From the Guidelines
I strongly recommend initiating oral iron supplementation with ferrous sulfate 200 mg taken once daily between meals for this 38-year-old female with iron deficiency anemia, as it is the most cost-effective option with a reasonable elemental iron content of 65 mg per tablet, as shown in the British Society of Gastroenterology guidelines 1. The laboratory values clearly indicate iron deficiency with a low hemoglobin (9.6 g/dL), low MCV (79.3 fL) indicating microcytosis, low MCH (24.5 pg) showing hypochromia, very low ferritin (4 ng/mL), low serum iron (21 μg/dL), elevated TIBC (466 μg/dL), low iron saturation (5%), and elevated RDW (15.0%). For optimal absorption, the iron supplement should be taken with vitamin C (such as orange juice) to improve absorption, as recommended by the AGA clinical practice update on management of iron deficiency anemia 1. The iron supplement should also be separated from calcium-containing foods, dairy products, coffee, tea, and antacids by at least 2 hours. Common side effects include constipation, nausea, and black stools; starting with once-daily dosing and gradually increasing can improve tolerance. A stool softener may be added if constipation occurs. Treatment should continue for 3-6 months even after normalization of hemoglobin to replenish iron stores. Follow-up labs should be checked after 4-8 weeks to assess response, with expected improvements in hemoglobin by 1-2 g/dL per month. Additionally, investigating the underlying cause of iron deficiency is essential, with common etiologies including menstrual blood loss, pregnancy, gastrointestinal bleeding, malabsorption, or poor dietary intake. It is also important to note that the absence of an Hb rise of at least 10 g/L after 2 weeks of daily oral iron replacement therapy is strongly predictive of subsequent failure to achieve a sustained haematological response, and alternative treatments such as ferric maltol or parenteral iron may be considered in such cases 1.
From the FDA Drug Label
Following intravenous administration, Venofer is dissociated into iron and sucrose and the iron is transported as a complex with transferrin to target cells including erythroid precursor cells. In 22 patients undergoing hemodialysis and receiving erythropoietin (recombinant human erythropoietin) therapy treated with iron sucrose containing 100 mg of iron, three times weekly for three weeks, significant increases in serum iron and serum ferritin and significant decreases in total iron binding capacity occurred four weeks from the initiation of iron sucrose treatment.
The patient has iron deficiency anemia with a low ferritin level of 4, low iron level of 21, and low iron saturation of 5.
- The patient's hemoglobin level is 9.6, which is below the normal range.
- The patient's hematocrit level is 31.1, which is also below the normal range. Based on the drug label, intravenous iron may be an effective treatment for this patient. The studies show that intravenous iron can increase hemoglobin, serum ferritin, and serum transferrin saturation levels in patients with iron deficiency anemia 2, 2. However, the patient's specific condition and medical history should be taken into consideration before making a treatment decision.
From the Research
Patient Information
- Age: 38 years
- Sex: Female
- Hemoglobin (Hb): 9.6 g/dL
- Hematocrit (Hct): 31.1%
- Mean Corpuscular Volume (MCV): 79.3 fL
- Mean Corpuscular Hemoglobin (MCH): 24.5 pg
- Ferritin: 4 ng/mL
- Iron: 21 μg/dL
- Total Iron Binding Capacity (TIBC): 466 μg/dL
- Iron Saturation: 5%
- Red Cell Distribution Width (RDW): 15.0%
Diagnosis and Treatment
- The patient's laboratory results indicate iron-deficiency anemia, characterized by low hemoglobin, low ferritin, and low iron saturation 3.
- The first line of treatment for iron-deficiency anemia is oral iron supplementation, which is usually efficacious in correcting iron-deficiency anemia and replenishing iron stores 4, 5.
- Oral iron supplementation can cause gastrointestinal side effects, which may reduce compliance 4, 5.
- If oral iron supplementation is contraindicated or not tolerated, intravenous iron therapy can be used to rapidly achieve therapeutic targets without gastrointestinal complications 4, 6.
Treatment Options
- Ferrous sulfate is a commonly prescribed oral iron supplement, but other ferrous salts and ferric complexes can also be used 4.
- Intravenous iron formulations, such as iron dextran, iron derisomaltose, ferric carboxymaltose, and ferrumoxytol, can be used to correct total iron deficit in patients who cannot tolerate oral iron or require rapid correction of iron deficiency 6.
- The choice of iron therapy should be individualized based on the patient's specific needs and medical history 6.
Monitoring and Follow-up
- Hemoglobin response to oral iron therapy can be assessed at day 14, and a ≥1.0-g/dL increase in hemoglobin can predict satisfactory overall hemoglobin response to oral iron 7.
- Patients who do not respond to oral iron therapy may require transition to intravenous iron supplementation 7.
- Regular monitoring of laboratory results, including hemoglobin, ferritin, and iron saturation, is necessary to assess the effectiveness of iron therapy and adjust treatment as needed 3, 6.