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MANAGEMENT

Aim of treatment

The aim of treatment should be to restore haemoglobin levels and red cell indices to normal, and replenish iron stores. If this cannot be achieved, consideration should be given to further evaluation.

Iron therapy

Treatment of an underlying cause should prevent further iron loss but all patients should have iron supplementation both to correct anaemia and replenish body stores (B)2. This is achieved most simply and cheaply with ferrous sulphate 200 mg twice daily. Lower doses may be as effective and better tolerated and could be considered in patients not tolerating traditional doses. Other iron compounds (e.g. ferrous fumarate, ferrous gluconate) or formulations (iron suspensions) may also be tolerated better then ferrous sulphate. Ascorbic acid (250–500 mg twice daily with the iron preparation) may enhance iron absorption. We recommend that oral iron is continued until three months after the iron deficiency has been corrected so that stores are replenished.

Parenteral iron may be used when there is intolerance or noncompliance with oral preparations. Intravenous iron sucrose, when given according to the manufacturers’ instructions, is reasonably well tolerated (35% of patients have mild side effects) with a low incidence of serious adverse reactions (0.03–0.04%).

Bolus intravenous dosing of iron sucrose (200mg iron) over 10 minutes is licensed and more convenient than a two-hour infusion. Intravenous iron dextran can replenish iron and haemoglobin levels in a single infusion. but serious reactions can occur (0.6–0.7%) and there have been fatalities associated with infusion (31 reported between 1976–1996). However, it can be given via the intramuscular route when venous access is problematic.

Blood transfusions should be reserved for patients with, or at risk of, cardiovascular instability due to their degree of anaemia (C), particularly if they are due to have endoscopic investigations before a response from iron treatment is expected. Transfusions should aim to restore haemoglobin to a safe level, but not necessarily normal values. Iron treatment should follow transfusion to replenish stores.

Follow-up

Once normal, the haemoglobin concentration and red cell indices should be monitored at intervals. We suggest three monthly for one year then again after a further year. Additional oral iron should be given if the haemoglobin or red cell indices fall below normal (ferritin levels can be reserved for cases where there is doubt). Further investigation is only necessary if the haemoglobin and red cell indices cannot be maintained in this way. It is reassuring to know that iron deficiency does not return in most patients in whom a cause for IDA is not found after OGD, small bowel biopsy and barium enema.

Summary flow chart
A management chart is shown in Figure 1.

FIGUE 1. Management of iron deficiency in adults