How to treat iron deficiency anemia with elevated TIBC and low serum iron?

Treatment of Iron Deficiency Anemia with TIBC 452 and Serum Iron 74

Start oral iron supplementation immediately with ferrous sulfate 200 mg once daily (65 mg elemental iron), taken on an empty stomach, and continue for 3 months after hemoglobin normalizes to replenish iron stores. 1

Interpretation of Your Lab Values

Your elevated TIBC (452 mg/dL, normal 250-370) and low serum iron (74 mg/dL, normal 50-175) confirm iron deficiency anemia. 1 The elevated TIBC indicates your body is producing more transferrin to capture whatever iron is available, which is a classic response to iron depletion. 1

Initial Treatment Approach

Oral Iron Therapy (First-Line)

• Start with ferrous sulfate 200 mg once daily (provides 65 mg elemental iron), taken in the fasting state 1
• Alternative formulations include ferrous fumarate or ferrous gluconate if ferrous sulfate is not tolerated 1
• Do not start with three-times-daily dosing - recent evidence shows once-daily dosing is equally effective with better tolerability 1, 2

Enhancing Absorption

• Add vitamin C (250-500 mg) with each iron dose to enhance absorption 1
• Take iron on an empty stomach (1 hour before or 2 hours after meals) for optimal absorption 1

If Side Effects Occur

• Switch to alternate-day dosing (one tablet every other day) - this maintains similar efficacy with significantly fewer gastrointestinal side effects 1
• Consider ferric maltol 30 mg twice daily as an alternative if traditional iron salts are not tolerated 1

Monitoring Response

• Check hemoglobin at 4 weeks - you should see at least a 10 g/L (1 g/dL) rise 1
• If no response after 4 weeks, consider non-compliance, continued blood loss, malabsorption, or switch to parenteral iron 1
• Continue oral iron for 3 months after hemoglobin normalizes to replenish iron stores 1

When to Use Intravenous Iron

Switch to IV iron if: 1

• Oral iron is not tolerated despite trying alternate-day dosing
• No hemoglobin response after 4 weeks of adequate oral therapy
• Severe symptomatic anemia requiring rapid correction
• Malabsorption conditions are present

Preferred IV formulations: Ferric carboxymaltose (1000 mg over 15 minutes) or iron sucrose (200 mg over 10 minutes) - these require only 1-2 infusions versus multiple doses 1

Follow-Up Schedule

• Hemoglobin check at 4 weeks to confirm response 1
• Once normalized, monitor every 3 months for the first year, then annually 1
• If hemoglobin or MCV drops again, restart iron supplementation and check ferritin 1

Critical Pitfalls to Avoid

• Do not use three-times-daily dosing initially - this increases side effects without improving efficacy and reduces compliance 1, 2
• Do not stop iron when hemoglobin normalizes - continue for 3 months to replenish stores 1
• Do not check ferritin immediately after IV iron - wait 8-10 weeks as levels are falsely elevated 1
• Do not give iron supplementation if ferritin is normal or high - this is potentially harmful 1

Investigation for Underlying Cause

While treating with iron, investigate the source of iron loss: 1

• Upper endoscopy with duodenal biopsies (to exclude celiac disease)
• Colonoscopy or CT colonography
• Consider menstrual history in premenopausal women
• Test for H. pylori if gastritis is found 1