52-year-old woman with fatigue and hemoglobin 9.6
A 52-year-old woman with seropositive rheumatoid arthritis and long-term ibuprofen use comes to clinic for 2 months of fatigue and reduced exercise tolerance. She has no melena, hematemesis, or weight loss. Temperature is 36.8 C, blood pressure 122/74 mm Hg, pulse 88/min. Conjunctivae are pale. Hemoglobin is 9.6 g/dL, mean corpuscular volume is 72 fL, reticulocyte count is low, ferritin is 7 ng/mL, serum iron is 20 mcg/dL, total iron-binding capacity is 460 mcg/dL, and transferrin saturation is 4%. Which of the following is the most appropriate next step in management?
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A
Explanation
Clinical Pearl:
In adult men and postmenopausal women, iron deficiency anemia warrants evaluation for occult gastrointestinal bleeding even when a potential alternative explanation, such as NSAID exposure, is present. Iron studies showing low ferritin with high total iron-binding capacity strongly support absolute iron deficiency rather than anemia of chronic inflammation.
Explanation:
This patient has clear iron deficiency anemia, shown by microcytosis, very low ferritin, low serum iron, elevated total iron-binding capacity, and low transferrin saturation. In a postmenopausal adult, current practice is to search for a gastrointestinal source of blood loss with upper endoscopy and colonoscopy rather than assuming dietary deficiency or attributing the anemia only to rheumatoid arthritis or NSAID use. Oral iron is appropriate treatment, but starting it without evaluating for occult bleeding risks missing a malignancy or other important lesion. Serum erythropoietin testing is not part of the routine workup for this pattern of anemia. Intravenous steroids would not treat iron deficiency and the laboratory pattern does not fit isolated anemia of chronic inflammation, which more often has normal or increased ferritin with low or normal total iron-binding capacity. Hemoglobin electrophoresis is used when thalassemia is suspected, but thalassemia trait usually has normal iron stores and often a relatively preserved red blood cell count despite marked microcytosis.
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