Iron Deficiency Anemia Management

Explanation

Oral iron is first line for iron deficiency anemia whenever the patient can absorb it and is not actively bleeding or hemodynamically compromised. A ferritin below 30 µg/L with microcytosis confirms depleted stores, and here the cause is chronic occult blood loss from NSAID induced erosive gastritis. Complete management therefore has three parts: stop the ibuprofen, start a proton pump inhibitor to heal the mucosa, and replace iron. Ferrous sulfate 65 mg of elemental iron given once daily or on alternate days is now preferred to divided daily dosing, because a single dose transiently raises hepcidin and blunts absorption for about 24 hours, so less frequent dosing improves net uptake and reduces nausea and constipation. Taking it on an empty stomach with vitamin C aids absorption, while tea, calcium, and proton pump inhibitors reduce it. A reticulocyte rise is expected within 1 week and hemoglobin should climb by about 10 g/L every 2 to 3 weeks; treatment continues 3 months beyond normalization to refill stores. Intravenous iron is reserved for malabsorption, intolerance of oral iron, ongoing losses that outpace absorption, chronic kidney disease, or a need for rapid repletion. Transfusion is for hemodynamic instability, active major bleeding, or symptomatic anemia usually below 70 g/L, and this patient is stable with a hemoglobin of 90 g/L. Erythropoietin treats anemia of chronic kidney disease and is ineffective when iron stores are empty. In a man of 66 with iron deficiency, colonoscopy is still required to exclude a colonic malignancy even though upper endoscopy found a lesion.

Why each option

A.

Intravenous iron is reserved for malabsorption, intolerance or failure of oral iron, ongoing heavy losses, or when rapid repletion is required.

B.

Transfusion is indicated for active major bleeding, hemodynamic compromise, or symptomatic anemia usually below 70 g/L, none of which is present here.

C.

Correct. A stable patient with NSAID related occult blood loss and a ferritin of 8 µg/L should stop the NSAID, take a proton pump inhibitor, and start oral ferrous sulfate.

D.

Erythropoietin is used in anemia of chronic kidney disease and cannot work while iron stores are depleted.

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