Gastro experts offer best practice advice on iron to treat anemia

The American Gastroenterological Association recently issued a clinical practice update on the management of iron-deficiency anemia.

The update offers best practice advice statements, drawn from a review of the published literature and from expert opinion, on options for oral and IV iron repletion and best practices for management of iron deficiency in common GI conditions. No systematic review was performed, so the statements do not carry formal ratings for strength or quality of evidence. The recommendations, published by Clinical Gastroenterology and Hepatology on June 11, include the following.

• No single formulation of oral iron has any advantages over any other. Ferrous sulfate is preferred as the least expensive iron formulation.
• Give oral iron once a day at most. Every-other-day dosing may be better tolerated by some patients, with similar rates of iron absorption as daily dosing.
• Add vitamin C to oral iron supplementation to improve absorption.
• IV iron should be used if the patient does not tolerate oral iron, ferritin levels do not improve with a trial of oral iron, or the patient has a condition making oral iron not likely to be absorbed.
• IV iron formulations that can replace iron deficits with one or two infusions are preferred over those that require more than two infusions.
• All IV iron formulations have similar risks; true anaphylaxis is very rare. The vast majority of reactions to IV iron are complement activation–related pseudo-allergy (infusion reactions) and should be treated as such.
• IV iron therapy should be used in patients who have undergone bariatric procedures (particularly those that are likely to disrupt normal duodenal iron absorption) and have iron-deficiency anemia with no identifiable source of chronic GI blood loss.

Other specific advice in the update addresses how to treat iron-deficiency anemia in patients with inflammatory bowel disease, portal hypertensive gastropathy, gastric antral vascular ectasia, celiac disease, or small-bowel angioectasias.

"Management of [iron-deficiency anemia] includes both repletion of iron stores, and, if possible, management of the underlying etiology," the update said. "Further studies are needed to determine optimal formulations and routes for iron repletion as well as to identify patients who would benefit from earlier IV iron administration."