How to use it
Five tabs, one patient. Diagnose interprets ferritin (and TSAT if you have it) with or without inflammation. Treat (oral) picks a product and schedule and gives the cost, a prescription, the expected Hb response and when to switch to IV iron. Prevent is for patients who are not deficient now: target intake, strategy and products. Current iron looks up what the patient already takes (search by brand, salt or type, browse, or enter a custom product) and checks the dose. IV iron gives the total dose and schedule for each IV product, each by its own Canadian monograph.
The Treat and Current iron tabs share an optional clinical context (IBD activity, Hb, intolerance, malabsorption, bleeding, ESA). A blank Hb there uses the Hb from the Diagnose tab.
Reading ferritin
| Setting | Iron deficiency if | Source |
|---|---|---|
| Any | Ferritin <15 µg/L (highly specific) | BSG 2021 |
| Adults, no inflammation | Ferritin ≤30 µg/L | ASH 2026 (ECCO 2015: <30) |
| Anemia, no inflammation | Ferritin <45 µg/L | AGA 2020 |
| Symptoms or ongoing risk factors, no inflammation | Ferritin ≤50 µg/L may be used | ASH 2026 (remark) |
| Inflammation (active IBD, CKD, infection) | Ferritin <100 µg/L or TSAT <20%; test both together | ECCO 2015; ASH 2026 |
| Inflammation, ferritin 100–150 with TSAT <20% | Functional deficiency (anemia of inflammation); absolute deficiency possible | ECCO 2015; ASH 2026 |
| Ferritin >150 µg/L | Iron deficiency unlikely, even with inflammation and TSAT <20%; consider anemia of inflammation and other causes | BSG 2021 (the tool follows BSG here) |
In men and postmenopausal women with iron deficiency anemia, look for a GI cause. BSG says not to delay iron while waiting for the tests.
What changed in 2026
The American Society of Hematology published the first GRADE guideline on diagnosing iron deficiency (Blood Advances, August 2026). It raised the adult ferritin threshold from 15 to 30 µg/L, allows 50 µg/L with symptoms or ongoing risk factors, and in inflammation suggests ferritin and TSAT together, with ferritin <100 µg/L or TSAT <20%. All recommendations are conditional and based on low-certainty evidence. ASH treatment guidance is expected in 2027.
Where the guidelines disagree. Above 150 µg/L with inflammation and TSAT <20%, BSG 2021 regards absolute iron deficiency as unlikely; ASH 2026 sets no upper ferritin limit when TSAT is low. Dr. Squirell agrees with BSG above 150 µg/L, so the tool says iron deficiency is unlikely and suggests looking for anemia of inflammation and other causes. At 150 µg/L or below it follows ASH. Between 45 and 50 µg/L with anemia, AGA 2020 (45) and ASH 2026 (50 with risk factors) differ; the tool calls it possible iron deficiency. Most GI patients with anemia have a risk factor (blood loss, IBD, malabsorption, bariatric surgery), so the 50 µg/L remark often applies.
Oral iron
| Product (Canada) | Elemental iron | Cost a month at 1 daily | Ontario Drug Benefit |
|---|---|---|---|
| Ferrous fumarate 300 mg (Jamp-Fer, Euro-Fer, Wampole) | 100 mg | about $4–9 | Benefit (Jamp-Fer) |
| Palafer 300 mg capsules | 100 mg | about $12–14 | Not a benefit |
| Palafer suspension (300 mg per 5 mL) | 100 mg per 5 mL | about $25–27 | Benefit |
| Ferrous sulfate 300 mg | 60 mg | about $4–5 | Not listed |
| Ferrous gluconate 300 mg | 35 mg | about $2–3 | Benefit (AA Pharma) |
| FeraMAX Pd Therapeutic 150 (polydextrose-iron complex) | 150 mg | about $24–33 | Not listed |
| Heme iron polypeptide (Proferrin, Optifer Alpha; labelled up to 3 a day) | 11 mg | about $21–29 | Not listed |
| Ferric maltol (Accrufer), 30 mg twice daily, prescription | 30 mg | over $30 (no Canadian retail price verified) | Not listed |
Prices were checked at Canadian pharmacies and online retailers in October 2026. They are approximate and vary by pharmacy; the sources are listed at the side. Where no price could be verified the tool shows a tier ($ under $10, $$ $10–30, $$$ over $30 a month) or nothing.
Dose and schedule. BSG 2021: one tablet a day of a ferrous salt (50–100 mg elemental iron once daily, fasting, is the best compromise); every other day if not tolerated. ECCO 2024 (IBD): 60–120 mg as a single morning dose on alternate days. A dose of 60 mg or more raises hepcidin for about a day and cuts absorption of the next dose by 35–45%; a third dose within 24 hours adds nothing (Moretti 2015). Alternate-day dosing raised fractional absorption from 16.3% to 21.8% in iron-depleted women (Stoffel 2017), but in trials of patients with anemia the Hb rise was similar or slightly faster with daily dosing (Pasupathy 2023: +1.05 vs +1.36 g/dL at 8 weeks, not significant). Choose by tolerance. Take it fasting, away from tea, coffee, calcium and antacids (food can cut absorption by up to 75%). Vitamin C adds nothing (Li 2020), and BSG 2021 does not recommend it. Modified-release products release iron beyond the duodenum and are not recommended. Separate iron from levothyroxine by 4 hours (Synthroid monograph), and from quinolones, tetracyclines, bisphosphonates and mycophenolate by 2–4 hours (Accrufer monograph).
Response. A rise of 10 g/L or more in 2 weeks strongly suggests iron deficiency; no such rise after 2 weeks of daily iron predicts failure. At about 4 weeks a rise of 20 g/L, or into the normal range, is adequate. With alternate-day iron (at 4 weeks) or ferric maltol (at 6 weeks), a rise under 10 g/L means IV iron. Continue about 3 months after Hb normalises (BSG 2021).
When to use IV iron instead. In IBD: clinically active disease, previous intolerance to oral iron, or a need for an ESA (ECCO 2024); Hb below 100 g/L (ECCO 2015). ECCO 2024 keeps oral iron for mild anemia (Hb 110 g/L or more) with inactive disease, and ECCO 2015 caps oral iron at 100 mg a day in IBD. In anyone: ongoing significant bleeding, malabsorption from GI disease, or iron deficiency combined with anemia of inflammation (BSG 2021).
Ferric maltol (Accrufer, 30 mg iron per capsule) has been marketed in Canada since February 2025. It is labelled for iron deficiency anemia in adults who did not respond to, or could not tolerate, other oral iron: 30 mg twice daily on an empty stomach for at least 12 weeks. Its monograph advises against use during an IBD flare. BSG 2021 suggests it as an alternative to IV iron when Hb is above 95 g/L.
Prevention and maintenance
Prevention is for patients whose iron studies are normal now, and who have a reason. Deficiency needs a full treatment course and a search for the cause, not a prevention dose.
| Life stage | RDA (mg/day, total intake) |
|---|---|
| Men 19 and older; women 51 and older | 8 |
| Women 19–50 | 18 |
| Males 14–18 / females 14–18 | 11 / 15 |
| Pregnancy | 27 |
| Breastfeeding 19–50 / 14–18 | 9 / 10 |
These are Health Canada Dietary Reference Intakes for total intake from food and supplements, not supplement doses. Vegetarians need 1.8 times more because plant iron is less well absorbed. The upper limit (UL) is 45 mg/day from age 14; it is based on GI side effects and does not apply to iron given under medical supervision (IOM 2001).
| Situation | What to do | Source |
|---|---|---|
| Low intake | Iron-rich food; a daily multivitamin with iron covers the shortfall (check the label: Centrum Forte Essentials, for example, has 10 mg a tablet) | Health Canada DRI |
| Pregnancy | A daily multivitamin with 16–20 mg iron and 0.4 mg folic acid | Health Canada (AHS 2024) |
| Regular blood donor | 37.5 mg elemental iron daily for at least 8 weeks after each donation; ferritin in donors under 20 or giving twice a year or more; ferritin <25 µg/L, pause donation for 6 months | Canadian Blood Services 2023; Kiss 2015 |
| Gastric bypass, sleeve or duodenal switch | 45–60 mg elemental iron a day from all supplements, apart from calcium | ASMBS 2016 |
| IBD after repletion | Hb and ferritin every 3–6 months for a year, then every 6–12 months; re-treat when ferritin <100 µg/L or Hb <120 (women) or <130 g/L (men) | ECCO 2024 |
| Ongoing losses or recurrent deficiency | Treat the cause; one low-dose iron product daily (28–49 mg elemental iron); if deficiency recurs or Hb or ferritin are not kept stable, continue at full treatment dose; CBC every 3 months for a year | Clinic practice; BSG 2021 |
No guideline sets a preventive dose for heavy menstrual bleeding or other ongoing losses. The low-dose regimen above is Dr. Squirell’s clinic practice, and the tool labels it so.
Current iron (lookup)
The product list holds the common Canadian oral iron products, with elemental iron as labelled (checked against the salt’s iron fraction where the salt weight is known: ferrous fumarate 32.9%, ferrous sulfate heptahydrate 20.1%, ferrous gluconate 11.6%). Liquids are counted in mL. Anything else can be entered as a custom product, by elemental iron or by salt weight.
The result gives iron per dose, per day and per week, and flags: more than one dose a day (after doses of 60 mg or more, absorption of the next dose falls; Moretti 2015), multivitamin-level iron (27 mg or less per dose), more than 150 mg a day (above the treatment range of 50–150 mg a day; 150 mg once daily is a labelled treatment dose, and BSG 2021 finds 50–100 mg enough for most), more than 100 mg a day in IBD, enteric-coated or slow-release products, and a daily amount above the UL when compared with a prevention target.
IV iron
| Product | How the total is set | Per dose |
|---|---|---|
| Ferric carboxymaltose (Ferinject) | Monograph table by Hb (<100, 100–<140, ≥140 g/L) and weight (<35, 35–<70, ≥70 kg) | ≤15 mg/kg and ≤1000 mg; ≤1000 mg a week; ≥7 days apart |
| Ferric derisomaltose (Monoferric) | Monograph table by Hb (<100, ≥100 g/L) and weight (<50, 50–<70, ≥70 kg), or Ganzoni | ≤20 mg/kg; single doses above 1500 mg not recommended |
| Iron sucrose (Venofer) | Ganzoni | 200 mg per injection |
Ganzoni: weight (kg) × (target Hb − actual Hb, g/L) × 0.24 + 500 mg for stores. The monograph default target is 150 g/L; a lower target such as 130 g/L may be chosen. For an 80 kg patient with Hb 120 g/L, Ganzoni gives 1,076 mg, but the Ferinject monograph table gives 1,500 mg. Use each product’s own method.
Obesity. The Monoferric monograph uses ideal body weight in Ganzoni for obese patients, for example the weight at BMI 25 (25 × height²). Enter the height and the tool does this when BMI is 30 or more; the per-kg dose caps still use the actual weight.
Recheck Hb no earlier than 4 weeks after the last dose. Don’t start oral iron within 5 days of Ferinject.
Ontario Drug Benefit. Monoferric (LU 610) and Ferinject (LU 735) are Limited Use: confirmed iron deficiency anemia after at least 4 weeks of oral iron that failed, was not tolerated or is contraindicated; no hemochromatosis; given where reactions can be managed.
Pitfalls
- Hypophosphatemia after ferric carboxymaltose. In PHOSPHARE-IDA it occurred in about 74–75% after Ferinject vs about 8% after ferric derisomaltose. The Canadian monograph lists IBD, vitamin D deficiency and osteoporosis as risk factors and reports osteomalacia and fractures with repeated doses. Check phosphate in patients at risk, and before repeat courses.
- Pregnancy (from 16 weeks). Ferinject: cumulative maximum 1000 mg if Hb >90 g/L, 1500 mg if Hb ≤90 g/L. Monoferric: maximum single dose 1000 mg and cumulative 2000 mg. Tick Pregnancy on the IV tab to apply these caps.
- Prevention numbers are totals. The RDA is total intake from food and supplements; a supplement only covers the shortfall.
- Heme iron polypeptide (Proferrin, Optifer Alpha) is made from bovine hemoglobin: not suitable for vegetarians.
- Iron sucrose is labelled in Canada for CKD only. Use for IBD or other causes is off-label, and the Ganzoni total shown here is not from the monograph. The Venofer monograph gives a fixed 1000 mg course: 200 mg × 5 within 14 days (not on dialysis), 100 mg per hemodialysis session, or 300 + 300 + 400 mg over 28 days (peritoneal dialysis).
- Hemodialysis. Ferinject single doses should not exceed 200 mg in dialysis-dependent CKD.
- Product labels change. Check the package for the elemental iron content.