What is the treatment for iron deficiency with normal Iron Binding Capacity (IBC)?

Treatment of Iron Deficiency with Normal Iron Binding Capacity

All patients with iron deficiency should receive oral iron supplementation to correct anemia and replenish body stores, regardless of iron binding capacity values. 1

First-Line Treatment: Oral Iron Supplementation

The most recent British Society of Gastroenterology guidelines (2021) recommend starting with one tablet per day of ferrous sulphate (200 mg), ferrous fumarate, or ferrous gluconate as initial therapy. 1 This represents an evolution from older recommendations that suggested three times daily dosing 1, as newer evidence shows once-daily dosing maximizes absorption while reducing side effects.

Optimal Dosing Strategy

• Start with 50-100 mg elemental iron once daily (e.g., ferrous sulphate 200 mg = 65 mg elemental iron). 1
• Take on an empty stomach in the morning for optimal absorption, as hepcidin levels rise after iron dosing and remain elevated for 24 hours. 2
• Consider alternate-day dosing if daily dosing is not tolerated, as this may actually increase fractional iron absorption by allowing hepcidin levels to normalize between doses. 1, 2

Duration of Treatment

• Continue iron supplementation for 3 months after correction of anemia to adequately replenish iron stores. 1
• Monitor hemoglobin response at 4 weeks—expect a rise of approximately 2 g/dL after 3-4 weeks of treatment. 1

When Oral Iron Fails

Parenteral iron should be considered when oral iron is contraindicated, ineffective, or not tolerated. 1

Indications for Parenteral Iron:

• Intolerance to at least two oral iron preparations 1
• Non-compliance with oral therapy 1
• Malabsorption (e.g., celiac disease, inflammatory bowel disease with active inflammation) 1
• Continued blood loss despite oral supplementation 1

Parenteral Iron Options:

• Iron sucrose (Venofer): 200 mg over 10 minutes 1
• Ferric carboxymaltose (Ferinject): 1000 mg over 15 minutes 1
• Iron dextran (Cosmofer): 20 mg/kg over 6 hours (higher risk of anaphylaxis—0.6-0.7%) 1

Important caveat: Resuscitation facilities must be available when administering intravenous iron due to risk of anaphylaxis. 1

Adjunctive Measures

• Ascorbic acid (250-500 mg twice daily) may enhance iron absorption when taken with oral iron, though evidence for clinical effectiveness is limited. 1
• Treat underlying causes of iron deficiency (e.g., gastrointestinal bleeding, menorrhagia, malabsorption) to prevent recurrence. 1

Follow-Up Monitoring

• Monitor hemoglobin and red cell indices every 3 months for the first year, then annually. 1
• After restoration of iron stores, monitor blood counts every 6 months initially to detect recurrent deficiency. 1
• Reinitiate iron supplementation if hemoglobin or MCV falls below normal. 1

Common Pitfalls to Avoid

• Do not delay iron replacement therapy while awaiting diagnostic workup unless colonoscopy is imminent. 1
• Do not assume normal IBC excludes iron deficiency—ferritin and transferrin saturation are more reliable markers. 1
• Do not use modified-release preparations—they are less suitable for prescribing due to unpredictable absorption. 1
• Failure to respond to oral iron is usually due to poor compliance, misdiagnosis, continued blood loss, or malabsorption—not inadequate dosing. 1