eMedicine Specialties > Hematology > Red Blood Cells and Disorders
Iron Deficiency Anemia: Treatment & Medication
Updated: Aug 4, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
Medical care consists of establishing the diagnosis and reason for the iron deficiency. In most patients, the iron deficiency should be treated with oral iron therapy, and the underlying etiology should be corrected so the deficiency does not recur.
Surgical Care
Surgical treatment consists of stopping hemorrhage and correcting the underlying defect so that it does not recur. This may involve surgery for treatment of either neoplastic or nonneoplastic disease of the gastrointestinal tract, the genitourinary tract, the uterus, and the lungs.
Consultations
- Surgical consultation often is needed for the control of hemorrhage and treatment of the underlying disorder. In the investigation of a source of bleeding, consultation with certain medical specialties may be useful to identify the source of bleeding and to provide control.
- Gastroenterology consultation is the most frequently sought consult among the medical specialties. Endoscopy has become a highly effective tool in identifying and controlling gastrointestinal bleeding. If bleeding is brisk, angiographic techniques may be useful in identifying the bleeding site and controlling the hemorrhage. Radioactive technetium labeling of autologous erythrocytes also is used to identify the site of bleeding. Unfortunately, these radiographic techniques do not detect bleeding at rates less than 1 mL/min and may miss lesions with intermittent bleeding.
Diet
- On a worldwide basis, diet is the major cause of iron deficiency. To suggest that iron-deficient populations correct the problem by the addition of significant quantities of meat to their diet is unrealistic. The addition of nonheme iron to national diets is initiated in some areas of the world. Problems encountered in these enterprises include changes in taste and appearance of food after the addition of iron and the need to supplement foodstuffs that are consumed by most of the population in predictable quantities. In addition, many dietary staples, such as bread, contain iron chelators that markedly diminish the absorption of the iron supplement (phosphates, phytates, carbonates, oxalates, tannates).
- In North America and Europe, persons on an iron-poor diet need to be identified and counseled on an individual basis. Educate older individuals on a tea and toast diet about the importance of improving their diet, and place them in contact with community agencies that will provide them with at least 1 nutritious meal daily. Patients who have dietary-related iron deficiency due to pica need to be identified and counseled to stop their consumption of clay and laundry starch.
Activity
Restriction of activity is usually not required.
- Patients with moderately severe iron deficiency anemia and significant cardiopulmonary disease should limit their activities until the anemia is corrected with iron therapy.
- If these patients become hypoxic or develop evidence of coronary insufficiency, they should be hospitalized and placed at bed rest until improvement of their anemia cells can be accomplished by transfusion of packed red blood.
- Obviously, these decisions need to be made on an individual basis and differ somewhat depending upon the severity of the anemia and the comorbid conditions.
- March hemoglobinuria can produce iron deficiency, and its treatment requires modification of activity. Cessation of jogging or wearing sneakers while running usually diminishes the hemoglobinuria.
Medication
The most economical and effective medication in the treatment of iron deficiency anemia is the oral administration of ferrous iron salts. Among the various iron salts, ferrous sulfate most commonly is used. Claims are made that other iron salts are absorbed better and have less morbidity. Generally, the toxicity is proportional to the amount of iron available for absorption. If the quantity of iron in the test dose is decreased, the percentage of the test dose absorbed is increased, but the quantity of iron absorbed is diminished. There are advocates for the use of carbonyl iron because of the greater safety with children who ingest their mothers' medication. Decreased gastric toxicity is claimed but not clearly demonstrated in human trials. Bioavailability is approximately 70% of a similar dose of ferrous sulfate.
Reserve parenteral iron for patients who are either unable to absorb oral iron or who have increasing anemia despite adequate doses of oral iron. It is expensive and has greater morbidity than oral preparations of iron.
Reserve transfusion of packed RBC for patients with either significant acute bleeding or patients in danger of hypoxia and/or coronary insufficiency.
Mineral supplementations
These agents are used to provide adequate iron for hemoglobin synthesis and to replenish body stores of iron (see Image 5). Iron is administered prophylactically during pregnancy because of anticipated requirements of the fetus and losses that occur during delivery.
Ferrous sulfate (Feratab, Fer-Iron, Slow-FE)
Mainstay treatment for treating patients with iron deficiency anemia. They should be continued for about 2 mo after correction of the anemia and its etiological cause in order to replenish body stores of iron. Ferrous sulfate is the most common and cheapest form of iron utilized. Tablets contain 50-60 mg of iron salt. Other ferrous salts are used and may cause less intestinal discomfort because they contain a smaller dose of iron (25-50 mg). Oral solutions of ferrous iron salts are available for use in pediatric populations.
Adult
325 mg (60 mg iron) PO with each meal tid
Pediatric
Administer weight-based dosing; 3-6 mg/kg/d PO divided tid suggested, depending on severity of anemia
Calcium supplementation decreases bioavailability of iron when metals are ingested simultaneously; absorption is enhanced by ascorbic acid; interferes with tetracycline absorption; food and antacids impair absorption
Documented hypersensitivity; microcytic anemias without laboratory documentation of iron deficiency
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Iron poisoning is common in children; preferably, provide tablets containing <20 mg of iron to pregnant women without iron deficiency; adequate as dietary supplement to prevent iron deficiency and reduces risk if child ingests tablets; iron tablets should be dispensed in child-proof containers and stored away from young children; iron pills resemble a commonly available candy; children watch their mother consume iron tablets and then mimic her actions; children who consume multiple iron tablets should be taken to an ED immediately to prevent shock and death; in pregnant women with iron deficiency anemia, pregnancy vitamin and mineral tablets may not suffice to correct deficiency state; administer iron orally separate from the combination tablets
Carbonyl iron (Feosol)
Used as a substitute for ferrous sulfate. Has a slower release of iron and is more expensive than ferrous sulfate. Slower release affords the agent greater safety if ingested by children. On an mg basis, it is 70% as efficacious as ferrous sulfate. Claims are made that there is less gastrointestinal toxicity, prompting use when ferrous salts are producing intestinal symptoms and in patients with peptic ulcers and gastritis. Tablets are available containing 45 mg and 60 mg of iron.
Adult
1 tab PO tid (usual dose recommended)
Pediatric
Administer weight-based dosing; 3-6 mg/kg/d PO divided tid suggested, depending on severity of anemia
Calcium supplementation decreases bioavailability of iron when metals are ingested simultaneously
Documented hypersensitivity; microcytic anemias without laboratory documentation of iron deficiency
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Iron poisoning is common in children; preferably, provide tablets containing <20 mg of iron to pregnant women without iron deficiency; this is adequate as a dietary supplement to prevent iron deficiency and reduces risk if a child ingests tablets; iron tablets should be dispensed in child-proof containers and stored away from young children; iron pills resemble a commonly available candy; children watch their mother consume iron tablets and then mimic her actions; children who consume multiple iron tablets should be taken to an ED immediately to prevent shock and death
Dextran-iron (INFeD)
Replenishes depleted iron stores in the bone marrow where it is incorporated into hemoglobin. Parenteral use of iron-carbohydrate complexes has caused anaphylactic reactions, and its use should be restricted to patients with an established diagnosis of iron deficiency anemia whose anemia is not corrected with oral therapy. Required dose can be calculated (3.5 mg iron/g of hemoglobin) or obtained from tables in the PDR. For IV use, INFeD may be diluted in 0.9% sterile saline. Do not add to solutions containing medications or parenteral nutrition solutions.
Adult
Test dose: 0.5 mL IV/IM (slowly over 1 min if IV); observe for 60 min before providing additional medication
Usual adult dose: 2 mL/d (100 mg iron); may be given until amenia is corrected
Pediatric
<5 kg: Not established
5-10 kg: 50 mg iron (1 mL) IV/IM
10-50 kg: 100 mg iron (2 mL) IV/IM
>50 kg: Administer as in adults
Absorption is enhanced by ascorbic acid; interferes with tetracycline absorption; food and antacids impair absorption
Documented hypersensitivity; microcytic anemias without laboratory documentation of iron deficiency; absence of iron deficiency anemia; anemia that cannot be corrected with oral therapy of iron
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Administer IM INFeD in upper outer quadrant of buttock using a Z-track technique to avoid tattooing; anaphylaxis, death, delayed serum sickness, fever, chest pain, respiratory arrest, wheezing and dyspnea, abdominal pain with nausea and vomiting, seizures, dizziness and disorientation, arthralgia, and back pain may occur; teratogenic effects are reported with high doses in some animals
More on Iron Deficiency Anemia |
| Overview: Iron Deficiency Anemia |
| Differential Diagnoses & Workup: Iron Deficiency Anemia |
 Treatment & Medication: Iron Deficiency Anemia |
| Follow-up: Iron Deficiency Anemia |
| Multimedia: Iron Deficiency Anemia |
| References |
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References
Mateos Gonzalez ME, de la Cruz Bertolo J, Lopez Laso E, Valdes Sanchez MD, Nogales Espert A. [Review of haematology and biochemistry parameters to identify iron deficiency] [Spanish]. An Pediatr (Barc). Aug 2009;71(2):95-102. [Medline]. [Full Text].
Beutler E, Lichtman MA, Coller BS. Williams Hematology. 6th ed. New York, NY: McGraw-Hill Book Co; 2001:295-304, 447-70.
Bothwell TH, Charlton RW, Cook JD. Iron Metabolis in Man. 1979:1-77.
Conrad ME, Umbreit JN. Iron absorption and transport-an update. Am J Hematol. Aug 2000;64(4):287-98. [Medline].
Hoffman R, Benz EJ Jr, Shattil SJ. Hematology: Basic Principles and Practice. Vol 3. New York, NY: Churchill Livingston; 1998:397-427.
Lee GR, Foerster J, Lukens J. Wintrobe's Clinical Hematology. Vol 10. 10th ed. Baltimore, Md: Williams & Wilkins; 1999:979-1011.
McLoughlin MT, Tham TC. Long-term follow-up of patients with iron deficiency anaemia after a negative gastrointestinal evaluation. Eur J Gastroenterol Hepatol. Aug 2009;21(8):872-6. [Medline].
Further Reading
Keywords
sideropenia, posthemorrhagic anemia, erythropoiesis, hemosiderosis, sprue, celiac disease, regional enteritis, ferric iron, ferrous iron, small bowel disease, regional enteritis, previous gastrointestinal surgery, intestinal parasites, hookworms,
gastrointestinal neoplasms, gastrointestinal bleeding, pica eating, clay eating, starch eating, hematuria, hematemesis, hemoptysis, hemorrhage, melanotic stool, pagophagia, leg cramps, dysphagia with esophageal webbing, koilonychia, glossitis, angular stomatitis, gastric atrophy, atrophic changes of the tongue, splenomegaly, phytates, oxalates, phosphates,
carbonates, tannates, hemosiderinuria, hemoglobinuria, pulmonary hemosiderosis, paroxysmal nocturnal hemoglobinuria, brisk intravascular hemolytic anemia, prolonged achlorhydria, celiac syndrome, sex-linked anemia, microcytic anemia, metabolic processes
