Iron Deficiency Anemia - Full Clinical Guide

Overview

Iron deficiency anemia (IDA) and iron deficiency without anemia are very common in newly arrived refugees, particularly women of reproductive age and young children. While poor dietary intake is a frequent cause, blood loss must always be considered before attributing IDA to diet alone.

Always Wait for the Hemoglobinopathy Screen

Do not interpret MCV in isolation. Thalassemia trait causes microcytosis and can coexist with or mimic iron deficiency. Always wait for the complete hemoglobinopathy screen results before attributing microcytosis to iron deficiency alone.

Finding the Underlying Cause

Before prescribing iron, consider the following causes and investigate where clinically indicated:

* Dietary iron deficiency: most common cause, especially in children and women

* Gastrointestinal blood loss: hookworm and whipworm infections are common in refugees and often asymptomatic

* H. pylori infection: causes occult GI blood loss

* Abnormal uterine bleeding: ask specifically about menstrual patterns

* Celiac disease: consider in patients with GI symptoms or persistent unexplained IDA

* Hematuria: order a urinalysis

For asymptomatic adult patients under 50 with iron deficiency anemia and low risk of GI malignancy, consider the following before referring for endoscopy:

- H. pylori stool antigen test

- Stool Ova and Parasites examination (at least 3 samples)

- Celiac screen (anti-tTG IgA + total IgA)

- Urinalysis

Treatment

First-Line: Ferrous Sulfate

Ferrous sulfate is the only iron formulation covered by the IFHP. It should be taken with orange juice or vitamin C to improve absorption. Avoid taking with tea, coffee, or calcium-rich foods.

Patient Formulation Dose Duration

Adults Ferrous sulfate 300 mg tablet (60 mg elemental iron) 1 tablet twice daily 3 months

Children Ferrous sulfate oral solution (15 mg/mL elemental iron) 6 mg/kg/day divided once or twice daily 3 months

Follow-Up

Repeat CBC and iron studies 3 months after starting iron supplementation. The hemoglobin should rise by approximately 10 g/L per month if the correct diagnosis is iron deficiency and adherence is adequate.

If iron studies do not improve after 3 months:

* Reassess adherence and tolerability

* Reconsider the diagnosis (thalassemia trait, anemia of chronic disease)

* Investigate further for ongoing blood loss if not already done

Parasites and H. Pylori as Causes

Hookworms and whipworms are common causes of iron deficiency in refugees and should be treated alongside iron supplementation if detected. Treating H. pylori also improves iron absorption. See the GI Parasites and Dyspepsia pages for treatment details.

References

2018 Alberta TOP Guidelines for Iron Deficiency Anemia: topalbertadoctors.org