What is the recommended treatment for a patient with confirmed iron deficiency, low-normal hemoglobin, and a history of fluctuating hemoglobin levels?

Treatment Recommendation for Confirmed Iron Deficiency

You should start oral iron supplementation immediately with ferrous sulfate 200 mg twice daily, continue for 3 months after your hemoglobin normalizes to replenish iron stores, and undergo investigation to identify the underlying cause of your declining ferritin levels. 1

Immediate Iron Supplementation

All patients with confirmed iron deficiency should receive iron supplementation to correct anemia and replenish body stores. 1 Your ferritin of 27 ng/mL confirms iron deficiency, and the progressive decline from 119.7 to 27 over several years indicates ongoing iron loss that requires both treatment and investigation. 2

Oral Iron Therapy - First Line

• Start with ferrous sulfate 200 mg twice daily (each 325 mg tablet contains 65 mg elemental iron). 1, 3 This is the most cost-effective and appropriate first-line treatment for your situation.

• Alternative formulations include ferrous gluconate or ferrous fumarate if you experience intolerance to ferrous sulfate. 1

• Lower doses may be equally effective and better tolerated - consider alternate-day dosing if gastrointestinal side effects occur. 1

• Add ascorbic acid (vitamin C) 250-500 mg twice daily with your iron tablets to enhance absorption, particularly if your response is suboptimal. 1

Expected Response and Duration

• Your hemoglobin should increase by 2 g/dL within 3-4 weeks of starting treatment. 1 This is the benchmark for adequate response.

• Continue iron supplementation for 3 months after your hemoglobin normalizes to fully replenish iron stores. 1

• Failure to achieve this response suggests poor compliance, continued blood loss, malabsorption, or misdiagnosis. 1

When to Consider Intravenous Iron

Intravenous iron is not indicated as first-line therapy in your case, but should be considered if: 1

• You develop intolerance to at least two different oral iron preparations
• You have documented malabsorption
• Your hemoglobin fails to rise appropriately despite compliance with oral therapy
• Evidence of ongoing significant blood loss emerges

Mandatory Investigation for Underlying Cause

Your progressive ferritin decline from 119.7 to 27 over several years mandates investigation for an underlying cause of iron loss. 1 The British Society of Gastroenterology guidelines are clear that iron deficiency in adults requires evaluation even without overt anemia.

Investigation Algorithm

The specific investigations needed depend on your age, sex, and symptoms:

• If you are a premenopausal woman: Heavy menstrual bleeding is the most common cause (affects 5-10% of menstruating women). 1 However, if you are over age 45, full gastrointestinal investigation is still recommended. 1

• If you are a man or postmenopausal woman: You require bidirectional endoscopy (upper endoscopy with small bowel biopsies for celiac disease AND colonoscopy) to exclude gastrointestinal blood loss and malignancy. 1, 4, 5 This is non-negotiable given your progressive iron depletion.

• Additional considerations: Review medications (NSAIDs, antacids), assess for dietary insufficiency, and consider testing for Helicobacter pylori if initial endoscopy is unrevealing. 1

Follow-Up Monitoring

Monitor your hemoglobin and red cell indices at specific intervals: 1

• Recheck hemoglobin after 3-4 weeks to confirm adequate response (should rise by 2 g/dL)
• Once normalized, monitor every 3 months for the first year, then annually 1
• Recheck ferritin if hemoglobin or MCV falls below normal during follow-up
• Resume oral iron supplementation if deficiency recurs

Critical Pitfalls to Avoid

• Do not accept "low-normal" hemoglobin as adequate - your goal is to normalize both hemoglobin AND iron stores (ferritin should reach at least 30 ng/mL). 1, 2

• Do not stop iron therapy when hemoglobin normalizes - continue for 3 months afterward to replenish stores. 1

• Do not skip investigation of the underlying cause - progressive ferritin decline indicates ongoing iron loss that will recur without identifying and treating the source. 1, 2

• Do not use enteric-coated or sustained-release preparations - they are poorly absorbed and ineffective. 6