How should an adult patient with acute ulcerative colitis and iron deficiency anemia, presenting with a mildly elevated blood glucose level, be managed?

Management of Ulcerative Colitis with Iron Deficiency Anemia and Mildly Elevated Blood Glucose

A blood glucose of 111 mg/dL is minimally elevated and does not alter the management of your ulcerative colitis or iron deficiency anemia—focus immediately on treating the anemia with intravenous iron as first-line therapy given the active inflammatory bowel disease. 1

Prioritize the Anemia Management

The mildly elevated glucose (111 mg/dL, just above the normal fasting threshold of 100-110 mg/dL) is clinically insignificant in this acute context and should not distract from addressing the iron deficiency anemia, which directly impacts your quality of life through fatigue and delays recovery from ulcerative colitis. 1

Iron Replacement Strategy

Initiate intravenous iron immediately rather than oral iron. 1

• Intravenous iron is the standard of care for patients with active ulcerative colitis and iron deficiency anemia because systemic inflammation inhibits iron absorption through elevated hepcidin levels. 1

• Oral iron should be avoided in active disease as more than 90% remains unabsorbed, frequently causes gastrointestinal adverse effects (nausea, flatulence, diarrhea), and can potentially exacerbate IBD through generation of reactive oxygen species. 1

• If oral iron must be used in inactive disease, limit to no more than 100 mg elemental iron daily, preferably given once daily or on alternate days to improve absorption. 1

• IV iron delivers faster response rates (hemoglobin increase of 2.2 g/dL at 1 month versus 1.4 g/dL with oral iron) and is safer in all but very few patients. 1, 2

Specific Indications for IV Iron in Your Case

You meet multiple criteria for intravenous iron therapy: 1

• Active ulcerative colitis with pronounced disease activity
• Moderate anemia if hemoglobin is <10 g/dL (100 g/L)
• Intolerance or insufficient response to oral iron (if previously attempted)

Interpreting Iron Studies in Inflammatory States

Ferritin levels up to 100 μg/L in the presence of inflammation may still reflect iron deficiency, so do not be falsely reassured by "normal" ferritin in the 30-100 range. 1

• Measure transferrin saturation to help confirm iron deficiency—levels <20% support the diagnosis. 1

• Target iron parameters after treatment: transferrin saturation 30-40% and ferritin 200-500 μg/L. 1

Control the Underlying Inflammation

Optimizing your ulcerative colitis therapy to achieve remission is equally critical, as chronic inflammation is frequently the key driver of anemia in IBD. 3, 4

• Controlling inflammation improves iron absorption and utilization, making iron replacement more effective. 1, 4

• Recurrent anemia despite iron therapy may indicate persistent intestinal inflammatory activity even with normal inflammatory biomarkers. 1

When to Consider Additional Therapies

Erythropoietic therapy (ESA) should be considered only if anemia does not improve despite intravenous iron therapy and control of inflammation. 1, 3

• ESA therapy must always be combined with intravenous iron supplementation to prevent functional iron deficiency. 1, 3

• Target hemoglobin with ESA is 11-13 g/dL, as higher levels increase thrombosis risk (already elevated in ulcerative colitis). 1

• ESA is a risk factor for thrombosis, a common complication particularly in UC. 1

Blood Transfusion Criteria

Blood transfusion should be restricted to very specific situations: acute severe anemia with hemodynamic instability, severe anemia-related weakness and fatigue, or failure of all other treatments. 1, 3

Monitoring Strategy

• Recheck complete blood count in 4 weeks to assess response to IV iron therapy. 3

• Monitor for recurrent iron deficiency every 3 months for at least a year after correction, then periodically thereafter. 1

• Check hemoglobin every 6 months in patients with mild disease activity. 3

• Measure vitamin B12 and folate at least annually or if macrocytosis develops, as these deficiencies can contribute to anemia in IBD. 1, 3

Addressing the Mildly Elevated Glucose

The blood glucose of 111 mg/dL warrants only basic follow-up, not urgent intervention:

• Repeat fasting glucose or obtain HbA1c to determine if this represents prediabetes (fasting glucose 100-125 mg/dL) or is an isolated finding.

• Corticosteroid use for ulcerative colitis can elevate glucose—if you are on steroids, this may explain the mild elevation.

• Standard lifestyle modifications (diet, exercise) are appropriate if prediabetes is confirmed, but this does not change your IBD or anemia management.

Common Pitfalls to Avoid

• Do not use oral iron if you have active disease—hepcidin elevation blocks absorption, making it ineffective and potentially harmful. 1, 3

• Do not delay IV iron while attempting oral iron trials—this prolongs anemia-related fatigue and delays recovery. 1

• Do not assume normal ferritin excludes iron deficiency in the setting of inflammation—use transferrin saturation to clarify. 1

• Do not ignore the need for ongoing monitoring, as anemia recurrence is common in IBD (seen in more than half of UC patients even in remission). 1, 2