ASH Clinical Practice Guidelines in Development and Remaining Evidence Gaps in IDA Management

An expert reviews the scope and methodology of the ASH clinical practice guidelines on iron deficiency anemia currently in development, identifies the most significant remaining evidence gaps, and summarizes the practical takeaways for clinicians managing IDA today.

The American Society of Hematology is developing its first clinical practice guidelines specifically addressing iron deficiency anemia — a notable undertaking given how common the condition is and how much variation currently exists in diagnostic and management practices. The guidelines will address at least 10 clinical questions prioritized for their potential impact on practice, including diagnostic thresholds across populations such as children, pregnant women, and patients with inflammatory conditions; optimal oral iron dosing and formulation selection; IV iron use in specific populations; and preoperative anemia management. The panel includes more than 20 members — hematologists, pediatric hematologists, patient representatives, implementation science experts, and international members — and is applying GRADE methodology with systematic reviews. The guidelines are targeted for publication in Blood Advances.

The most consequential evidence gaps the ASH guidelines are designed to address reflect longstanding uncertainties that clinicians encounter daily. Optimal oral iron formulation and dosing schedules are not definitively established, though alternate-day dosing has gained traction as a tolerability strategy with comparable absorption. Head-to-head comparisons of IV iron formulations in specific populations — including those with IBD — remain limited, leaving formulation choice largely driven by practical and logistical factors rather than population-specific efficacy data. Management of IDA in pediatric and pregnant populations is currently extrapolated from adult data, and the ASH guidelines specifically plan to address these populations with dedicated evidence synthesis rather than continued extrapolation.

In this final segment of the video discussion on IDA management, Richard Godby, MD, synthesizes the practical bottom line for clinicians managing IDA in the current evidence environment. Ferrous sulfate once daily remains the appropriate starting point for most patients, with escalation to IV iron indicated when oral therapy fails, is not absorbed, or is not tolerated. IV iron formulation should be selected based on practical considerations — primarily the number of infusions required — given that all available products are considered safe and similarly efficacious. Godby closes with an emphasis that cutting across every clinical scenario discussed: iron repletion is necessary but not sufficient, and clinicians must maintain focus on identifying and managing the underlying source of iron deficiency to prevent recurrence and achieve durable benefit for their patients.