What is the appropriate management for a patient with iron deficiency anemia?

Management of Iron Deficiency Anemia

Start oral ferrous sulfate 200 mg three times daily immediately and continue for three months after hemoglobin normalizes to replenish iron stores. 1, 2

Immediate Treatment

Your lab values confirm iron deficiency anemia (hemoglobin 9.7 g/dL, ferritin 10 ng/mL, low iron 15 μg/dL, elevated TIBC 458 μg/dL), requiring prompt iron supplementation regardless of the underlying cause. 1, 2

First-Line Oral Iron Therapy

• Ferrous sulfate 200 mg three times daily is the gold standard treatment - it is the simplest, most effective, and least expensive option. 1, 2
• Alternative formulations include ferrous gluconate or ferrous fumarate if ferrous sulfate is not tolerated, as they are equally effective. 1
• Consider adding ascorbic acid (vitamin C) to enhance iron absorption if response is poor. 1, 2
• Expect hemoglobin to rise by approximately 2 g/dL after 3-4 weeks of treatment. 1, 2
• Continue treatment for three months after hemoglobin normalization to adequately replenish iron stores. 1, 2

When to Use Intravenous Iron

Reserve parenteral iron only for: 1, 2

• Intolerance to at least two different oral iron preparations
• Malabsorption conditions (celiac disease, post-bariatric surgery, inflammatory bowel disease)
• Non-compliance with oral therapy
• Need for rapid correction before surgery

Important caveat: Parenteral iron carries risks of anaphylactic reactions, is more expensive, and provides no faster hemoglobin rise than oral preparations. 1, 2

Investigation of Underlying Cause

The elevated platelet count (464) suggests reactive thrombocytosis from chronic blood loss, making source identification critical. 3

Age-Based Investigation Strategy

If patient is ≥45 years old or male of any age: 1, 2

• Perform bidirectional endoscopy (upper endoscopy AND colonoscopy) to exclude gastrointestinal malignancy
• Upper GI cancer is 1/7 as common as colon cancer in iron deficiency anemia. 4
• Screen for celiac disease with tissue transglutaminase antibody (IgA) and total IgA level. 4

If premenopausal woman <45 years old: 1, 2

• Screen for celiac disease with antiendomysial antibody and IgA measurement. 1
• Evaluate for menorrhagia, pregnancy, or breastfeeding as likely causes. 1, 2
• Perform endoscopy only if: upper GI symptoms present, family history of colorectal cancer, or persistent anemia after iron supplementation. 2

Additional Considerations

• Exclude urinary tract bleeding by checking for hematuria. 1
• Review medications for NSAIDs or anticoagulants causing occult bleeding. 3
• Avoid faecal occult blood testing - it is insensitive and non-specific with no diagnostic value. 1

Monitoring and Follow-Up

Short-Term Monitoring

• Recheck hemoglobin after 3-4 weeks to confirm 2 g/dL rise. 1, 2
• If hemoglobin fails to rise appropriately, consider: 1, 2
  • Poor compliance (most common cause)
  • Misdiagnosis
  • Continued blood loss
  • Malabsorption

Long-Term Monitoring

• Monitor hemoglobin and red cell indices every three months for one year after normalization. 1, 2
• Recheck once more after another year. 1, 2
• Add oral iron if hemoglobin or MCV falls below normal (check ferritin in doubtful cases). 1
• Further investigation is only necessary if hemoglobin cannot be maintained with supplementation. 1

Common Pitfalls to Avoid

• Stopping iron therapy when hemoglobin normalizes - this fails to replenish stores and leads to recurrence. 1, 2
• Not investigating the underlying cause in patients ≥45 years - this can miss gastrointestinal malignancy. 2
• Switching to parenteral iron prematurely - try at least two different oral formulations first. 1, 2
• Discontinuing therapy due to GI side effects without trying alternative oral formulations or alternate-day dosing. 2, 5