What is the appropriate treatment plan for a patient with iron deficiency and significant weight loss?

Sample Hematology Note: Iron Deficiency Anemia with Significant Weight Loss

Chief Complaint

Iron deficiency anemia with unintentional weight loss

History of Present Illness

[Age]-year-old [male/female] presenting with iron deficiency anemia (Hb: [value] g/dL, MCV: [value] fL, ferritin: [value] ng/mL) and [amount] weight loss over [timeframe]. Patient reports [fatigue, dyspnea, lightheadedness, pica, restless legs syndrome]. 1

Assessment

Iron Deficiency Anemia

• Hemoglobin: [value] g/dL (normal: M 13.5-17.5, F 12-16)
• MCV: [value] fL (microcytic if <80)
• Ferritin: [value] ng/mL (diagnostic threshold <30 ng/mL without inflammation) 1
• Transferrin saturation: [value]% (diagnostic if <20%) 1

Weight Loss Evaluation

The combination of iron deficiency anemia and significant weight loss mandates urgent investigation for gastrointestinal malignancy, malabsorption syndromes (particularly celiac disease), or chronic inflammatory conditions. 2

Diagnostic Plan

Age-Stratified Approach

For patients >45 years:

• Upper GI endoscopy with duodenal biopsies (to evaluate for celiac disease, H. pylori gastritis, gastric/duodenal pathology) 2
• Colonoscopy (to evaluate for colorectal malignancy, inflammatory bowel disease) 2
• Both procedures should be performed unless a definitive cause is identified with the first investigation 2

For patients <45 years:

• Upper GI endoscopy with small bowel biopsy if upper GI symptoms present 2
• Anti-endomysial antibody with IgA level (to exclude celiac disease; IgA measurement essential as IgA deficiency makes test unreliable) 2
• Colonoscopy only if specific indications present 2

Additional Testing

• H. pylori testing (via biopsy at endoscopy or separate testing if indicated) 2
• Stool for Giardia ELISA if diarrhea present 2
• Exclude hematuria (urinalysis) 2
• Inflammatory markers (CRP) to assess for inflammatory conditions 2

Treatment Plan

Iron Replacement Therapy

First-line: Oral Iron

• Ferrous sulfate 200 mg twice daily (British Society of Gastroenterology recommends lower doses may be as effective and better tolerated than traditional three-times-daily dosing) 2
• Alternative formulations if intolerance: ferrous gluconate, ferrous fumarate, or liquid preparations 2
• Continue for 3 months after correction of anemia to replenish iron stores 2
• Consider ascorbic acid 250-500 mg twice daily with iron to enhance absorption if response is poor 2

Expected Response:

• Hemoglobin should rise by 2 g/dL after 3-4 weeks 2
• Failure to respond indicates poor compliance, misdiagnosis, continued blood loss, or malabsorption 2

Indications for IV Iron:

• Intolerance to at least two oral preparations 2
• Malabsorption (confirmed celiac disease, post-bariatric surgery) 2, 1
• Active inflammatory bowel disease with compromised absorption 2
• Ongoing blood loss unresponsive to oral therapy 2
• Non-compliance with oral therapy 2

IV Iron Options (if indicated):

• Ferric carboxymaltose 1000 mg over 15 minutes (single dose for total body iron replacement) 2
• Iron sucrose 200 mg over 10 minutes (requires multiple doses) 2
• Iron dextran 20 mg/kg over 6 hours (requires resuscitation facilities available due to anaphylaxis risk) 2

Management of Underlying Cause

Treatment must address the source of iron loss or malabsorption to prevent recurrence. 2

For celiac disease: Strict gluten-free diet to improve iron absorption; consider oral iron supplementation based on severity and tolerance, followed by IV iron if stores do not improve 2

For inflammatory bowel disease: Treat active inflammation effectively to enhance iron absorption or reduce iron depletion; IV iron preferred with active inflammation and compromised absorption 2

For portal hypertensive gastropathy: Oral iron initially; IV iron if ongoing bleeding without response; consider nonselective β-blockers for portal hypertension management 2

For gastric antral vascular ectasia: Endoscopic therapy with band ligation or argon plasma coagulation if inadequate response to iron replacement 2

Follow-Up Plan

Monitoring Schedule

• Repeat CBC in 3-4 weeks to confirm hemoglobin rise of 2 g/dL 2
• Once normalized: monitor hemoglobin and red cell indices every 3 months for 1 year, then at 1 year 2
• Do not recheck ferritin for 8-10 weeks after IV iron (falsely elevated) 2

Failure to Respond

If hemoglobin/MCV cannot be maintained with supplementation, further investigation is necessary. 2 Consider:

• Compliance assessment
• Continued occult blood loss
• Malabsorption syndromes
• Alternative diagnoses

Target Outcomes

• Resolution of anemia by 6 months (achievable in 80% of patients) 2
• Restoration of hemoglobin, MCV to normal and replenishment of iron stores 2

Clinical Pitfalls to Avoid

• Do not perform fecal occult blood testing (insensitive and non-specific for iron deficiency anemia workup) 2
• Do not delay endoscopic evaluation in patients >45 years with unexplained iron deficiency anemia and weight loss (high risk for malignancy) 2
• Do not use parenteral iron as first-line unless specific indications present (oral iron equally effective for hemoglobin rise at 12 weeks) 2
• Do not stop iron supplementation when hemoglobin normalizes; continue for 3 months to replenish stores 2