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Iron Deficiency Anemia

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In one line

·Iron deficiency anemia happens when the body runs out of iron, so red blood cells become too small and pale to carry enough oxygen.

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Normal physiology

·Iron moves through the body in a careful cycle: you absorb it from food in the duodenum, store extras as ferritin in the liver, build it into hemoglobin inside red blood cells in the bone marrow, and recycle most of it when old red blood cells die after about 120 days.

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What goes wrong

·Iron deficiency anemia happens when iron leaves the body faster than it comes in, or when the gut cannot absorb it properly, or when the body suddenly needs much more than usual.

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Hallmark signs

·Feeling very tired and weak all the time
·Pale skin, especially inside the eyelids, under the nails, and on the palms
·Shortness of breath, especially when active
·Fast or pounding heartbeat
·Headaches and trouble concentrating or remembering things
·Cold hands and feet
·Craving ice or non-food items like dirt or starch (called pica)
·Sore, smooth, or swollen tongue

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Red flags · escalate now

·Blood in your stool (black, tarry stools or bright red blood) or vomiting blood — can mean bleeding in your stomach or intestines
·Sudden, severe chest pain or trouble breathing — your heart may be struggling because of very low oxygen
·Ongoing heavy menstrual bleeding that soaks through a pad or tampon every hour — can lead to dangerous iron loss
·Unintended weight loss, belly pain, or trouble swallowing — could signal a hidden source of bleeding like cancer or an ulcer
·Signs of severe anemia: confusion, fainting, extreme weakness, or very fast heartbeat at rest — means your organs aren't getting enough oxygen

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Workup

·Complete blood count (CBC) with red cell indices
·Serum ferritin
·Serum iron and total iron-binding capacity (TIBC), calculated as transferrin saturation
·Reticulocyte count
·Fecal occult blood test (FOBT) or fecal immunochemical test (FIT)
·Upper endoscopy (esophagogastroduodenoscopy) and colonoscopy
·Tissue transglutaminase IgA (tTG-IgA) with total IgA, or celiac serology panel
·Hemoglobin electrophoresis (if MCV low but ferritin normal)

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Treatment

·Identify and treat the source: colonoscopy and upper endoscopy in men and postmenopausal women; address heavy menstrual bleeding in premenopausal women; screen for celiac disease if malabsorption suspected
·Oral ferrous sulfate 325 mg (65 mg elemental iron) every other day on an empty stomach, or ferrous gluconate or ferrous fumarate at equivalent elemental iron dose
·Intravenous iron: ferric carboxymaltose 750–1000 mg, iron sucrose 200 mg, or low-molecular-weight iron dextran, if oral fails, malabsorption present, severe anemia (hemoglobin < 10 g/dL), inflammatory bowel disease, chronic kidney disease, or pregnancy
·Recheck hemoglobin at 4 weeks, then every 8 weeks until normal; recheck ferritin at 3 months to confirm iron stores are replenished (goal ferritin > 50–100 ng/mL)
·Vitamin C 200 mg with oral iron to boost absorption (optional, not required)
·Blood transfusion: packed red blood cells, 1–2 units, if hemoglobin < 7 g/dL with symptoms (severe fatigue, chest pain, shortness of breath) or < 8 g/dL with active bleeding or heart disease

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NCLEX trap

·In iron deficiency anemia, transfusion is rarely the first move. The body adapted to losing iron slowly over weeks; it can handle getting iron back slowly, too. Transfuse only if hemoglobin falls below 7 or the patient has chest pain, trouble breathing, or is at risk for stroke. First, find where the iron is leaking from—usually the gut or very heavy periods—and stop the leak. Then give iron pills. Slow and steady wins.
·Taking iron every other day actually works better than three times a day. When you take iron every day, the gut gets tired and stops absorbing as much, plus it causes cramps and diarrhea. If you give the gut a day off between doses (325 mg every other day), it absorbs more iron and the patient feels better. The slow way is the smart way in iron deficiency anemia.
·Heavy periods can definitely cause iron deficiency anemia, but never assume that is the only place iron is leaking. Always ask: is there also bleeding from the stomach or intestines? Screen for celiac disease (it blocks iron absorption), check a stool sample for hidden blood, ask if stools are black or tarry. Treat the heavy periods, but do not miss a second source—especially a tumor or ulcer.
·Hemoglobin rises slowly in iron deficiency anemia—expect only 1 to 2 points per month. At 2 weeks, the bone marrow is still waking up and starting to make new red blood cells. Before switching to IV iron, ask: Is the patient actually taking the pills? Do they have celiac disease or another reason they cannot absorb iron? Is bleeding still happening somewhere? Save IV iron for people who truly cannot absorb pills or who get severe nausea and cramps from them. Do not switch just because you are impatient.
·Ferritin is a storage protein for iron, so when it is low, iron deficiency is very likely. But ferritin also rises when the body is fighting infection, inflammation, or liver disease—even if iron is still low. If the patient has a fever, arthritis, or liver problems, ferritin can look normal or high and hide the real iron deficiency. Always check ferritin together with serum iron and TIBC (total iron-binding capacity) to confirm the full picture.
·In older adults with iron deficiency anemia, the gut is the most common place iron leaks out. If the colonoscopy (camera in the colon) is negative, you must do an upper endoscopy (camera down the throat into the stomach and small intestine)—that is where ulcers, Barrett esophagus, and early cancers hide. A negative stool test does not rule out slow bleeding. Never settle for one negative test in an older adult with iron deficiency anemia; the danger you are looking for is cancer.

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