Is oral iron cheaper? Not if you count all the costs

In this issue of Blood Advances, Wang et al 1 reports developing a Markov model simulation, which demonstrates that intravenous (IV) iron is more cost effective than oral iron for initial treatment of iron deficiency anemia (IDA) in women with heavy menstrual bleeding (HMB).IDA occurs in billions of people worldwide and disproportionately affects women, with menstrual blood loss, especially HMB, 2 being the primary contributor to the increased prevalence in this population. 3Oral iron therapy has long been touted as first-line therapy due to ease of administration, availability, efficacy, and low cost while IV iron is typically reserved for those with inadequate response to or inability to tolerate oral iron.Challenges with oral iron include tolerability, adherence, absorption, and real-world sustained effectiveness, and most clinicians can discern which patients will respond to oral iron within the first month of treatment, yet there may be years-long delays before a patient is transitioned to IV iron, if ever.Barriers include a combination of higher upfront cost and insurance denials, perceived greater risk of adverse effects, and limited infusion center capacity.