Key Feature 3: In all patients with anemia, determine the iron status before initiating treatment.
Skill: Clinical Reasoning
Phase: Investigation, Diagnosis
In follow-up to my previous post on the assessment of anemia, if a patient is found to have iron-deficiency anemia, it is important to determine the iron status before initiating treatment in order to be able to monitor the response to therapy. And of course, it is important to work up the cause of the iron-deficiency if it is not already apparent.
Baseline labs that you want to have include CBC, ferritin, TIBC, and reticulocyte count, which you would likely have already given that you came to the conclusion that the patient was iron deficient.
The exception to this would be, as I quoted UpToDate in my previous post, when children less than 2 years of age present with a microcytic anemia with a history that supports a diagnosis of dietary deficiency. In this case you may presume that the anemia is secondary to iron deficiency and begin treatment, because common things are common.
After you've started your choice of iron supplementation and recommended associated dietary suggestions (particularly in pediatric patients), you will then need to monitor response to treatment. For both children and adults:
If there is a poor response to iron supplementation, then you need to consider why. Reasons to consider include:
In any case, you may want to just consider switching to IV iron therapy and be done with it. There are pros and cons to choosing to supplement iron by mouth or intravenously. UpToDate has a great table that contrasts the pros and cons of these choices:
Patients who you will likely want to consider giving IV supplementation to right off the get-go include, for various reasons:
(I won't get into to the nitty-gritty about what exactly to choose for iron supplementation, as there are many choices and there doesn't seem to be a gold standard as to the best way to replace iron.)