Is aspirin recommended for patients with Iron Deficiency Anemia (IDA) and a normal platelet count?

Aspirin is NOT Recommended for Iron Deficiency Anemia with Normal Platelet Count

A platelet count of 15 lakhs (1,500,000/μL) is markedly elevated and represents thrombocytosis, not a normal count. In the context of iron deficiency anemia (IDA), this reactive thrombocytosis should be treated with iron supplementation first, not aspirin. 1

Understanding the Clinical Context

Your patient has two key findings that require careful interpretation:

• Iron deficiency anemia (IDA): The primary pathology requiring treatment
• Thrombocytosis (platelet count 1,500,000/μL): A reactive phenomenon secondary to IDA 1

Why Aspirin is Contraindicated in This Scenario

Aspirin Worsens Iron Deficiency

• Aspirin itself causes iron deficiency anemia through occult gastrointestinal blood loss and should be discontinued whenever possible in patients with IDA 2, 3
• Low-dose aspirin (100 mg daily) increases the incidence of anemia by 20% in healthy elderly adults (hazard ratio 1.20) and causes greater decline in ferritin levels by 11.5% compared to placebo 4
• Aspirin metabolites (salicyluric acid, salicylic acid, and dihydroxybenzoic acids) have iron-chelating properties that mobilize iron from body stores and increase iron excretion, exacerbating iron deficiency 5
• During history-taking for any patient with IDA, aspirin use should be specifically documented and stopped whenever possible 2, 3

Extreme Thrombocytosis Increases Bleeding Risk with Aspirin

• Aspirin is contraindicated in essential thrombocythemia patients with platelet counts >1,500,000/μL due to acquired von Willebrand factor deficiency, which creates a paradoxical bleeding diathesis 6
• At very high platelet counts, aspirin may unmask latent bleeding disorders and result in severe hemorrhagic complications 6

The Correct Treatment Approach

First-Line: Iron Supplementation

Iron replacement is the definitive treatment that addresses both the anemia and the reactive thrombocytosis simultaneously. 1

• All patients with IDA require iron supplementation to correct anemia and replenish body stores, regardless of platelet count 2
• Start with oral ferrous sulfate 200 mg twice daily (or lower doses if not tolerated) 2
• Continue oral iron for 3 months after iron deficiency is corrected to replenish stores 2

Expected Response to Iron Therapy

The thrombocytosis will resolve with iron treatment alone:

• 50% of IDA patients with thrombocytosis will have platelet counts normalize below 450,000/μL within 2 weeks of iron supplementation 1
• 100% of patients will have resolution of thrombocytosis within 6 weeks of iron treatment 1
• IDA patients with thrombocytosis show more severe anemia and more advanced iron deficiency than those without thrombocytosis 1

When to Consider Aspirin (Special Circumstances Only)

Aspirin has extremely limited indications in the IDA population:

• In cancer patients with thrombocytopenia and acute coronary syndrome: Aspirin as a single agent can be given if platelet count >10,000/μL, with careful risk-benefit assessment 2
• In MIS-C with Kawasaki-like features: Low-dose aspirin (3-5 mg/kg/day) is used when platelet count ≥450,000/μL, but should be avoided if platelet count ≤80,000/μL 2

Neither of these scenarios applies to your patient with IDA and reactive thrombocytosis.

Monitoring Strategy

• Increase follow-up frequency for IDA patients with thrombocytosis to monitor platelet count response and prevent potential thrombotic events 1
• Check hemoglobin and platelet count at 2-week intervals initially 1
• If thrombocytosis persists despite adequate iron repletion after 6-8 weeks, consider evaluation for a concomitant clonal myeloproliferative disorder 1
• Monitor hemoglobin at 3-month intervals for 1 year after normalization, then annually 2

Critical Pitfall to Avoid

Do not prescribe aspirin to "prevent thrombosis" in reactive thrombocytosis secondary to IDA. This approach:

• Worsens the underlying iron deficiency 5, 4
• Increases bleeding risk at extreme platelet counts 6
• Fails to address the root cause 2, 3
• Is unnecessary since iron therapy alone resolves the thrombocytosis 1