What is the best course of action for a female patient of childbearing age with rheumatoid arthritis and chronic anemia, presenting with dizziness, weakness, and exhaustion, and laboratory results indicating iron deficiency anemia, who is currently taking liquid iron twice daily with vitamin C, vitamin D, and a prenatal vitamin?

Management of Iron Deficiency Anemia in a Woman of Childbearing Age with Rheumatoid Arthritis

This patient requires immediate escalation of oral iron therapy to 60-120 mg of elemental iron daily (taken between meals without food to maximize absorption), with reassessment of hemoglobin in 4 weeks, and if no response occurs despite confirmed compliance, transition to intravenous iron therapy while investigating for gastrointestinal blood loss and coeliac disease. 1, 2

Critical Laboratory Interpretation

The patient's labs confirm severe iron deficiency anemia requiring urgent intervention:

• Ferritin 2.5 ng/mL indicates depleted iron stores (normal >15 ng/mL) 1
• MCV 78.8 fL and MCH 25.6 pg demonstrate microcytic, hypochromic anemia consistent with iron deficiency 1
• Hematocrit 35.4% with symptomatic anemia (dizziness, weakness, exhaustion) warrants aggressive treatment 1

Important caveat: In rheumatoid arthritis, ferritin can behave as an acute phase reactant and may be falsely elevated, meaning this patient's ferritin of 2.5 is unequivocally low even accounting for inflammatory disease 3, 4. The microcytic indices confirm true iron deficiency rather than anemia of chronic disease alone.

Immediate Treatment Protocol

Optimize Current Oral Iron Regimen

The patient is already taking liquid iron twice daily, but the current approach needs modification:

• Increase to therapeutic dosing: 60-120 mg elemental iron daily 1, 2
• Take between meals on an empty stomach to maximize absorption, as food significantly reduces iron uptake 2
• Continue vitamin C co-administration as it enhances absorption, though the patient is already doing this correctly 2
• Discontinue the prenatal vitamin temporarily or take it at a different time of day, as it may contain calcium or other minerals that interfere with iron absorption 5

Expected Response and Monitoring

• Recheck hemoglobin/hematocrit in 4 weeks expecting an increase of ≥1 g/dL hemoglobin or ≥3% hematocrit 1, 2
• Continue iron supplementation for 2-3 additional months after hemoglobin normalizes to replenish iron stores 1
• Monthly monitoring throughout treatment is essential given the severity of anemia and rheumatoid arthritis 6

When Oral Iron Fails

If hemoglobin does not increase by ≥1 g/dL after 4 weeks despite confirmed compliance and absence of acute illness, perform additional testing:

• MCV, RDW, and repeat serum ferritin to confirm iron deficiency versus other causes 1, 2
• Screen for coeliac disease with coeliac serology, as malabsorption is a common cause of refractory iron deficiency 1, 2
• Consider thalassemia trait if appropriate ethnic background (African, Mediterranean, Southeast Asian ancestry) 1

Transition to intravenous iron if the patient:

• Fails oral therapy after 4 weeks with confirmed compliance 2
• Cannot tolerate oral preparations due to gastrointestinal side effects 2, 5
• Requires rapid correction given symptom severity 2

Intravenous iron saccharate administered in fractionated doses is highly effective and safe in rheumatoid arthritis patients with severe anemia, with significant hemoglobin improvements sustained over 1 year without disease flare 7.

Investigate Underlying Causes

All women of childbearing age with confirmed iron deficiency anemia should be screened for coeliac disease regardless of gastrointestinal symptoms 1, 2. This is particularly important if oral iron fails to correct the anemia.

Consider gastrointestinal investigation if:

• Anemia persists despite adequate iron replacement 1
• There is a family history of gastrointestinal malignancy 1
• The patient has symptoms suggesting GI blood loss 1

Do not attribute iron deficiency solely to rheumatoid arthritis or NSAIDs without completing appropriate investigations, as these do not reduce the likelihood of underlying pathology 2.

Address Rheumatoid Arthritis-Specific Factors

The anemia in rheumatoid arthritis is multifactorial, involving both true iron deficiency and anemia of chronic disease 7, 3, 4:

• Optimize rheumatoid arthritis disease control as active inflammation suppresses erythropoiesis and impairs iron utilization 3, 4
• Iron supplementation is still indicated even with active RA, as this patient has documented iron deficiency (ferritin 2.5) 7, 4
• Intravenous iron is particularly effective in RA patients with severe anemia, especially those with depleted bone marrow iron stores 7

Common Pitfalls to Avoid

• Do not assume the patient is taking the iron correctly: Verify timing (between meals), dosing, and actual compliance, as gastrointestinal side effects frequently lead to discontinuation 2, 5
• Do not delay treatment waiting for dietary modification alone: The severity of anemia (hematocrit 35.4%) and symptomatic presentation require immediate pharmacologic intervention 6
• Do not ignore the transfusion history: Chronic anemia requiring transfusions suggests either inadequate previous treatment, ongoing blood loss, or malabsorption that must be identified 1
• Do not overlook medication interactions: Iron should be taken at least 2 hours apart from antibiotics and other medications that interfere with absorption 5

Quality of Life Considerations

The patient's symptoms (dizziness, weakness, exhaustion, nodding off throughout the day) significantly impair daily functioning and quality of life. Aggressive correction of anemia will directly improve these symptoms and reduce morbidity 8, 9. In women of childbearing age, untreated iron deficiency also increases risks during future pregnancies, including preterm delivery and low birthweight 6.