What is the treatment for a female patient with Iron Deficiency Anemia (IDA) and a hemoglobin level of 10.9 g/dl?

Treatment of Iron Deficiency Anemia in a Female with Hemoglobin 10.9 g/dL

All patients with confirmed iron deficiency anemia should receive iron supplementation to both correct the anemia and replenish body iron stores, with oral iron as first-line therapy. 1

Immediate Management

Iron Supplementation

• Initiate oral iron therapy immediately with ferrous sulfate 325 mg daily (containing 65 mg elemental iron) or ferrous gluconate 324 mg three to four times daily (containing 38 mg elemental iron per dose). 2, 3, 4
• Alternatively, oral iron 100-200 mg elemental iron daily or alternate-day dosing (ferrous sulfate 325 mg every other day) can be used, as alternate-day dosing may improve tolerability while maintaining efficacy. 4
• Continue iron therapy for 2-3 months after hemoglobin normalizes to adequately replenish iron stores. 1

Expected Response

• Monitor hemoglobin after 4 weeks of treatment—expect an increase of at least 1 g/dL (or hematocrit increase of 3%) if the patient is compliant and has no acute illness. 1
• A good response to iron therapy (Hb rise ≥10 g/L within 2 weeks) confirms absolute iron deficiency even if initial iron studies were equivocal. 1

Investigation for Underlying Cause

Premenopausal Women Considerations

• Screen for coeliac disease with tissue transglutaminase (tTG) antibody testing in all premenopausal women with IDA. 1
• Assess menstrual blood loss as the most common cause of IDA in premenopausal women. 1
• Consider dietary history, focusing on iron-rich food intake and use of whole cow's milk (which can impair iron absorption). 4

When to Pursue GI Investigation

• Upper and lower GI endoscopy is NOT routinely required in premenopausal women with IDA if menstrual blood loss adequately explains the anemia. 1
• Consider GI investigation if there are GI symptoms, NSAID use, family history of GI malignancy, or if anemia fails to respond to iron therapy despite compliance. 1
• Urgent investigation is warranted if hemoglobin <10 g/dL in non-menstruating women, as lower hemoglobin suggests more serious underlying disease. 1

Alternative Iron Therapy

Parenteral Iron Indications

• Use intravenous iron when oral iron is not tolerated, in cases of malabsorption (coeliac disease, post-bariatric surgery), ongoing blood loss, or chronic inflammatory conditions. 1, 4
• IV iron is also indicated during second and third trimesters of pregnancy. 4
• Parenteral options include iron dextran, iron gluconate, or iron sucrose. 5

Common Pitfalls

Non-Response to Oral Iron

• If anemia does not respond after 4 weeks, evaluate for:
  • Non-compliance with iron supplementation 1
  • Ongoing blood loss exceeding iron replacement 4
  • Malabsorption (coeliac disease, atrophic gastritis, H. pylori infection) 1, 4
  • Incorrect diagnosis—consider thalassemia minor or sickle cell trait, particularly in women of African, Mediterranean, or Southeast Asian ancestry 1
  • Further testing should include MCV, RDW, serum ferritin, and consideration of hemoglobin electrophoresis. 1

Blood Transfusion

• Reserve blood transfusions only for patients with or at risk of cardiovascular instability due to the degree of anemia—not routinely indicated at Hb 10.9 g/dL unless symptomatic with cardiac compromise. 1

Monitoring During Treatment

• Recheck hemoglobin at 4 weeks, then every 3 months until normalized. 1
• Once hemoglobin normalizes, reduce iron dose to maintenance levels (30 mg elemental iron daily) if ongoing risk factors exist. 1