## IV Iron in Malabsorption ### Rationale for Parenteral Iron in Celiac Disease **Key Point:** Celiac disease causes villous atrophy and decreased absorptive surface area, making oral iron absorption unreliable even with ferrous salts. IV iron bypasses the GI tract entirely and is the definitive choice. **High-Yield:** In malabsorption syndromes (celiac disease, Crohn's disease, post-gastrectomy, tropical sprue), oral iron has inherently poor bioavailability regardless of formulation. Parenteral iron is mandatory. ### Why Ferric Carboxymaltose is Optimal Here | Criterion | Ferric Carboxymaltose | Iron Sucrose | Iron Dextran | | --- | --- | --- | --- | | **Dosing frequency** | 1–2 infusions total | 3× weekly × 4–6 weeks | Variable, outdated | | **Infusion time** | 15 minutes | 30 minutes | 30–60 minutes | | **Anaphylaxis risk** | <0.1% | <0.1% | 0.6–0.7% | | **Compliance** | Excellent (rapid completion) | Moderate (multiple visits) | Poor | | **Cost-effectiveness** | High (fewer visits) | Moderate | Low | **Clinical Pearl:** In patients with poor compliance or malabsorption, ferric carboxymaltose's ability to replicate total iron stores in 1–2 infusions makes it superior to iron sucrose, which requires prolonged weekly infusions. ### Management of Underlying Celiac Disease **Warning:** Iron replacement alone will fail if celiac disease is not managed. Strict gluten-free diet must be enforced to allow intestinal healing and restoration of absorptive capacity. Repeat iron studies in 3–6 months post-repletion. ### Monitoring After IV Iron 1. Reticulocyte count rises by day 3–5 2. Hemoglobin increases 1–2 g/dL per week 3. Ferritin normalizes within 3–6 months 4. Repeat endoscopy + biopsy to confirm mucosal healing (6–12 months) **Mnemonic:** **CARB** — CArboxymaltose Repletes Best (in malabsorption).
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