If gastrointestinal side effects occur, switch to alternate-day dosing rather than discontinuing treatment 1
• Lower doses (50-100 mg elemental iron daily) may be better tolerated with reasonable efficacy 1, 2

Enhancing absorption:

• Consider adding ascorbic acid (vitamin C) 250-500 mg with iron doses to enhance absorption, particularly if response is poor 1
• Take iron on an empty stomach when possible, avoiding tea, coffee, and calcium-containing foods 2

Expected Response and Monitoring

You should see:

• Hemoglobin rise of at least 10 g/L (1 g/dL) after 2 weeks of daily oral therapy 1
• Hemoglobin increase of 2 g/dL after 3-4 weeks 1
• Failure to achieve this response indicates non-compliance, malabsorption, continued bleeding, or other pathology 1

Follow-up testing:

• Recheck hemoglobin and iron studies at 2 weeks to confirm response 1
• Repeat testing at 8-10 weeks to assess treatment success 1, 2
• Monitor every 3 months for one year, then annually after normalization 1

When to Use Intravenous Iron

Consider IV iron if:

• Intolerance to at least two different oral iron preparations 1
• Failure to respond to oral iron after 2 weeks (no hemoglobin rise ≥10 g/L) 1
• Malabsorption conditions (celiac disease, inflammatory bowel disease, post-bariatric surgery) 1, 3
• Severe symptomatic anemia requiring rapid correction 1
• Ongoing blood loss that cannot be controlled 1

IV iron options:

• Ferric carboxymaltose (Ferinject): 1000 mg over 15 minutes, most convenient single-dose option 1, 4
• Iron sucrose (Venofer): 200 mg over 10-15 minutes, requires multiple doses 1, 5
• Iron dextran (Cosmofer): 20 mg/kg over 6 hours, single total dose replacement but higher anaphylaxis risk 1

Important safety note: All IV iron preparations carry risk of anaphylaxis (0.6-0.7% for iron dextran, lower for newer formulations), and resuscitation facilities must be available 1

Blood Transfusion

Transfusion is rarely indicated for iron deficiency anemia because:

• Most patients adapt to slowly developing anemia 1
• IV iron produces clinically meaningful hemoglobin response within one week 1
• Reserve transfusion only for severe symptomatic anemia with circulatory compromise 1
• If transfused, target hemoglobin 70-90 g/L (80-100 g/L with unstable coronary disease), then follow with iron replacement 1

Investigating the Underlying Cause

Critical next step: Identify and treat the source of iron loss:

• Age >45 years: Upper endoscopy with small bowel biopsy AND colonoscopy (or barium enema) to exclude gastrointestinal bleeding or malignancy 1
• Age <45 years: Consider celiac disease screening (anti-endomysial antibodies with IgA level), endoscopy only if upper GI symptoms present 1
• Menstruating women: Heavy menstrual bleeding is common cause, but still investigate if symptoms persist or age >45 years 1
• Exclude NSAID use, assess for inflammatory bowel disease, and check for hematuria 1

Common Pitfalls to Avoid

• Don't stop oral iron too early: Continue for 3 months after hemoglobin normalizes to replenish stores 1
• Don't use modified-release preparations: These are less suitable for prescribing due to reduced absorption 1
• Don't assume dietary deficiency alone: Always investigate for pathological blood loss, especially in adults 1
• Don't use parenteral iron as first-line unless specific contraindications to oral therapy exist 1
• Don't supplement iron if ferritin is normal or high: This is potentially harmful and not recommended 1, 2