Just check Hb, if low look for rise in Hb after 2 weeks of alternate day oral Iron before investigating further. 

As per the National Family Health Survey (NFHS) - IV (20015-16), 54.2 percent women (15-49 years) and 59.5 percent children (6-59 months) in rural India are anemic.

The most common cause of anemia is iron deficiency caused by inadequate dietary iron intake or absorption, increased needs for iron during pregnancy or growth periods, and increased iron losses as a result of menstruation and helminth (or intestinal worms) infestation.

On 8th December, 2019 a health camp was organized at Mera Clinic, Kotla Mubarakpur in Delhi. At the camp 100 women were screened for Hb and the reports showed that more than 90% of the females had hemoglobin levels below 12. These results were in consonance with the data seen in the NFHS-IV. We provided free albendazole to the women and recommended them to start oral iron. 

We are all aware that regardless of the presence of symptoms, all patients with iron deficiency anemia and most patients with iron deficiency without anemia should be treated.

It is imperative to identify and address the cause of iron deficiency, especially in adults with new onset iron deficiency. In a camp set up, most people come for free treatment, hence sending them for investigations may not be feasible. In such kind of community outreach, the best approach is to start with oral iron with a follow up HB check in 2 weeks. At the end of this period, if there is no rise of Hb, they should be investigated to identify other causes of anemia. 

In routine clinical practice, we treat patients with severe, severely symptomatic (with symptoms of myocardial ischemia), or life-threatening anemia with red blood cell (RBC) transfusion. In addition, in a rural or semi urban set up, we do not offer IV iron in nonpregnant females, unless the patient has inflammatory bowel disease, gastric surgery, or chronic kidney disease. However, in rural set up, owing to the ease of administration of oral iron, we treat patients who have uncomplicated iron deficiency. 

In most of the cases, oral iron is as efficient as IV formulation. For individuals treated with oral iron, the preferred dose is recommended to be taken every alternate day rather than a daily dose.

This is based on evidence that in individuals with iron deficiency the alternate day dosing has been shown to improve absorption and reduce gastrointestinal side effects. Some individuals may reasonably choose every-day dosing if they find that it improves tolerability or ease of use.

Effective treatment of iron deficiency results in resolution of symptoms, a modest reticulocytosis (peaking in 7 to 10 days), and normalization of the hemoglobin level in six to eight weeks. 

An effective regimen for the treatment of uncomplicated iron deficiency with oral iron preparations should lead to the following responses:

• If pica for ice is present, it disappears almost as soon as oral iron therapy is begun, well before there are any observable hematologic changes 
• The patient will note an improved feeling of well-being within the first few days of treatment.
• The Hb concentration will rise slowly, usually beginning after approximately one to two weeks of treatment and will rise approximately 2 g/dL over the ensuing three weeks. The hemoglobin deficit should be halved by approximately one month, and the hemoglobin level should return to normal by six to eight weeks.
• Typically, papillation of the tongue is decreased in patients with iron deficiency and can be used as a gauge of duration of symptoms. Classically, loss of papillae begins at the tip and lateral borders and moves posteriorly and centrally. Following iron repletion, a rapid correction (weeks to months) is observed. 

For patients receiving oral iron, we often re-evaluate the patient two weeks following the initiation of the dose. 

Our recommendation 

1. The recommended daily dose for the treatment of iron deficiency in adults is 150 to 200 mg of elemental iron daily. A 325 mg ferrous sulphate tablet contains 65 mg of elemental iron per tablet; three tablets per day will provide 195 mg of elemental iron, of which approximately 25 mg is absorbed and used in production of heme and other molecules.
2. We prefer alternate-day dosing (taking the iron every other day rather than every day) for better iron absorption than daily dosing. The patients can follow M-W-F approach (Monday-Wednesday-Friday).
3. We give 1 to 3 tablets [65 to 200 mg]) based on patient preference and tolerance.

Dr KK Aggarwal

Padma Shri Awardee

President Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA