This is an abbreviated version of the full GGC guideline Iron Deficiency Anaemia in Adults: Oral and Intravenous Iron Therapy Treatment.
The guideline does not cover the diagnosis or treatment in the following clinical situations:
Iron deficiency anaemia (IDA) occurs in more severe stages of iron deficiency, when the body is iron deficient to the degree that red blood cell and haemoglobin (Hb) production is reduced. The cause of IDA is often multifactorial, and can be broadly attributed to:
For diagnosis of IDA, see flowchart.
Serum ferritin (SF):
For further information on the interpretation of iron studies, please refer to the Medicines Update blog article, search for 'Diagnosis of IDA - Iron Studies'.
Treatment with iron replacement therapy should be considered for patients with clinically relevant IDA in whom the clinical benefit of treatment outweighs any risk. Investigation and 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.
Give ferrous fumarate oral 210mg or ferrous sulphate 200mg once a day.
The optimal dose of oral iron-replacement therapy for adults with IDA is not clearly defined. Traditionally oral iron salts were taken as a split dose, two or three times a day (100mg/200mg elemental iron daily). More recent data suggest that lower doses and more infrequent administration may be just as effective and likely to be associated with lower rate of adverse effects.
Hb levels should rise by at least 20g/L over 3-4 weeks. Treatment should be continued for 3 months after Hb is optimised and then stopped.
If response is poor, consider:
*If oral iron treatment is not tolerated, adverse effects should be addressed by:
Iron salts are not well absorbed orally and their absorption is reduced if taken concurrently with certain foods/drugs/supplements such as:
Oral iron can reduce the absorption of some drugs if taken concurrently (including tetracyclines, quinolones and bisphosphonates) reducing bioavailability and clinical effect. A suitable interval to separate administration is advised (See Medicines Update blog, search for 'Warning- Antibiotic treatment risk failure', for information on the management of these interactions).
This does not produce a faster Hb response than oral iron, provided that the oral iron preparation is taken reliably and is absorbed adequately. It may produce severe adverse effects, and should be reserved for patients who meet the inclusion criteria below.
Intravenous iron therapy should be initiated by a consultant, specialist trainee or equivalent. Some services may delegate responsibility to nominated non-medical prescribers.
There can be complications with IV iron. See below for details. Administration should only occur during working hours when adequate supervision is available.
A guide to help with product selection based on patient characteristics can be found here, alternatively consider prescribing the most familiar product within your clinical area. See the individual dosing and administration guides for Ferinject® (ferric carboxymaltose) or Monofer® (ferric derisomaltose).
Note: These guides should be printed for use as prescribing and administration checklists in clinical areas. These can be printed from the links above.
These include serious and potentially fatal anaphylactic / anaphylactoid reactions. Caution is needed with every dose of IV iron that is given, even if previous administrations have been well tolerated. The steps outlined in the administration checklists for Ferinject® (ferric carboxymaltose) or Monofer® (ferric derisomaltose) should be taken to monitor patients during and for at least 30 minutes after every administration. If hypersensitivity reactions or signs of intolerance occur, the infusion must be stopped immediately and appropriate management initiated. A guide to the management of hypersensitivity reactions during the administration of IV iron can be found here (link active on website only).
Paravenous leakage at the infusion site may lead to irritation and potentially long lasting or permanent brown discolouration at the site of infusion. Patients should be informed about the possibility of discolouration and advised to report any signs of irritation or pain at the infusion site immediately. The most effective safeguard against extravasation is to visually inspect the infusion site regularly. The steps outlined in the checklists for Ferinject® (ferric carboxymaltose) or Monofer® (ferric derisomaltose) should be taken to monitor the infusion site during and for at least 30 minutes following administration. In case of suspected paravenous leakage, treatment requires prompt attention as outlined here.
Hb and ferritin levels should be rechecked to assess response to IV iron treatment. These should be assessed no earlier than 4 weeks following treatment. Hb levels should rise by at least 20g/L over 4 weeks.
Treatment with IV iron should be clearly communicated with the patient’s GP and other healthcare professionals. This could be via a discharge letter or outpatient clinic letter. It should include details of the treatment received and clearly state arrangements in place for follow up blood monitoring.
Guideline reviewed: September 2022
Page last updated: December 2023
