A 42-year-old woman with iron deficiency anemia (Hb 7.8 g/dL, ferritin 8 ng/mL) secondary to celiac disease presents with severe malabsorption. She has failed oral iron therapy twice due to poor compliance and persistent GI symptoms. What is the drug of choice for iron replacement?

Question

Accepted Answer

C. Ferric carboxymaltose 750 mg IV as single or two doses. ## 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| **Dosing frequency** | 1–2 infusions total | 3× weekly × 4–6 weeks | Variable, outdated |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).

Answer

A. Ferrous fumarate 200 mg twice daily

Answer

B. Iron sucrose 200 mg IV thrice weekly

Answer

D. Ferrous sulfate 325 mg once daily with vitamin C

A 42-year-old woman with iron deficiency anemia (Hb 7.8 g/dL, ferritin 8 ng/mL) secondary to celiac disease presents with severe malabsorption. She has failed oral iron therapy twice due to poor compliance and persistent GI symptoms. What is the drug of choice for iron replacement?

Explanation

IV Iron in Malabsorption

Rationale for Parenteral Iron in Celiac Disease

Why Ferric Carboxymaltose is Optimal Here

Management of Underlying Celiac Disease

Monitoring After IV Iron

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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