Iron Deficiency Anemia and Anemia of Chronic Disease are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.
Iron Deficiency Anemia vs Anemia of Chronic Disease at a glance
Iron Deficiency Anemia: Microcytic hypochromic anemia from depleted iron stores — most common anemia worldwide.
Anemia of Chronic Disease: Normocytic (sometimes microcytic) anemia driven by hepcidin-mediated iron sequestration in chronic inflammation.
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Question 1HematologyEasy
A 25-year-old woman reports several months of heavy menstrual bleeding and fatigue. Laboratory studies show hemoglobin 11.8 g/dL, mean corpuscular volume 74 fL, ferritin 6 ng/mL, total iron-binding capacity (TIBC) 420 ug/dL, and transferrin saturation 8%. Which of the following is the most appropriate initial treatment?
AOral ferrous sulfate
BIntravenous iron infusion
COral folic acid
DIntramuscular cyanocobalamin
Reveal answer & full explanation
Correct answer: A — Oral ferrous sulfate
AOral ferrous sulfate✓
BIntravenous iron infusion
COral folic acid
DIntramuscular cyanocobalamin
Why Oral ferrous sulfate is correct
Low ferritin (the most specific marker), elevated TIBC, low transferrin saturation, and microcytic indices confirm iron deficiency anemia.
Menorrhagia is the leading cause of iron deficiency in premenopausal women.
Oral ferrous sulfate (about 65 mg elemental iron per tablet) is first-line; reticulocytosis appears at 1-2 weeks and hemoglobin rises roughly 1 g/dL within 2 weeks (about 2 g/dL by 4 weeks).
Continue therapy about 3 months after normalization to replenish stores.
Why the others are wrong
Intravenous iron infusion — reserved for oral intolerance, malabsorption, or need for rapid repletion; choosing it first is right-diagnosis, wrong-step.
Oral folic acid — treats megaloblastic (macrocytic) anemia; the microcytic indices point away from it (buzzword trap on the word anemia).
Intramuscular cyanocobalamin — treats vitamin B12 deficiency; no macrocytic or neurologic features support it here.
Question 2HematologyMedium
A 64-year-old woman is evaluated for fatigue and reduced exercise tolerance over the past several months. Her hemoglobin is 9.8 g/dL with a normal MCV; serum iron and total iron-binding capacity are low and ferritin is 240 ng/mL. C-reactive protein and ESR are elevated. Her clinician concludes she has anemia of chronic disease and reviews her history for the underlying driver. Which of the following elements of her history is the strongest risk factor for this type of anemia?
AHeavy daily alcohol use over many years
BA strict vegetarian diet for several decades
CDaily low-dose aspirin use for many years
DActive rheumatoid arthritis with synovitis
Reveal answer & full explanation
Correct answer: D — Active rheumatoid arthritis with synovitis
AHeavy daily alcohol use over many years
BA strict vegetarian diet for several decades
CDaily low-dose aspirin use for many years
DActive rheumatoid arthritis with synovitis✓
Why Active rheumatoid arthritis with synovitis is correct
Anemia of chronic disease (anemia of inflammation) is driven by sustained inflammatory cytokine release, chiefly IL-6, which stimulates hepatic hepcidin production.
Hepcidin internalizes ferroportin, blocking intestinal iron absorption and trapping iron in reticuloendothelial macrophages, producing the low serum iron, low TIBC, and normal-to-elevated ferritin seen here.
Chronic autoimmune disease (RA, SLE, IBD, vasculitis) is among the strongest and most direct risk factors; active synovitis signals the ongoing inflammation that perpetuates the anemia.
Why the others are wrong
Daily low-dose aspirin use for many years predisposes to chronic occult GI blood loss and iron deficiency anemia (low ferritin, high TIBC), the opposite iron-study pattern from this patient.
A strict vegetarian diet restricts dietary iron and predisposes to iron deficiency anemia (low ferritin, high TIBC), again the opposite iron-study pattern.
Heavy daily alcohol use can cause anemia through marrow suppression, nutritional deficiency, and macrocytosis, but it does not drive the inflammatory hepcidin pathway that explains this iron-study pattern.
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Microcytic hypochromic anemia from depleted iron stores — most common anemia worldwide.
Normocytic (sometimes microcytic) anemia driven by hepcidin-mediated iron sequestration in chronic inflammation.
Classic presentation
Pica with ice craving plus microcytic anemia and low ferritin is highly suggestive of iron deficiency.; Fatigue, dyspnea on exertion, exercise intolerance, lightheadedness; Headache, poor concentration, irritability; Pica (craving ice/pagophagia, clay, starch) — relatively specific for iron deficiency; Restless legs syndrome; Hair loss,…
Mild normocytic anemia (Hb 9-11) with low serum iron, low TIBC, and normal or elevated ferritin in a patient with chronic inflammation.; Often asymptomatic or symptoms attributed to the underlying disease; Fatigue, reduced exercise tolerance, dyspnea on exertion; Worsening of preexisting angina or heart failure; Pallor, tachycardia;…
Workup / key labs
Anemia (low Hb for age and sex) plus ferritin <30 ng/mL indicates iron deficiency (<15 ng/mL is highly specific). With inflammation or CKD, which raise ferritin, a ferritin <100 ng/mL with transferrin saturation <20% still supports iron deficiency. Low transferrin saturation alone does not separate IDA from anemia of chronic disease.…
Mild-to-moderate anemia + identifiable chronic inflammatory state + low serum iron + low TIBC + normal/elevated ferritin.; CBC — Hb usually 8-11 g/dL; MCV normal (sometimes mildly low); Iron studies — low serum iron, low TIBC, transferrin saturation 10-20%, ferritin normal or elevated (>100 ng/mL); Reticulocyte count low (inadequate…
Imaging
Upper and lower endoscopy in men and postmenopausal women with IDA, and in premenopausal women not responding to iron; Capsule endoscopy if EGD/colonoscopy nondiagnostic and bleeding persists
Driven by suspected underlying condition; no specific imaging for ACD itself
First-line treatment
Identify and correct the underlying cause (most important step); Oral iron — ferrous sulfate 325 mg (65 mg elemental), ferrous gluconate, ferrous fumarate; one tablet every other day improves absorption and tolerability versus daily dosing; Take on empty stomach with vitamin C (orange juice) to enhance absorption; avoid concurrent…
Treat the underlying disease — most effective intervention; Optimize comorbidities (HF, diabetes, CKD); Iron repletion only if concurrent iron deficiency documented (combined picture). IV iron preferred in hemodialysis (KDIGO 2026) and in active IBD (hepcidin impairs oral absorption); oral or IV iron is acceptable in non-dialysis or…
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Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.