Iron Deficiency Anemia Treatment & Management

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. However, avoid giving iron to patients who have a microcytic iron-overloading disorder (eg, thalassemia, sideroblastic anemia). Do not administer parenteral iron therapy to patients who should be treated with oral iron, as anaphylaxis may result.

Transfer of a patient rarely is required for treatment of simple iron deficiency anemia; however, it may be necessary to identify the etiology of the anemia, such as occult blood loss undetected with chemical testing of stool specimens, for identification of a source of bleeding that requires endoscopic examinations or angiography or for treatment of an underlying major illness (eg, neoplasia, ulcerative colitis).

The British Society of Gastroenterology guidelines suggest that all patients require iron supplementation and that parenteral iron can be used if oral preparations are not well tolerated. The guidelines also state that blood transfusions should be reserved only for patients who are at risk for or who have cardiovascular instability due to their anemia.^[2]

Go to Anemia, Sideroblastic Anemias, and Chronic Anemia for complete information on these topics.

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.

Some authors advocate the use of carbonyl iron because of the greater safety for 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. Parenteral iron has been used safely and effectively in patients with inflammatory bowel disease (eg, ulcerative colitis, Crohn disease),^[3] as the ferrous sulfate preparations may aggravate the intestinal inflammation.

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 (GI) tract, the genitourinary (GU) tract, the uterus, and the lungs.

Reserve transfusion of packed red blood cells (RBCs) for patients who either are experiencing significant acute bleeding or are in danger of hypoxia and/or coronary insufficiency.

On a worldwide basis, diet is the major cause of iron deficiency. However, 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 has been 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 diet-related iron deficiency due to pica need to be identified and counseled to stop their consumption of clay and laundry starch.

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 on bed rest until improvement of their anemia can be accomplished by transfusion of packed RBCs. Obviously, such decisions must be made on an individual basis and will depend on 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.

Certain populations are at sufficiently high risk for iron deficiency to warrant consideration for prophylactic iron therapy. These include pregnant women, women with menorrhagia,^[4] consumers of a strict vegetarian diet, infants,^[5] adolescent females, and regular blood donors.

Pregnant women have been given supplemental iron since World War II, often in the form of all-purpose capsules containing vitamins, calcium, and iron. If the patient is anemic (hemoglobin < 11 g/dL), administer the iron at a different time of day than calcium because calcium inhibits iron absorption.

The practice of routinely administering iron to pregnant females in affluent societies has been challenged; however, it is recommended to provide prophylactic iron therapy during the last half of pregnancy, except in settings where careful follow-up for anemia and methods for measurement of serum iron and ferritin are readily available.

Iron supplementation of the diet of infants is advocated. Premature infants require more iron supplementation than term infants. Infants weaned early and fed bovine milk require more iron because the higher concentration of calcium in cow milk inhibits absorption of iron. Usually, infants receive iron from fortified cereal. Additional iron is present in commercial milk formulas.

Iron supplementation in populations living on a largely vegetarian diet is advisable because of the lower bioavailability of inorganic iron than heme iron.

The addition of iron to basic foodstuffs in affluent nations where meat is an important part of the diet is of questionable value and may be harmful. The gene for familial hemochromatosis (HFe gene) is prevalent (8% of the US white population). Excess body iron is postulated to be important in the etiology of coronary artery disease, strokes, certain carcinomas, and neurodegenerative disorders because iron is important in free radical formation.

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.

Among the medical specialties, gastroenterology is the most frequently sought consultation. Endoscopy has become a highly effective tool in identifying and controlling GI 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 that bleed only intermittently.

Monitor patients with iron deficiency anemia on an outpatient basis to ensure that there is an adequate response to iron therapy and that iron therapy is continued until after correction of the anemia to replenish body iron stores. Follow-up also may be important to treat any underlying cause of the iron deficiency.

Response to iron therapy can be documented by an increase in reticulocytes 5-10 days after the initiation of iron therapy. The hemoglobin concentration increases by about 1 g/dL weekly until normal values are restored. These responses are blunted in the presence of sustained blood loss or coexistent factors that impair hemoglobin synthesis.