How should I manage a 15‑year‑old patient with thalassemia trait and iron deficiency anemia?

Management of a 15-Year-Old with Thalassemia Trait and Iron Deficiency

Treat the confirmed iron deficiency with oral iron supplementation at 60-120 mg elemental iron daily, because thalassemia trait does not preclude iron deficiency anemia and patients with thalassemia trait face the same risk of developing iron deficiency as the general population. 1

Confirm True Iron Deficiency

• Verify iron deficiency with serum ferritin < 15 μg/L, as this is the most specific indicator of depleted iron stores in adolescents 2
• Check mean corpuscular volume (MCV) and red cell distribution width (RDW) to distinguish iron deficiency from thalassemia trait alone 3, 2
• Iron deficiency anemia typically shows low MCV with elevated RDW (>14%), whereas thalassemia trait shows low MCV with normal RDW (≤14%) 3
• The presence of thalassemia trait does not exclude concurrent iron deficiency—approximately 7-9% of children with microcytic anemia have both conditions simultaneously 4

Critical Distinction: Thalassemia Trait vs. Iron Deficiency

• Thalassemia trait patients typically have an elevated red blood cell count despite microcytosis, whereas iron deficiency shows a low or normal red cell count 3
• Do not assume microcytic anemia in a patient with known thalassemia trait is solely due to the hemoglobinopathy—iron deficiency must be actively excluded 3, 4
• Patients with thalassemia trait are asymptomatic carriers but remain at the same risk for iron deficiency anemia as the general population 1

Treatment Protocol for Confirmed Iron Deficiency

• Prescribe 60-120 mg elemental iron daily (one to two 325 mg ferrous sulfate tablets, each containing 65 mg elemental iron) 2, 5, 6
• Administer iron on an empty stomach or between meals to maximize absorption, though it may be taken with food if gastrointestinal side effects occur 5
• Recommend vitamin C-rich foods or supplements with iron to enhance absorption 2, 5
• Provide dietary counseling emphasizing heme iron sources (meat, poultry, fish) which have 15-35% bioavailability compared to <10% for plant-based non-heme iron 2

Monitoring and Response Assessment

• Recheck hemoglobin after 4 weeks of iron therapy—an increase of ≥1 g/dL confirms iron deficiency anemia as the diagnosis 2, 5
• If hemoglobin rises appropriately, continue iron supplementation for an additional 2-3 months to replenish iron stores 2, 5
• Total treatment duration should be at least 3 months for confirmed iron deficiency anemia 5
• Reassess hemoglobin approximately 6 months after treatment completion 2

Management of Non-Response to Iron Therapy

• If hemoglobin does not increase by ≥1 g/dL after 4 weeks, obtain additional testing including MCV, RDW, and repeat serum ferritin 2, 5
• Non-response suggests the anemia is due to thalassemia trait alone, not iron deficiency, or there is poor compliance with iron therapy 3
• Consider hematology consultation if the diagnosis remains unclear after this workup 2

Key Pitfalls to Avoid

• Never withhold iron therapy from a patient with thalassemia trait who has documented iron deficiency—they require treatment just like any other patient with iron deficiency 1
• Do not discontinue iron as soon as hemoglobin normalizes; stores must be replenished over 2-3 additional months 2, 5
• Do not assume all microcytic anemia in thalassemia trait patients is due to the hemoglobinopathy—parallel investigation for iron deficiency is essential 4
• Thalassemia trait patients do not require iron chelation therapy (that is reserved for transfusion-dependent thalassemia major) 1, 7

Ongoing Screening Considerations

• Assess for risk factors including heavy menstrual bleeding (if female), low dietary iron intake, or restrictive diets 2
• Consider annual screening if ongoing risk factors are present 2