The n e w e ng l a n d j o u r na l of m e dic i n e

Review Article

Dan L. Longo, M.D., Editor

Iron-Deficiency Anemia
Clara Camaschella, M.D.

I
From Vita Salute University and San Raf- ron deficiency and iron-deficiency anemia are global health
faele Scientific Institute, Milan. Address problems and common medical conditions seen in everyday clinical practice.
reprint requests to Dr. Camaschella at
Vita Salute University, San Raffaele Sci- Although the prevalence of iron-deficiency anemia has recently declined some-
entific Institute, Via Olgettina, 58, 20132 what, iron deficiency continues to be the top-ranking cause of anemia worldwide,
Milan, Italy, or at [email protected]. and iron-deficiency anemia has a substantial effect on the lives of young children
N Engl J Med 2015;372:1832-43. and premenopausal women in both low-income and developed countries.1 The
DOI: 10.1056/NEJMra1401038 diagnosis and treatment of this condition could clearly be improved.
Copyright 2015 Massachusetts Medical Society.
Iron is crucial to biologic functions, including respiration, energy production,
DNA synthesis, and cell proliferation.2 The human body has evolved to conserve
iron in several ways, including the recycling of iron after the breakdown of red
cells and the retention of iron in the absence of an excretion mechanism. How-
ever, since excess levels of iron can be toxic, its absorption is limited to 1 to 2 mg
daily, and most of the iron needed daily (about 25 mg per day) is provided through
recycling by macrophages that phagocytose senescent erythrocytes. The latter two
mechanisms are controlled by the hormone hepcidin, which maintains total-body
iron within normal ranges, avoiding both iron deficiency and excess.
Iron deficiency refers to the reduction of iron stores that precedes overt iron-
deficiency anemia or persists without progression. Iron-deficiency anemia is a
more severe condition in which low levels of iron are associated with anemia and
the presence of microcytic hypochromic red cells.
Iron-restricted erythropoiesis indicates that the delivery of iron to erythroid
precursors is impaired, no matter how replete the stores.3,4 Stores may be normal
or even increased because of iron sequestration in cases of anemia of chronic in-
flammation, which is observed in patients with autoimmune disorders, cancer,
infections, and chronic kidney diseases.3,4 The presence of both iron deficiency and
anemia of chronic disorders is common and may be seen in elderly patients5 and
patients with chronic kidney disease.6 However, a substantial fraction of the ane-
mia that is typical in elderly patients occurs in the absence of iron deficiency or
elevated hepcidin levels.7
Functional iron deficiency is a state of iron-poor erythropoiesis8 in which there
is insufficient mobilization of iron from stores in the presence of increased de-
mands, as is observed after treatment with erythropoiesis-stimulating agents.9 (See
the Glossary for definitions of terms related to iron-deficiency anemia.)
This review reconsiders iron deficiency and its anemia in light of advances in
the understanding of systemic iron homeostasis and examines causes, patho-
physiological features, and treatment options in adults. Readers are referred else-
where for information on the presentation, symptoms, and diagnosis of iron-defi-
ciency anemia through laboratory tests and on issues that are specific to children
or pregnancy.10-13

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 Iron-Deficiency Anemia

Glossary

Anemia of chronic disorders or anemia of inflammation: Multifactorial anemia associated with increased cytokine pro-
duction, up-regulation of hepcidin, and abnormal iron homeostasis.
Functional iron deficiency: Insufficient mobilization of erythroid iron in the presence of increased requests, as occurs
after treatment with erythropoiesis-stimulating agents.
Iron deficiency: Depressed levels of total body iron, especially iron stores, with preservation of levels of erythroid iron.
Iron-deficiency anemia: Depressed levels of total body iron in the presence of anemia.
Iron-restricted erythropoiesis: A reduced supply of iron for the purpose of erythropoiesis, regardless of the level of iron
stores, which are usually replete.

Iron-refractory iron-deficiency anemia (IRIDA): Iron-deficiency anemia that is unresponsive to oral iron treatment, in
most cases referring to the genetic disease caused by a mutation in TMPRSS6, the gene encoding transmembrane
protease, serine 6, also known as matriptase-2.

A Gl ob a l He a lth Probl em vegetarian diet or no intake of red meat) and

pathologic conditions (e.g., chronic blood loss or
Iron deficiency affects more than 2 billion people malabsorption) are the most common causes.
worldwide,1 and iron-deficiency anemia remains Paradoxically, it appears to be more difficult to
the top cause of anemia, as confirmed by the reduce the prevalence of iron-deficiency anemia
analysis of a large number of reports on the in high-income countries than in lower-income
burden of disease in 187 countries between 1990 countries. One reason for this seeming paradox
and 201014 and by a survey on the burden of ane- is the high rate of iron deficiency in aging popu-
mia in persons at risk, such as preschool chil- lations.14
dren and young women.15 Prevention programs
have decreased rates of iron-deficiency anemia Modific at ions of Iron
globally; the prevalence is now highest in Cen- Homeos ta sis in Iron Deficienc y
tral and West Africa and South Asia.14,15 The esti-
mated prevalence of iron deficiency worldwide is The mechanisms of iron acquisition are tightly
twice as high as that of iron-deficiency anemia. regulated by hepcidin-based homeostatic con-
The reported prevalence of iron deficiency in trols.2 Hepcidin is a peptide hormone that is
the absence of dietary fortification is approxi- synthesized primarily in the liver. It functions as
mately 40% in preschool children, 30% in men- an acute-phase reactant that adjusts fluctuations
struating girls and women, and 38% in pregnant in plasma iron levels caused by absorptive entero-
women.14-16 These rates reflect the increased cytes and macrophages in the spleen by binding
physiological need for dietary iron during spe- to and inducing the degradation of ferroportin,
cific life stages and according to sex. The which exports iron from cells.17 Hepcidin expres-
growth spurt of adolescence is another critical sion increases in response to high circulating
period. For patients in any of these categories, and tissue levels of iron and in persons with
pathologic causes of iron-deficiency anemia are systemic inflammation or infection. Its produc-
often absent and extensive diagnostic workups tion is inhibited by the expansion of erythropoie-
are not advised. However, as discussed below, sis, iron deficiency, and tissue hypoxia in response
when the response to treatment is unsatisfacto- to signals originating in the bone marrow, the
ry, multiple causes should be considered, even in liver, and probably muscle tissue and adipo-
patients in these high-risk groups. cytes.2,18 Increases in hepcidin levels that are
In developing countries, iron deficiency and induced by inflammatory cytokines, especially
iron-deficiency anemia typically result from in- interleukin-6, explain the iron sequestration and
sufficient dietary intake, loss of blood due to reduced supply of erythropoietic iron that occurs
intestinal worm colonization, or both. In high- in the anemia of chronic disease.
income countries, certain eating habits (e.g., a In the general population, hepcidin levels are

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 The n e w e ng l a n d j o u r na l of m e dic i n e

Erythropoiesis
Fe
DMT1
+
EPO
Fe Erythroblasts
HIF-2

Enterocyte HIF-2
ERFE?
TMPRSS6
Kidney
FPN Fe
Red
cells

BMP6
All
Fe Fe Fe
organs
Hepcidin

Hepatocyte

Fe
Fe
Apotransferrin
Heart
Fe
Skeletal Spleen
muscle Fe macrophage

Fe FPN

Figure 1. The Iron Cycle Mechanisms of Adaptation to Iron Deficiency.

The mechanisms of adaptation to iron deficiency are centered on the suppression of the hepatic hormone hepcidin
and the tissue hypoxia that develops consequent to anemia. The production of erythropoietin (EPO) by the kidney
increases in response to enhanced levels of hypoxia-inducible factor 2 (HIF-2). As a consequence of the stimula-
tion of erythropoietin, erythropoiesis is increased and hypochromic microcytic red cells are produced owing to the
low availability of iron. Senescent red cells are destroyed by macrophages, and their iron is recycled. The increase in
erythropoiesis suppresses the production of hepcidin. In mice, this function is mediated by erythroferrone (ERFE),
which is secreted by the erythroblasts21 to maintain adequate iron absorption and efficiency in erythropoiesis. HIF-2
increases the expression of the duodenal divalent metal transporter 1 (DMT1)22 on the apical surface of enterocytes
to increase the transfer of dietary iron from the lumen to enterocytes. Hepcidin levels are depressed in response to
a reduction in the physiologic signals that maintain its production (e.g., increases in levels of iron-bound transferrin
and in the iron content of the liver),2,18 to the increased activity of the inhibitor transmembrane protease, serine 6
(TMPRSS6),23 to the reduction in levels of the activator bone morphogenetic protein 6 (BMP6), and to increased in-
hibition from erythropoietin-stimulated erythropoiesis. Ferroportin (FPN), which is no longer being degraded because
of the low levels of hepcidin, exports the available iron across the enterocyte basal membrane and from macrophage
stores17 to the circulation. Once stores are exhausted, levels of circulating iron decrease, even if absorption from the
lumen is increased. Reduced levels of iron in the liver trigger increases in the synthesis of the iron carrier transferrin
(referred to as apotransferrin when not bound to iron), further decreasing levels of iron-bound transferrin, the ligand
of the transferrin receptor. Consequently, the uptake of iron from transferrin receptors by all cells and organs (e.g.,
skeletal muscles and the heart) is reduced.

low in girls and young women and higher strong direct correlation with serum levels of
similar to levels in men in postmenopausal ferritin.19,20 In iron deficiency, the transcription
women; fluctuations in hepcidin levels have a of hepcidin is suppressed. This adaptive mecha-

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 Iron-Deficiency Anemia

Table 1. Causes of Iron Deficiency.

Cause Example
Physiologic
Increased demand Infancy, rapid growth (adolescence), menstrual blood loss, pregnancy (second and
third trimesters), blood donation
Environmental Insufficient intake, resulting from poverty, malnutrition, diet (e.g., vegetarian, vegan,
iron-poor)
Pathologic
Decreased absorption Gastrectomy, duodenal bypass, bariatric surgery, Helicobacter pylori infection, celiac
sprue, atrophic gastritis, inflammatory bowel diseases (e.g., ulcerative colitis,
Crohns disease)*
Chronic blood loss Gastrointestinal tract, including esophagitis, erosive gastritis, peptic ulcer, diverticuli-
tis, benign tumors, intestinal cancer, inflammatory bowel diseases, angiodysplasia,
hemorrhoids, hookworm infestation, obscure source
Genitourinary system, including heavy menses, menorrhagia, intravascular hemoly-
sis (e.g., paroxysmal nocturnal hemoglobinuria, autoimmune hemolytic anemia
with cold antibodies, march hemoglobinuria, damaged heart valves, microangio-
pathic hemolysis)
Systemic bleeding, including hemorrhagic telangiectasia, chronic schistosomiasis,
Munchausens syndrome (e.g, self-induced hemorrhages)
Drug-related Glucocorticoids, salicylates, NSAIDs, proton-pump inhibitors
Genetic Iron-refractory iron-deficiency anemia
Iron-restricted erythropoietic Treatment with erythropoiesis-stimulating agents, anemia of chronic disease, chronic
kidney disease*

* Inflammatory conditions may be associated with iron deficiency. NSAIDs denotes nonsteroidal antiinflammatory drugs.

nism facilitates the absorption of iron (Fig. 1) losses are well-known causes of iron-deficiency
and the release of iron from body stores. Intes- anemia in developed countries (Table 1). Chron-
tinal iron uptake from the gut lumen through ic blood loss from the gastrointestinal tract, in-
divalent metal transporter 1 (DMT1) is increased cluding occult blood, especially in male patients
by the activation of hypoxia-inducible factor and elderly patients, may reveal the presence of
2.22 The degree of store repletion determines benign lesions, angiodysplasia, or cancer. The
the rapidity with which iron deficiency develops origin of obscure gastrointestinal blood loss,24
in cases of blood loss or a drastic reduction in especially from the small bowel, may be clari-
iron absorption. Hepatocytes appear to be a fied by means of video-capsule endoscopy, which
long-term reservoir for iron and release it more is increasingly used when conventional workups
slowly than macrophages. for iron-deficiency anemia return negative re-
sults.25 Persons who donate blood regularly are
also at risk for iron deficiency, and their iron
C ause s of Iron-Deficienc y
A nemi a levels should be monitored.
In rare forms of intravascular hemolysis, iron
Poverty, malnutrition, and famine are self-explan- is lost in the urine, and iron deficiency then ag-
atory causes of anemia in the multitude of peo- gravates anemia (e.g., in paroxysmal nocturnal
ple living with iron deficiency in developing hemoglobinuria). Anemia in endurance athletes
countries, especially children and pregnant may be due to hemolysis, blood loss, and often
women. In addition, a cereal-based diet decreas- mild inflammation. Nonsteroidal antiinflamma-
es iron bioavailability because phytates in grains tory drugs and anticoagulants may contribute to
sequester iron in a poorly absorbable complex. blood loss, and proton-pump inhibitors are a
Other common causes in developing countries frequently overlooked cause of impaired iron
include hookworm infections and schistosomia- absorption (Table 1).26
sis, which cause chronic blood loss.14 Strict vegan The simultaneous occurrence of multiple
and vegetarian diets, malabsorption, and chron- causes of iron deficiency is common. In develop-
ic blood loss resulting from heavy menstrual ing countries, low iron intake combined with

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 The n e w e ng l a n d j o u r na l of m e dic i n e

intestinal infections with nematodes may result iron. Typical findings include a striking micro-
in severe anemia, especially in young children. cytosis and extremely low transferrin saturation
The severity of iron deficiency is also associated in the presence of normal or borderline-low
with Ancylostoma duodenale (hookworm) load, ac- ferritin levels and high hepcidin levels.38 The
cording to the results of real-time polymerase- diagnosis ultimately requires sequencing of
chain-reaction assays of fecal samples.27 In TMPRSS6. IRIDA represents less than 1% of the
chronic schistosomiasis, blood losses combine cases of iron-deficiency anemia seen in medical
with the anemia of inflammation.28 Patients practice. However, knowledge of this condition
with hypermenorrhea may also have concomi- is valuable to clinicians, since it clarifies how
tant malabsorption of iron.29 In end-stage kid- essential the suppression of hepcidin is (Fig. 1)
ney disease, iron-deficiency anemia results from to the bodys response to pharmacologic iron.
blood loss during dialysis, reduced hepcidin clear- IRIDA also suggests the existence of genetic
ance, inflammation, and certain drugs (e.g., susceptibility to iron deficiency. Variants of
proton-pump inhibitors and anticoagulants). In TMPRSS6 have been associated with the modula-
elderly persons, the prevalence of anemia corre- tion of serum hepcidin levels in individual per-
lates with advanced age and multiple related sons,40 the variation in iron levels in population
conditions, including iron deficiency,5 inflam- studies,41,42 and even with iron-deficiency anemia
matory disorders, decreased levels of erythropoi- in elderly Chinese women.43 It is possible that
etin, and cancer.30 Obesity may be associated coexisting acquired factors explain the ethnic
with mild iron deficiency because of subclinical specificity of the latter association.
inflammation, increased hepcidin levels, and de- In most cases, iron resistance is due to disor-
creased iron absorption.31 Some studies report a ders of the gastrointestinal tract29 (Table 1).
high prevalence of iron deficiency (30 to 50%) in Partial or total gastrectomy or any surgical pro-
patients with congestive heart failure,32,33 prob- cedure that bypasses the duodenum can cause
ably because of impaired iron absorption and resistance to oral iron. Bariatric surgery, such as
inflammation: increased serum levels of hepci- laparoscopic Roux-en-Y gastric bypass, which is
din have been reported in the early stages of performed in selected obese patients to reduce
disease but not during disease progression.34 caloric intake and to correct diabetes, is an
emerging cause of iron deficiency and anemia
Iron-R efr ac t or y Iron- because the procedure effectively removes an ac-
Deficienc y A nemi a tive iron absorption site from the digestive pro-
cess and increases gastric pH.44 The limited fol-
Iron-deficiency anemia is usually acquired. How- low-up data on patients who have undergone the
ever, the elucidation of systemic iron homeosta- procedure indicate that iron deficiency develops
sis has led to the recognition of a rare autosomal in up to 45%,45 particularly in women; lifelong
recessive disorder, iron-refractory iron-deficiency nutritional monitoring and iron supplementa-
anemia (IRIDA) (Online Mendelian Inheritance tion are advised.46 Helicobacter pylori infection de-
in Man [OMIM] number, 206200).35 Iron-defi- creases iron absorption (Table 1) because the
ciency anemia is defined as refractory when microorganism competes with its human host
there is an absence of hematologic response for available iron, reduces the bioavailability of
(an increase of <1 g of hemoglobin) after 4 to vitamin C, and may lead to microerosions that
6 weeks of treatment with oral iron.29 IRIDA is cause bleeding.47 Since it is estimated that half
caused by a mutation in TMPRSS6,36 the gene en- the worlds population is infected with H. pylori,
coding transmembrane protease, serine 6, also clinicians should be aware of the possibility of
known as matriptase-2, which inhibits the sig- infection and provide treatment in order to
naling pathway that activates hepcidin (Fig. 1).37 eradicate this source of iron-resistant iron-defi-
Loss-of-function mutations in TMPRSS6 reported ciency anemia. The prevalence of celiac disease
in more than 50 families38,39 have led to consti- and its atypical manifestations, which include
tutively high production of hepcidin, which iron-deficiency anemia, are increasingly recog-
blocks the intestinal absorption of iron. This nized worldwide.48 In one study, screening for
type of anemia is variable, more severe in chil- the prevalence of gluten sensitivity with the use
dren, and unresponsive to treatment with oral of anti-transglutaminase antibodies uncovered

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 Iron-Deficiency Anemia

negligible incidence among iron-replete partici- and anemia of chronic diseases) are well estab-
pants, whereas 2.5% of participants with iron lished (Table 2). Serum ferritin level is the most
deficiency had sensitivity to gluten.49 In another sensitive and specific test used for the identifica-
study of a series of patients with iron-refractory tion of iron deficiency (indicated by a level of
iron-deficiency anemia, 5% of participants had <30 g per liter). Levels are lower in patients
gluten sensitivity.29 These findings suggest that with iron-deficiency anemia; a transferrin satu-
gluten sensitivity may be associated with iron- ration level of less than 16% indicates an iron
refractory iron-deficiency anemia. Similarly, au- supply that is insufficient to support normal
toimmune atrophic gastritis, another rare cause erythropoiesis. However, in determining iron
of iron-refractory deficiency anemia, which re- status, it is important to consider the whole pic-
sults from an immune reaction against gastric ture rather than relying on single test results.
parietal cells and intrinsic factor, should be Guidelines for the differential diagnosis of mi-
considered as a possible albeit unlikely cause of crocytic anemias have recently been reviewed
iron-refractory microcytic anemia.29 In patients elsewhere.11,53 The diagnosis of iron-deficiency
with inflammatory bowel disease, anemia may anemia in the context of inflammation is chal-
be iron-resistant, but it is multifactorial, often lenging and cannot be determined on the basis
resulting from a combination of deficiencies in of the results of a single test (Table 2): signifi-
iron, folate, and vitamin B12, inflammation, and cantly higher cutoff levels for ferritin are used to
side effects from drug therapy. define iron-deficiency anemia accompanied by
inflammation,3 with the best predictor being a
Cl inic a l Findings ferritin level of less than 100 g per liter. High-
er cutoff levels for ferritin are used in the diag-
Iron-deficiency anemia is chronic and frequently nosis of iron deficiency in other conditions (e.g.,
asymptomatic and thus may often go undiag- <300 g per liter for heart failure50 and for
nosed. Weakness, fatigue, difficulty in concen- chronic kidney disease in the presence of a
trating, and poor work productivity are nonspe- transferrin saturation level of less than 30%54).
cific symptoms ascribed to low delivery of The assessment of iron stores through iron
oxygen to body tissues and decreased activity of staining of bone marrow specimens obtained by
iron-containing enzymes. The extent to which means of biopsy is an option that is not used
these nonhematologic effects of iron deficiency frequently. At present, no reliable test for hepci-
are manifested before anemia develops is un- din levels is available.
clear. Signs of iron deficiency in tissue are subtle
and may not respond to iron therapy. Iron defi- Ther a py
ciency has been reported to decrease cognitive
performance and to delay mental and motor Cautions and General Guidelines
development in children. Patients with iron-deficiency anemia should re-
Severe iron-deficiency anemia in pregnancy is ceive iron supplementation. Caution must be
associated with an increased risk of preterm la- used in areas in which malaria is endemic be-
bor, low neonatal weight, and increased new- cause supplementation may reverse the poten-
born and maternal mortality. Iron deficiency tially protective effects of iron deficiency55 or
may predispose a person to infections, precipi- increase the susceptibility to coinfections.56 In
tate heart failure, and cause restless leg syn- vitro studies have shown that the malaria para-
drome. In patients with heart failure, iron defi- site Plasmodium falciparum is less efficient in infect-
ciency has a negative effect on the quality of life, ing iron-deficient erythrocytes than in infecting
irrespective of the presence of anemia.50 iron-replete erythrocytes, a protection that is re-
versed with iron supplementation.57 Some stud-
ies support the view that measurement of hepci-
De ter minat ion of Iron S tat us
din levels could help to determine the best time
The traditional laboratory measures and results (e.g., the end of malaria season) to provide
used to determine iron status and iron defi- children in these regions with iron supplementa-
ciency and related conditions (e.g., functional tion.58 Emerging data suggest that nonabsorbed
iron deficiency, iron-deficiency anemia, IRIDA, iron could be harmful to patients because it

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 1838
Table 2. Laboratory Tests for the Measurement of Iron Status in Adults.

Iron-Deficiency
Anemia and
Iron Functional Iron-Deficiency Anemia of Chronic Anemia of Chronic
Test Deficiency Iron Deficiency Anemia IRIDA Diseases Diseases Normal Value
Current
Iron mol/liter Low Lownormal Low Low Low Low 1030
Transferrin saturation % 16 Low normal <16* <10 Lownormal Lownormal >16 to <45
Ferritin g/liter <30 Normal <10 Variable >100 <100
The

Men 40300
Women 20200
Hemoglobin g/dl Normal Normal Low Low Low Low
Men >13
Women >12

n engl j med 372;19

Mean corpuscular volume fl Normal Normal <80 Very low Lownormal Low 8095
Mean corpuscular hemoglobin pg Normal Normal <27 Very low Lownormal Low 2734
Proposed

nejm.org
sTFR mg/liter High High High High Lownormal Variable Varies
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The New England Journal of Medicine

of

sTFR/log ferritin index NA NA >2 NA <1 >2 Varies

Hepcidin Low Low Very low Normalhigh High Normalhigh Varies

May 7, 2015
Zinc protoporphyrin** Normal High High High High High Varies
Reticulocyte hemoglobin content pg <25 <29 Low Low Low Low 31.21.6

Copyright 2015 Massachusetts Medical Society. All rights reserved.

m e dic i n e

Perls staining of bone marrow for iron Negative Variable Negative Positive Strongly positive Positive Positive

* The value for transferrin saturation in the diagnosis of iron-deficiency anemia is from Beutler and Waalen.51
The value for ferritin in the diagnosis of iron-deficiency anemia has a sensitivity of 92% and a specificity of 83% according to Goodnough et al.4
The value for ferritin in the anemia of chronic disease and the combined value for the anemia of chronic disease and iron deficiency are from Weiss and Goodnough.3
The value for the soluble transferrin receptor (sTFR), which is shed by the erythroblast membrane in serum, may be useful in the assessment of iron-deficiency anemia, but the meth-
ods used to measure sTFR have been not standardized.3
Normal values vary according to the method of measurement used.
The sTFR/log ferritin index has been proposed to distinguish iron-deficiency anemia in the anemia of chronic disease from the anemia of chronic disease alone.3

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** The values for zinc protoporphyrin are used only in screening for or monitoring iron-deficiency anemia..9
Reduction of reticulocyte hemoglobin content is an early sign of functional iron deficiency.52
 Iron-Deficiency Anemia

might modify the gut microbiota, increasing the Table 3. Indications for Parenteral Iron Therapy.
concentration of intestinal pathogens.59
The benefit of treating iron deficiency before Established indication
the development of anemia remains uncertain. A Failure of oral therapy
few small studies show that the administration Iron intolerance or with low iron levels that are refractory to treatment (e.g.,
of intravenous iron improves fatigue in women after gastrectomy or duodenal bypass, with Helicobacter pylori infection,
without anemia whose ferritin levels are in the or with celiac disease, atrophic gastritis, inflammatory bowel disease, or
genetically induced IRIDA*)
iron-deficient range.60 Some studies have also
Need for quick recovery (e.g., with severe iron deficiency in the second or third
suggested that oral iron supplementation bene- trimester of pregnancy or with chronic bleeding that is not manageable
fits physical performance in women of repro- with oral iron, as may occur in patients with congenital coagulation
ductive age,61 but such studies have included a disorders)
limited number of participants and are strik- Substitution for blood transfusions when not accepted by patient for religious
ingly heterogeneous. reasons
Patients with severe iron-deficiency anemia Use of erythropoiesis-stimulating agents in chronic kidney disease
that causes cardiovascular symptoms, such as Potential indication
heart failure or angina, should receive red-cell Anemia of chronic kidney disease (without treatment of erythropoiesis-stimu-
transfusions. This approach rapidly corrects not lating agents)
only hypoxia but also iron deficiency, since one Persistent anemia after use of erythropoiesis-stimulating agents in patients
unit of packed red cells provides approximately with cancer who are receiving chemotherapy
200 mg of iron. Anemia of chronic disease unresponsive to treatment with erythropoiesis-
stimulating agents alone
Oral Iron Therapy Potential indication with insufficient supporting data
The administration of oral iron is a convenient, Iron deficiency in heart failure
inexpensive, and effective means of treating Transfusion-sparing strategy in surgical patients
stable patients. Among the myriad preparations
on the market, iron sulfate is the most frequent- * Celiac disease or H. pylori infection should be considered if the anemia re-
mains refractory to treatment. IRIDA denotes iron-refractory iron-deficiency
ly used; gluconate and fumarate are also effec- anemia.
tive iron salts. The recommended daily dose for
adults with iron deficiency is 100 to 200 mg of
elementary iron and that for children is 3 to 6 such as the eradication of infection with H. py-
mg per kilogram of body weight of a liquid lori or the introduction of a gluten-free diet in
preparation; for both groups the supplement patients with celiac disease, may restore the ca-
should be administered in divided doses without pacity for iron absorption and eliminate the
food. The addition of vitamin C may improve need for supplementation in some patients.29
absorption. The low hepcidin levels in patients There are no known markers that can be used to
with iron-deficiency anemia ensure effective predict which patients will or will not have a
iron absorption and the rapid recovery of hemo- response to oral iron therapy. The oral iron chal-
globin levels; however, 3 to 6 months of treat- lenge test (in which 60 mg of oral iron is admin-
ment are required for the repletion of iron stores istered and serum iron levels are measured 1 to
and the normalization of serum ferritin levels. 2 hours afterward) is rarely used since it has not
Long-term use of oral iron is limited by side ef- been extensively validated. A pilot study showed
fects, including nausea, vomiting, constipation, that measurement of serum hepcidin levels
and metallic taste; these side effects are frequent could help to identify patients in whom a re-
and, although not severe, are often worrisome to sponse to oral iron is probable (those with low
patients. Although oral iron may cause dark hepcidin levels) and those in whom it is not
stools, it does not produce false positive results probable (those with normal or elevated hepci-
on tests for occult blood. If treatment with oral din levels).62 However, hepcidin tests are not
iron fails, the reasons may include premature routinely available for clinical use. Assessment
termination of treatment, lack of compliance of an early response to oral iron might also be
with the regimen or discontinuation by the pa- useful in the treatment of iron-deficiency ane-
tient, or a truly refractory response to treatment. mia in patients with anemia of chronic disease.
In the latter case, other, specific treatments, One study in patients with rheumatologic dis-

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 The n e w e ng l a n d j o u r na l of m e dic i n e

Table 4. Iron Preparations for Intravenous Use.*

Formulation Dose per Infusion

Standard Maximum per Single Infusion

Ferric gluconate (Ferlecit) 125 mg/1060 min 250 mg/60 min
Iron sucrose (Venofer) 100400 mg/290 min 300 mg/2 hr
Low-molecular-weight iron dextran 100 mg/2 min 1000 mg/14 hr)
(INFeD)
Ferumoxytol (Feraheme) 510 mg/>1 min 5101020 mg/1560 min
Ferric carboxymaltose (Ferinject) 7501000 mg/1530 min 7501000 mg/1530 min
Iron isomaltoside (Monofer) 20 mg/kg of body weight/15 min 20 mg/kg of body weight/15 min

* Data are adapted from Powers and Buchanan13 and Auerbach and Ballard66
Drugs that can be administered as a total dose in a single infusion.
Iron isomaltoside is licensed for use only in Europe.

ease and iron-deficiency anemia showed that a matory bowel disease is an emerging indication
change in the hemoglobin content of reticulo- for the use of intravenous iron (Table 3); oral
cytes (and in serum levels of iron and transferrin iron is not only ineffective but may also increase
saturation) may predict the response to the admin- local inflammation.68
istration of oral iron after 1 week of therapy.63 Intravenous iron is essential in the manage-
ment of anemia in patients with chronic kidney
Parenteral Iron Therapy disease who are receiving dialysis and treatment
The possibility of hypersensitivity reactions (in- with erythropoiesis-stimulating agents. The ad-
cluding anaphylaxis) to high-molecular-weight dition of iron supplementation may eliminate or
iron dextran has traditionally limited the indica- delay the need for these agents in some patients
tions for the intravenous administration of iron. with chronic kidney disease who are not receiv-
Newly approved, safer iron formulations are ing dialysis.6,69 Erythropoiesis-stimulating agents
modifying this clinical practice (Table 3). Be- are also used in selected patients with low-risk
cause the use of intravenous iron circumvents myelodysplastic syndrome and in patients with
the problem of iron absorption, it is more effec- cancer who are receiving chemotherapy: in these
tive and increases hemoglobin levels more quick- circumstances, iron supplementation is usually
ly than oral iron.54,64,65 Another advantage is that limited to patients with concomitant iron defi-
in some patients the total dose required (up to ciency or to those in whom there is no response
1000 mg) can be provided in a single infusion to erythropoiesis-stimulating agents; intrave-
(Table 4). The dose needed is calculated with nous iron is preferred when high hepcidin levels
this formula: body weight in kilograms 2.3 create a condition that is refractory to supple-
hemoglobin deficiency (target hemoglobin level mentation with oral iron.6 The way in which iron
patient hemoglobin level) + 500 to 1000 mg iron enhances the effect of erythropoiesis-stimulat-
for the repletion of iron stores. The cost of par- ing agents is unclear. One hypothesis suggests
enteral iron therapy is high, but the number of that increased iron in macrophages leads to the
hospital or clinic visits that are required is sig- overexpression of ferroportin by means of the
nificantly decreased.67 iron-responsive elementiron-regulatory protein
Patients with malabsorption and genetic system, which enhances the mobilization of iron
IRIDA38,39 may require intravenous iron. Intrave- for use in erythropoiesis.4 Intravenous iron
nous administration is also preferred when a should be avoided in the first trimester of preg-
rapid increase in hemoglobin level is required or nancy because of the lack of data on safety70; it
when iron-deficiency anemia caused by chronic has an acceptable side-effect profile when used
blood loss cannot be controlled with the use of later in pregnancy.71
oral iron, as is the case in patients with heredi- Studies of the use of parenteral iron therapy
tary hemorrhagic telangiectasia. Active inflam- for conditions other than those mentioned are

1840 n engl j med 372;19 nejm.org May 7, 2015

The New England Journal of Medicine

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 Iron-Deficiency Anemia

either limited or not controlled. A multicenter of atopy, and drug allergy. Practical recommen-
European trial of patients with iron deficiency dations for minimizing risk70 include a slow in-
and chronic heart failure showed that the use of fusion rate, careful patient observation, and ad-
intravenous iron supplementation led to im- ministration by trained health care personnel in
provements in physical performance, New York an environment with access to resuscitation fa-
Heart Association functional class,50 and quality cilities.75 The test dose may provide false reas-
of life independently from the correction of ane- surance; premedication with antihistamine is no
mia72; more recently, 1 year of treatment was longer advised because it may cause hypotension
associated with a reduced risk of hospitaliza- and tachycardia.70,75,76
tion.73 However, since these results were based Clinical trials are reassuring with regard to
largely on subjective evaluation, larger and lon- the efficacy and side-effect profile of intrave-
ger-term studies are required to assess the real nous iron. Some concern persists with regard to
benefit of administering iron to patients with the long-term biologic effects of iron and its
heart failure. effects on the generation of oxygen radicals,
The transient side effects of intravenous iron patient susceptibility to infections,54,66 and the
supplementation include nausea, vomiting, pru- potential such treatment would have to worsen
ritus, headache, and flushing; myalgia, arthral- conditions such as type 2 diabetes and other
gia, and back and chest pain usually resolve chronic metabolic disorders.77 Well-designed,
within 48 hours, even after total dose adminis- randomized, controlled trials are needed to ver-
tration.74 Hypersensitivity reactions are rare,66,74 ify the long-term effects of intravenous iron
as are severe or life-threatening reactions75; the supplementation.78 In the interim, intravenous
pathophysiological features of these reactions iron should be used only when the benefits out-
are uncertain and might be exacerbated by re- weigh the risks.
leased free iron,70,76 a phenomenon that does not No potential conflict of interest relevant to this article was
reported.
occur with currently used formulations. Predis- Disclosure forms provided by the author are available with the
posing conditions are rapid infusions, a history full text of this article at NEJM.org.

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