Treatment of Low Hemoglobin (Hypochromic Anemia)
For hypochromic anemia, oral iron supplementation with ferrous salts (ferrous sulfate, ferrous fumarate, or ferrous gluconate) at 100-200 mg elemental iron daily is the first-line treatment, with continuation for 3 months after hemoglobin normalization to replenish iron stores. 1
Initial Assessment and Iron Therapy
Oral Iron Supplementation (First-Line)
- Start with ferrous sulfate 200 mg three times daily, ferrous fumarate 200 mg three times daily, or ferrous gluconate as equivalent alternatives 1
- For symptom-free patients with mild anemia, 100 mg ferrous fumarate once daily is sufficient 2
- For severe anemia or symptomatic patients, prescribe 200 mg/day 2
- Continue iron therapy for 3 months after hemoglobin correction to replenish iron stores 1
Dosing Strategies to Improve Tolerance
- If gastrointestinal side effects occur, switch to alternate-day dosing (every other day) rather than stopping treatment 2
- Single daily dosing (40 mg elemental iron) is as effective as three-times-daily dosing for treating anemia 3
- Thrice-weekly dosing (200 mg ferrous fumarate) is non-inferior to thrice-daily dosing with fewer adverse effects 4
- Adding ascorbic acid (250-500 mg twice daily) may enhance iron absorption, though evidence for effectiveness in IDA treatment is limited 1
When to Use Intravenous Iron
Intravenous iron is indicated when: 1
- Oral iron is not tolerated despite dosing adjustments
- Oral iron fails to correct anemia after adequate trial
- Rapid hemoglobin increase is medically necessary
- Patient has severe anemia requiring urgent correction
- Specific conditions exist: dialysis-dependent renal insufficiency, heart failure, or active inflammatory bowel disease 2
IV Iron Options
Three preparations are available 1:
- Iron dextran (Cosmofer): 20 mg/kg maximum single dose over 6 hours
- Iron sucrose (Venofer): 200 mg over 10 minutes (bolus dosing licensed)
- Ferric carboxymaltose (Ferinject): 1000 mg over 15 minutes
Important caveat: Anaphylaxis may occur with IV iron; resuscitation facilities must be available 1. Iron dextran has the highest risk with serious reactions in 0.6-0.7% of patients 1.
Special Populations
Chronic Kidney Disease Patients
- When prescribing iron therapy, balance benefits of avoiding transfusions and ESA therapy against risks of anaphylactoid reactions 1
- Use ESA therapy with great caution in patients with active malignancy, history of stroke, or history of malignancy 1
- For CKD non-dialysis patients with hemoglobin <10.0 g/dL, individualize the decision to initiate ESA therapy based on rate of hemoglobin fall, prior iron response, transfusion risk, and anemia symptoms 1
- Maintain serum ferritin >100 ng/mL and transferrin saturation >20% during ESA therapy 1
Cancer Patients on Chemotherapy
- ESAs may be considered when hemoglobin ≤10 g/dL to increase hemoglobin by <2 g/dL or prevent further decline 1
- Do not use ESAs in cancer patients not receiving chemotherapy due to increased risk of death 1
- Discontinue ESA therapy if hemoglobin increase is <1 g/dL after 8-9 weeks 1
Heart Disease Patients
- Do not use ESAs in patients with mild to moderate anemia and heart failure or coronary heart disease—harms outweigh benefits 1
- Use restrictive transfusion strategy (trigger hemoglobin 7-8 g/dL) in hospitalized patients with coronary heart disease 1
Monitoring
- Check hemoglobin and red cell indices 3 monthly for 1 year, then after another year 1
- Give additional oral iron if hemoglobin or MCV falls below normal 1
- Further investigation is only necessary if hemoglobin cannot be maintained with iron supplementation 1
Common Pitfalls to Avoid
- Do not perform faecal occult blood testing—it is insensitive and non-specific 1
- Do not use intravenous route for vitamin B12—almost all will be lost in urine 5
- Avoid iron supplementation in hemochromatosis patients; avoid iron-fortified foods where possible 1
- Do not continue ESA therapy beyond 6-8 weeks without response 1