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absorption may exceed this amount in cases of severe deficiency), is the preferred therapy Compliance is improved by introducing the medicine more slowly in a gradually escalating dose with food Alternatively, in cases of poor tolerance, one pill of ferrous sulfate can be taken at bedtime on an empty stomach It is preferable to prescribe a lower dose of iron or to allow ingestion concurrent with food than to insist on a more rigorous schedule that will not be followed An appropriate response is a return of the hematocrit level halfway toward normal within 3 weeks with full return to baseline after 2 months Iron therapy should continue for 3 6 months after restoration of normal hematologic values to replenish iron stores Failure of response to iron therapy is usually due to noncompliance, although occasional patients may absorb iron poorly Other reasons for failure to respond include incorrect diagnosis (anemia of chronic disease, thalassemia) and ongoing gastrointestinal blood loss that exceeds the rate of new erythropoiesis



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Many chronic systemic diseases are associated with mild or moderate anemia Common causes include chronic infection or inflammation, cancer, and liver disease The anemia of chronic renal failure is somewhat different in pathophysiology, involving reduced production of erythropoietin, and is usually more severe Hepcidin has been identified as an important mediator of sequestration of iron within macrophages, and upregulation of hepcidin in response to mediators of inflammation, such as IL-6, is an important cause of anemia of chronic disease

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Figure 14-18 RJ-11 connectors (top and side views)





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The indications are intolerance to oral iron, refractoriness to oral iron, gastrointestinal disease (usually inflammatory bowel disease) precluding the use of oral iron, and continued blood loss that cannot be corrected Because of the possibility of anaphylactic reactions, parenteral iron therapy should be used only in cases of persistent anemia after a reasonable course of oral therapy Until recently, iron dextran had been the only form of parenteral iron available in the United States Now, sodium ferric gluconate is available, and has been shown to result in a lower incidence of severe anaphylaxis To date, no deaths have been reported with the use of this preparation The dose (total 15 2 g) may be calculated by estimating the decrease in volume of red blood cell mass and then supplying 1 mg of iron for each milliliter of volume of red blood cells below normal Approximately 1 g should then be added for storage iron Total body iron ranges between 2 g and 4 g: approximately 50 mg/kg in men and 35 mg/kg in women Most (70 95%) of the iron is present in hemoglobin in circulating red blood cells One milliliter of packed red blood cells (not whole blood) contains approximately 1 mg of iron In men, red blood cell volume is approximately 30 mL/ kg A 70-kg man will therefore have approximately 2100 mL of packed red blood cells and consequently 2100 mg of iron in his circulating blood In women, the red cell volume is about 27 mL/kg; a 50-kg woman will thus have 1350 mg of iron circulating in her red blood cells Thus, a woman whose hemoglobin is 9 g/dL would be treated with a total of 1315 mg of parenteral iron, 315 mg for the increased red blood cell mass and 1000 mg to provide iron stores The entire dose may be given as an intravenous infusion over 4 6 hours A test dose of a dilute solution is given first, and the patient should be observed during the entire infusion for anaphylaxis.

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Capurso G et al Can patient characteristics predict the outcome of endoscopic evaluation of iron deficiency anemia: a multiple logistic regression analysis Gastrointest Endosc 2004 Jun;59(7):766 71 [PMID: 15173787] Cook JD et al The quantitative assessment of body iron Blood 2003 May 1;101(9):3359 64 [PMID: 12521995]

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The clinical features are those of the causative condition The diagnosis should be suspected in patients with known chronic diseases; it is confirmed by the findings of low serum iron, low TIBC, and normal or increased serum ferritin (or normal or increased bone marrow iron stores) In cases of significant anemia, coexistent iron deficiency or folic acid deficiency should be suspected Decreased dietary intake of folate or iron is common in these ill patients, and many will also have ongoing gastrointestinal blood losses Patients undergoing hemodialysis regularly lose both iron and folate during dialysis

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