Can celiac disease present with iron deficiency anemia that is poorly responsive to oral iron supplementation?

From the Guidelines

Celiac disease can indeed present with iron deficiency anemia that is poorly responsive to oral iron supplementation, and a strict gluten-free diet is essential for improving iron absorption. This is a common extra-intestinal manifestation of celiac disease, occurring because the autoimmune damage to the small intestinal mucosa impairs absorption of iron from the diet and supplements, as noted in a recent expert review 1. When a patient has persistent iron deficiency anemia despite adequate oral iron therapy, celiac disease should be considered as a potential underlying cause. The diagnosis requires serological testing for tissue transglutaminase antibodies and anti-endomysial antibodies, followed by duodenal biopsy for confirmation.

Treatment involves strict adherence to a gluten-free diet, which allows the intestinal mucosa to heal and improves iron absorption, as recommended in a recent clinical practice update 1. During the healing phase, patients may require parenteral iron supplementation to correct severe anemia. Key considerations in management include:

• Ensuring adherence to a gluten-free diet to improve iron absorption
• Considering oral iron supplementation based on the severity of iron deficiency and patient tolerance
• Using intravenous iron therapy if iron stores do not improve with oral iron and a gluten-free diet, as suggested in the best practice advice 1 Once the intestinal lining recovers, which typically takes 6-12 months on a gluten-free diet, normal iron absorption usually resumes and anemia resolves. Other nutrient deficiencies like folate, vitamin B12, zinc, and vitamin D may also be present and require supplementation. It's crucial to evaluate and address these deficiencies to optimize patient outcomes, as emphasized in the context of managing iron deficiency anemia in patients with celiac disease 1.

From the Research

Coeliac Disease and Iron Deficiency Anemia

• Coeliac disease (CD) can present with iron deficiency anemia (IDA) that is poorly responsive to oral iron supplementation 2, 3.
• The iron absorption process is mainly impaired in the proximal duodenum, which is typically destroyed in CD, resulting in reduced iron absorption and subsequent IDA 2.
• The primary treatment of CD is a gluten-free diet (GFD), which is associated with adequate management of IDA, but iron replacement treatment may be necessary in some cases 2, 4.

Poor Response to Oral Iron

• Oral iron supplementation may have limited absorption in patients with active CD and unpredictable absorption in patients on a GFD 2.
• Poor tolerability of oral iron supplements is frequent in patients with CD or other inflammatory bowel diseases 2.
• Factors that predict a poor response to oral iron include severity of histological damage, poor adherence to GFD, and blood loss due to mucosal lesions 3.

Alternative Treatment Approaches

• A strict GFD can lead to an increase in serum iron, resolution of anemia, and restitution of normal mucosal morphology in patients with CD and IDA 4.
• A high-iron dietary intervention may be effective in women with CD and iron deficiency without anemia, but its efficacy is lower compared to oral iron supplementation with ferrous sulfate 5.
• Intravenous iron supplementation may be considered in patients with CD and IDA who do not respond to oral iron therapy or have severe iron deficiency 3, 6.