What is the best management approach for a patient with iron deficiency anemia (hemoglobin of 8.6, iron saturation of 20.59%) and an unspecified eye condition?

Management of Severe Iron Deficiency Anemia

This patient requires immediate hospitalization or urgent hematology consultation for consideration of blood transfusion, followed by aggressive iron replacement and mandatory bidirectional endoscopy to identify the source of gastrointestinal blood loss. 1

Immediate Assessment and Stabilization

A hemoglobin of 8.6 g/dL with iron saturation of 20.59% represents significant iron deficiency anemia that warrants urgent investigation and treatment. 2

Transfusion Consideration

• Men with hemoglobin <12 g/dL should be investigated more urgently, as lower hemoglobin levels suggest more serious underlying disease. 2
• While this patient's hemoglobin of 8.6 g/dL may not absolutely require transfusion if asymptomatic and stable, the threshold for transfusion should be individualized based on symptoms (dyspnea, chest pain, severe fatigue, cardiovascular instability). 2
• Reserve transfusions primarily for patients with severe anemia symptoms requiring rapid hemoglobin improvement, targeting 7-8 g/dL in stable, non-cardiac patients. 2

Mandatory Gastrointestinal Investigation

All adult men and postmenopausal women with iron deficiency anemia must undergo bidirectional endoscopy (both upper endoscopy and colonoscopy) to exclude gastrointestinal malignancy. 2, 1

Upper Endoscopy Requirements

• Perform upper endoscopy with duodenal biopsies to screen for celiac disease, even if celiac serology (tissue transglutaminase antibody) is negative, unless there are no other features suggesting celiac disease. 2
• The pretest probability of celiac disease in iron deficiency anemia alone is approximately 5%. 2
• Upper endoscopy also evaluates for gastric cancer, peptic ulcer disease, and angiodysplasia. 1

Lower Endoscopy Requirements

• Colonoscopy is mandatory to exclude colorectal cancer and polyps, which are the most common causes of occult gastrointestinal blood loss in this population. 1
• Dual pathology (bleeding sources in both upper and lower GI tracts) occurs in 1-10% of patients and should be increasingly considered with advancing age. 2

Iron Replacement Protocol

First-Line Oral Iron Therapy

Start ferrous sulfate 324 mg (65 mg elemental iron) three times daily on an empty stomach. 1, 3

• Add vitamin C 500 mg with each iron dose to enhance absorption. 1
• Continue iron therapy for 3 months after hemoglobin normalizes to replenish body iron stores. 1
• Recheck CBC in 3-4 weeks to confirm hemoglobin rise of ≥2 g/dL, which indicates adequate response. 1, 4

Alternative: Intravenous Iron Indications

Consider intravenous iron if: 5

• Oral iron intolerance develops
• Poor absorption is suspected (celiac disease, post-bariatric surgery)
• Chronic inflammatory conditions are present
• Ongoing blood loss continues
• No response to oral iron after 4 weeks

Critical Medication Review

Explicitly ask about and immediately discontinue all NSAIDs (including over-the-counter ibuprofen, naproxen, aspirin), as these are common and often unreported causes of gastrointestinal blood loss. 2, 1

Monitoring Strategy

• Recheck CBC every 3-4 weeks initially until hemoglobin normalizes. 1, 4
• Monitor CBC and MCV every 3 months for 1 year after normalization. 1
• Recheck ferritin after 3 months of continued iron therapy to confirm store repletion, targeting >50 ng/mL. 1
• Recheck at 2 years to ensure no recurrence. 1

Common Pitfalls to Avoid

• Do not delay endoscopic evaluation while treating with iron—investigation must proceed regardless of response to iron therapy. 2
• Do not assume dietary insufficiency alone in adult men; gastrointestinal blood loss is the most common cause and must be excluded. 2
• Do not stop investigation after finding one source of bleeding; dual pathology is common enough to warrant complete bidirectional evaluation. 2
• Do not use intramuscular iron injections—there is no role for this route of administration. 6