What are the necessary steps to manage a patient with severe iron deficiency anemia, characterized by low iron saturation and ferritin levels, over the weekend before a scheduled iron infusion on Monday?

Management of Critical Iron Deficiency Over the Weekend

Start oral iron supplementation immediately this weekend with ferrous sulfate 325 mg daily (or 200 mg three times daily if tolerated), ensure the patient is hemodynamically stable, and assess for any symptoms requiring urgent intervention before Monday's scheduled IV iron infusion. 1, 2

Immediate Weekend Actions

Assess Clinical Stability

• Evaluate for symptoms of severe anemia including chest pain, dyspnea at rest, altered mental status, or hemodynamic instability (tachycardia, hypotension). 3
• If the patient has coronary artery disease or acute coronary syndrome, consider transfusion to maintain hemoglobin ≥10 g/dL rather than waiting until Monday. 4
• For hemodynamically stable patients without cardiac disease, a restrictive transfusion threshold of 7-8 g/dL is appropriate. 4, 3

Initiate Oral Iron Therapy

• Begin ferrous sulfate 325 mg daily immediately, even though IV iron is planned for Monday—this provides some iron availability and demonstrates your proactive management. 1, 2
• Alternative dosing of 200 mg three times daily can be used if the patient tolerates it, though weekend initiation makes once-daily more practical. 1
• Oral iron absorption is enhanced when taken on an empty stomach with 500 mg vitamin C, though taking with food is acceptable if better tolerated. 4

Rule Out Urgent Bleeding

• With iron saturation of 7% and ferritin of 9 ng/mL, this represents severe absolute iron deficiency that typically results from chronic blood loss. 4, 1, 2
• Assess for active gastrointestinal bleeding: check for melena, hematochezia, hematemesis, or orthostatic vital signs. 2, 5
• In menstruating women, assess for heavy menstrual bleeding as the likely source. 2
• If there are signs of active bleeding with hemodynamic compromise, transfusion should not wait until Monday. 4, 3

Why IV Iron on Monday is Appropriate

IV iron is clearly indicated here given the severity of deficiency (ferritin 9 ng/mL, iron saturation 7%), and the patient likely has either malabsorption, intolerance to oral iron, or ongoing blood loss that makes oral therapy insufficient. 1, 2, 3

Advantages of IV Iron in This Case

• Ferric carboxymaltose 1 gram over 15 minutes is a well-studied option that rapidly replenishes iron stores. 1
• IV iron bypasses gastrointestinal absorption issues and is superior to oral iron in severe deficiency states. 4
• Expected hemoglobin rise is approximately 2 g/dL after 3-4 weeks of adequate iron replacement. 1

Common Pitfalls to Avoid

Don't Delay Workup for Underlying Cause

• All adults with iron deficiency this severe require investigation for gastrointestinal blood loss, including upper endoscopy and colonoscopy (unless the patient is a menstruating woman with documented heavy periods). 1, 2
• In patients over 50 or with any alarm symptoms, colonoscopy should be prioritized as 9% of elderly patients with iron deficiency anemia have gastrointestinal cancer. 5

Recognize Ferritin as an Acute Phase Reactant

• A ferritin of 9 ng/mL definitively indicates depleted iron stores, but be aware that in inflammatory conditions, ferritin can be falsely elevated. 4
• In this case with ferritin of 9 ng/mL, there is no ambiguity—this is absolute iron deficiency. 1, 2

Plan for Adequate Duration of Treatment

• Continue iron supplementation for at least 3 months after hemoglobin normalizes to adequately replenish iron stores. 1
• Recheck hemoglobin and ferritin 8-10 weeks after starting treatment to assess response. 1

What NOT to Do This Weekend

• Do not transfuse unless the patient is symptomatic or hemodynamically unstable—with iron saturation of 7% and ferritin of 9 ng/mL, this is chronic iron deficiency, not acute blood loss requiring emergent transfusion. 4, 3
• Do not delay the hematology referral—your plan for Monday is appropriate and timely. 1
• Do not order unnecessary repeat labs this weekend—the critical values have already been identified and Monday's hematology visit will guide further management. 1