Iron refractory or Iron Resistant Iron Deficiency Anemia in Adult Celiac Disease Resolves with a Gluten-free Diet

Iron deficiency anemia is a common presentation of adult celiac disease. In a retrospective review of over 200 adults with celiac disease complicated by iron deficiency anemia, 7 patients were selected that were treated either with oral iron supplements with a limited hematologic response or unable to tolerate oral iron. Subsequently, treatment with a strict gluten free diet alone was provided. In all, resolution of the anemia resulted without a need for concomitant oral iron supplements. Another patient with marked fatigue and exercise intolerance was treated with intravenous iron, but the iron deficiency anemia only partially improved. After a strict gluten-free diet, her iron deficiency anemia resolved completely. Clinical experience in these celiac patients indicates that the key element in the treatment of iron deficiency anemia is a positive intestinal mucosal response to a gluten-free diet. In celiac patients with iron deficiency anemia, particularly with a limited hematologic response, intolerance or side effects to iron supplements, treatment solely with a gluten-free diet may be a reasonable option. Iron deficiency anemia in celiac disease is heterogeneous and may have multiple causes. Although duodenal mucosal disease is a critical factor, other factors may alter the regulation of iron homeostasis in this setting, including altered erythropoiesis due to the underlying chronic intestinal inflammatory process.