Iron Deficiency — Viva Defence

Opening statement (SASPOP, delivered aloud)

"Mrs Ward is a 61-year-old postmenopausal woman with confirmed, clinically significant iron-deficiency anaemia — Hb 82 with a ferritin of 11. Her main problems are: first, the anaemia itself and its symptoms; second, that iron deficiency in a postmenopausal woman is occult gastrointestinal blood loss until proven otherwise, so this is a potential malignancy presentation; and third, she needs iron replacement with a monitored response. I would like to assess her for GI and gynaecological sources, arrange bidirectional endoscopy and coeliac serology, and replete her iron with a defined follow-up plan." [1] [3]

Structured problem list

1. Severe iron-deficiency anaemia (Hb 82, ferritin 11) — absolute deficiency; severity and symptom burden determine tempo, not transfusion [3].
2. Presumed occult GI blood loss — malignancy must be excluded; in the landmark prospective series, 62 of 100 adults with iron-deficiency anaemia had a causative GI lesion and 11 had a GI cancer [2].
3. Possible malabsorption — coeliac disease presents exactly like this and must be screened before it is forgotten [4].
4. Iron repletion and response surveillance — route, regimen, expected trajectory, and a plan for non-response [5] [6].

Integrated management plan

• Assess severity and stability: exertional symptoms, angina, syncope, haemodynamics — transfusion only if compromised; she is stable, so iron, not blood [3].
• History for the source: weight loss, change in bowel habit, PR bleeding, dysphagia, NSAIDs and anticoagulants, diet, family history of GI cancer; postmenopausal status removes the commonest benign explanation [1].
• Investigate: B12/folate, CRP, renal and liver function; coeliac serology (tTG-IgA with total IgA); gastroscopy with duodenal biopsies AND colonoscopy — bidirectional because lesions coexist and symptoms localise poorly; gynaecological review only if history suggests postmenopausal bleeding [1] [4].
• Replace iron: oral ferrous sulfate 65 mg elemental iron once daily or alternate days, empty stomach if tolerated, away from tea and PPIs — alternate-day dosing has the better absorption evidence; recheck Hb and ferritin at 4 weeks and continue about 3 months after normalisation [5] [3].
• Communicate: explain honestly that the blood count pattern in someone her age requires us to look at the bowel, that most causes are benign and treatable, and that the endoscopy proceeds regardless of how she responds to iron [1].

Probing questions with model answers

"Why scope her at all when she has no GI symptoms?" — "Because iron-deficiency anaemia in a postmenopausal woman IS the symptom. Rockey and Cello scoped 100 consecutive patients bidirectionally and found a causative lesion in 62 and cancer in 11 — and symptoms at a specific site only modestly predict where the lesion is, which is why the guidance is gastroscopy plus colonoscopy, not one or the other. A faecal occult blood test cannot exclude anything here." [2] [1]

"Her GP checked a ferritin last year and it was 46 — was that falsely reassuring?" — "Possibly, and it's the ferritin trap: ferritin is an acute phase reactant, so intercurrent inflammation can lift it into the reference range while stores are failing. Read beside CRP and a transferrin saturation — TSAT below 20% would have unmasked deficiency then. Ferritin answers 'what is in the store'; TSAT answers 'what is reaching the marrow' — I want both." [1] [3]

"Justify once-daily rather than three-times-daily iron." — "Each 60 mg-plus dose of oral iron raises hepcidin for about 24 hours, which closes ferroportin and blunts absorption of the next dose. The randomised absorption trials showed alternate-day dosing absorbed more iron than consecutive daily dosing, and a single morning dose more than split dosing — with fewer GI side effects, which is what actually determines adherence." [5]

"Her Hb hasn't moved after a month of tablets. What now?" — "That is non-response, and it gets a structured workup, not a shrug: verify adherence, dose timing and formulation in elemental terms; re-verify the diagnosis; look for ongoing loss and for malabsorption — coeliac serology, autoimmune gastritis, H. pylori; and switch to IV iron, because non-response to a verified oral trial is itself an IV indication. If she is refractory to everything, I remember the rarities — IRIDA and marrow disease." [6]

"If you do give IV iron, which product and what do you warn about?" — "A large single-dose formulation — ferric carboxymaltose or ferric derisomaltose, about 15–20 mg/kg. Minor flushing-type infusion reactions are the common issue; true anaphylaxis is rare with modern products. With ferric carboxymaltose specifically I remember the phosphate: it raises FGF23 and can cause hypophosphataemia — common in the trial meta-analysis — so I check phosphate if she needs repeated courses and prefer derisomaltose when repeat dosing is likely." [7]

"Both endoscopies are normal and her coeliac serology is negative. Are you done?" — "Not if she's still losing iron. I recheck the response to repletion, revisit NSAID and anticoagulant exposure, consider urinary loss if there's any intravascular haemolysis hint, and — if blood loss is ongoing and obscure — move to small-bowel evaluation with capsule endoscopy. Iron deficiency with negative bidirectional endoscopy is a surveillance problem, not a closed file." [1] [6]

Communication points

• Name the possibility of cancer honestly and early: "most causes turn out benign, but we must look" — then make sure the looking actually happens [1].
• Set adherence up to succeed: warn about dark stools and constipation before they happen, and offer the alternate-day regimen as an easier, evidence-based option [5].
• Close the safety net: documented plan for repeat bloods, endoscopy dates, and what to do if symptoms change while waiting [1].