Scope of this summary
Adults with suspected or confirmed iron deficiency, with or without anemia. Acute major bleeding, pregnancy, advanced chronic kidney disease, cancer-treatment anemia, pediatric disease and severe inflammatory disease need population-specific protocols. Iron replacement does not remove the obligation to identify blood loss or malabsorption.
The Bottom Line
- Confirm anemia and iron deficiency using the complete blood count, ferritin and transferrin saturation interpreted with inflammation, kidney or liver disease; microcytosis can be absent early and ferritin can be misleadingly normal or high during inflammation.
- Look for the cause from menstrual and gastrointestinal blood loss, diet, pregnancy, blood donation, bariatric or gastric surgery, celiac disease, inflammatory bowel disease, medications and other malabsorption before assuming intake alone.
- When oral replacement is appropriate, AGA advises no more than once-daily dosing; every-other-day dosing can improve tolerance with similar absorption, and inexpensive ferrous sulfate is reasonable rather than claiming one formulation is universally superior.
- Use intravenous iron when oral iron is not tolerated, ferritin fails to improve after a trial or absorption is unlikely; select a formulation and setting that can replace the deficit efficiently and manage infusion reactions.
- For unexplained iron-deficiency anemia, use the AGA gastrointestinal pathway: bidirectional endoscopy is recommended for most men and postmenopausal women and considered with shared decisions in premenopausal women.
Practical clinical workflow
1
Record bleeding, menstrual pattern, pregnancy possibility, bowel symptoms, diet, donation, surgery, acid suppression, NSAIDs or anticoagulants and family or inherited hematologic history; examine for hemodynamic compromise and source clues.
2
Obtain CBC with indices, reticulocyte information, ferritin and transferrin saturation, adding inflammatory, kidney, hemolysis, B12, folate or celiac testing when the pattern requires it.
3
Treat the identified source and begin oral or IV replacement with a documented elemental-iron plan, adverse-effect counseling and interaction or absorption review.
4
Check symptoms, hemoglobin and iron stores at an interval appropriate to severity and route; failure to respond requires reassessment of adherence, ongoing loss, wrong diagnosis, inflammation or malabsorption.
5
Continue long enough to restore stores after hemoglobin improves, then prevent recurrence through source treatment and a clear monitoring plan rather than indefinite unreviewed supplementation.
Safety boundaries and escalation
- Hemodynamic instability, chest pain, syncope, ongoing major bleeding or profound symptomatic anemia requires emergency stabilization and transfusion decisions; transfused red cells do not replace the full iron deficit.
- New iron deficiency in an adult can be the first sign of gastrointestinal or gynecologic malignancy and must not be closed by a temporary hemoglobin response alone.
- Keep iron products away from children; overdose can be fatal, and unnecessary long-term iron can cause toxicity in a non-deficient patient.
- IV infusion symptoms require immediate assessment to distinguish transient reactions from rare anaphylaxis and avoid both dangerous rechallenge and inappropriate permanent denial of iron.
Localization
AGA guidance informs US oral and IV replacement and GI evaluation, while payer authorization and infusion protocols vary. the laboratory and condition-specific US pathway controls.
Source documents
Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.
- American Gastroenterological AssociationAGA Clinical Practice Update on Management of Iron Deficiency Anemia: Expert ReviewDOI 10.1016/j.cgh.2024.03.046 路 published 2024-06-11 路 accessed 2026-08-20view source
- American Gastroenterological AssociationGastrointestinal Evaluation of Iron Deficiency AnemiaDOI 10.1053/j.gastro.2020.06.046 路 published 2020-08-15 路 accessed 2026-08-20view source
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