How to treat mild anemia with iron deficiency?

Treatment of Mild Anemia with Normal Iron Studies

Start oral ferrous sulfate 200 mg (65 mg elemental iron) once daily in the morning on an empty stomach, and continue for 3 months after hemoglobin normalizes to replenish iron stores. 1, 2

Why This Patient Needs Treatment Despite "Normal" Iron Saturation

Your iron saturation of 41% and serum iron of 73 may appear normal, but ferritin of 508 ng/mL with hemoglobin of 10.5 g/dL indicates anemia of chronic disease or inflammation, not simple iron deficiency. 1 However, the treatment approach remains iron supplementation because:

• Hemoglobin 10.5 g/dL meets criteria for mild anemia (normal for women is ≥12 g/dL, for men ≥13 g/dL) 3, 1
• TIBC of 178 is low (normal 250-450), suggesting inflammation or chronic disease rather than true iron deficiency 1
• The elevated ferritin (508) is likely an acute phase reactant, not a reflection of adequate iron stores 1

Specific Oral Iron Regimen

Ferrous sulfate 200 mg (containing 65 mg elemental iron) once daily in the morning 1, 2, 4

• Take on an empty stomach for optimal absorption, though taking with food is acceptable if gastrointestinal side effects occur 2
• Add vitamin C 500 mg with the iron dose to enhance absorption 2
• Do not take multiple times daily – once-daily dosing improves tolerability with similar or better efficacy because iron doses ≥60 mg stimulate hepcidin elevation that persists 24 hours and blocks subsequent iron absorption 2, 5
• If side effects occur, switch to alternate-day dosing (same 200 mg dose but every other day), which maximizes fractional absorption while reducing gut irritation 5

Expected Response and Monitoring

• Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks 2
• Recheck hemoglobin, ferritin, and complete blood count at 3 months 1
• Continue iron for 3 months after hemoglobin normalizes to fully replenish stores 1, 2

When to Reassess or Switch to IV Iron

If hemoglobin does not rise by 1 g/dL after 4 weeks despite adherence, reassess for: 3, 2

• Ongoing blood loss (especially gastrointestinal)
• Malabsorption syndromes (celiac disease, inflammatory bowel disease, post-bariatric surgery)
• Non-adherence to therapy
• Misdiagnosis (consider thalassemia trait in patients of African, Mediterranean, or Southeast Asian ancestry) 3

Switch to intravenous iron if: 3, 2

• Oral iron fails after 4 weeks of adherence
• Hemoglobin <10 g/dL with active inflammatory bowel disease
• Previous oral iron intolerance
• Malabsorption documented

Investigation for Underlying Cause

Your elevated ferritin (508) with low TIBC (178) suggests chronic inflammation or occult disease. 1 Consider:

• Gastrointestinal evaluation if you are male or postmenopausal female, as iron deficiency in these populations warrants bidirectional endoscopy to exclude malignancy 2, 6
• Celiac disease screening with tissue transglutaminase antibody if <45 years without upper GI symptoms 2, 6
• Inflammatory markers (CRP, ESR) to assess for chronic inflammatory conditions 6

Critical Pitfalls to Avoid

• Do not delay treatment because hemoglobin is "only mildly low" – mild anemia still impairs quality of life and requires correction 1
• Do not stop iron when hemoglobin normalizes – continue for 3 months to replenish stores 1, 2
• Do not prescribe iron multiple times daily – this increases side effects without improving absorption 2
• Do not fail to investigate the underlying cause while supplementing, especially with your elevated ferritin suggesting inflammation 1, 2
• Do not overlook vitamin C supplementation when oral iron response is suboptimal 2

Target Goals

• Hemoglobin: 12-13 g/dL (depending on sex) 1
• Ferritin: >100 ng/mL to adequately replenish stores and prevent rapid recurrence 1