A 32-year-old woman with menorrhagia presents with iron deficiency anemia (Hb 8.5 g/dL, serum ferritin 12 ng/mL, TIBC elevated). She has no gastrointestinal symptoms. What is the drug of choice for iron replacement?

Question

Accepted Answer

A. Ferrous sulfate 325 mg once daily. ## Iron Replacement in Iron Deficiency Anemia

### First-Line Oral Iron Therapy

**Key Point:** Ferrous sulfate 325 mg once daily is the gold standard first-line treatment for iron deficiency anemia in patients with intact gastrointestinal absorption.

**High-Yield:** Ferrous salts (ferrous sulfate, ferrous fumarate, ferrous gluconate) are preferred over ferric salts because ferrous iron (Fe²⁺) is absorbed more efficiently in the duodenum and proximal jejunum than ferric iron (Fe³⁺).

### Dosing & Absorption

| Parameter | Ferrous Sulfate | Ferrous Gluconate | Ferric Carboxymaltose |
| --- | --- | --- | --- |
| **Elemental iron per dose** | 65 mg (325 mg salt) | 36 mg (300 mg salt) | 750 mg (IV only) |
| **Route** | Oral | Oral | IV |
| **First-line status** | Yes | Alternative oral | Reserved for IV indication |
| **Cost** | Low | Low | High |
| **GI side effects** | Common | Less common | None (IV) |

### When to Use IV Iron

**Clinical Pearl:** IV iron (ferric carboxymaltose, iron sucrose, iron dextran) is reserved for:
  - Intolerance to oral iron (severe GI upset, nausea)
  - Malabsorption syndromes (celiac disease, post-gastrectomy)
  - Chronic kidney disease on hemodialysis
  - Inability to meet iron needs orally (ongoing blood loss)
  - Pregnancy with severe anemia

**Warning:** IM iron (iron dextran) is rarely used now due to risk of local reactions, staining, and superior efficacy of IV formulations.

### Expected Response

1. Reticulocytosis begins within 3–5 days
2. Hemoglobin rise: 1–2 g/dL per week
3. Ferritin normalization: 3–6 months
4. Total iron stores replenishment: 6–12 months

**Mnemonic:** **FIGS** — Ferrous Iron is Gut-absorbed Superbly (compared to ferric).

Answer

B. Iron dextran 100 mg IM weekly

Answer

C. Ferrous gluconate 300 mg twice daily

Answer

D. Ferric carboxymaltose 750 mg IV

A 32-year-old woman with menorrhagia presents with iron deficiency anemia (Hb 8.5 g/dL, serum ferritin 12 ng/mL, TIBC elevated). She has no gastrointestinal symptoms. What is the drug of choice for iron replacement?

Explanation

Iron Replacement in Iron Deficiency Anemia

First-Line Oral Iron Therapy

Dosing & Absorption

When to Use IV Iron

Expected Response

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Parameter	Ferrous Sulfate	Ferrous Gluconate	Ferric Carboxymaltose
Elemental iron per dose	65 mg (325 mg salt)	36 mg (300 mg salt)	750 mg (IV only)
Route	Oral	Oral	IV
First-line status	Yes	Alternative oral	Reserved for IV indication
Cost	Low	Low	High
GI side effects	Common	Less common	None (IV)