IRON DEFICIENCY

• Anaemia (WHO):
• Hb <130 g/L in males:
• Hb <120 g/L in non-pregnant females
• normal range for Hb includes patients who are anaemic
• look for cause

Symptoms

• Patients may tolerate a very low Hb levels
• do not base clinical decisions on Hb value alone

Severe

• Heart failure symptoms
• Chest pain

Moderate

• Shortness of breath at rest
• Palpitations

Mild

• Fatigue
• Shortness of breath on exertion

Assessment

Bleeding history

• Menstrual history
• Previous surgery
• Dental extraction
• Epistaxis, mucocutaneous bleeding symptoms

GI blood loss

• change in bowel habit, dyspepsia, melaena

Social history

• Diet: vegan/vegetarian, dietary content
• Medications
• Alcohol history

Medical history

• Coeliac disease
• Inflammatory bowel disease
• Anaemia/transfusion/iron

Family history

• Bleeding, anaemia, malignancy

Investigations

• FBC
• Serum Ferritin
• most reliably correlate with relative total body iron stores 

Ferritin

• If infection/inflammation present, ferritin can be high with iron deficiency
• rheumatoid disease, liver disease, malignancy
• hyperthyroidism, kidney disease,
• heavy alcohol intake
• raised CRP/ESR

Ferritin < 15ng/mL

• Absolute iron deficiency

Ferritin 15-30 ng/mL

• Likely absolute iron deficiency

Ferritin 30-100 ng/mL with raised inflammatory markers/chronic inflammation

• Possible absolute iron deficiency
• Check transferrin saturations
• if < 20%, likely Iron deficiency

Normal/ raised Ferritin with infectious, inflammatory and malignant disease or CKD

• Potential functional iron deficiency due to iron restricted erythropoiesis
• In patients with CKD, review %HRC

Look for cause

On history and age/co-morbidities

• OGD/colonoscopy/CT colonoscopy
• Urinalysis for haematuria
• Anti-tTG Ab for coeliac (+IgA levels)
• Gynaecological review where appropriate
• Consider stool screening for parasites as per travel history
• Consider screening for H.Pylori
• Refer to haematologist if:
• No cause found
• IDA has recurred despite treatment or poor response to treatment

Usually unnecessary to further investigate

• Healthy young people with clear cause e.g. regular blood donors
• Menstruating young women with no history of GI symptoms or FHx colorectal cancer
• Pregnant women
• Terminally ill or unable to undergo invasive investigations
• When management would not be influenced by the results
• severe comorbidity
• potentially advanced age as discussed with the patient and carers
• Patients who refuse further investigations

Oral iron

• Where time/history allows, prescribe elemental iron 100–200 mg oral daily
• ferrous sulphate (dried) 200mg daily
• ferrous fumarate 200mg daily
• ferrous gluconate 300mg daily

Administration

• To improve absorption, advise to take oral iron:
• with a source of vitamin C e.g. over-the-counter vitamin C tablet or orange juice
• away from other medications especially proton pump inhibitors and antacids
• away from tea and coffee as contain tannins that reduce absorption
• away from calcium including tablets and dietary sources
• Do not exceed maximum single dose
• Use concomitant laxatives where necessary

Stopping oral iron

• Unless haemoglobinopathy, continue oral iron for 3 months following normalisation of Hb/MCV/MCH
• to ensure iron stores replenished

Intolerance

• Change formulation, or
• Reduce dose and/or
• Use alternate day dosing

Intravenous iron (IVFe)

• Offer when oral iron is assessed as ineffective or inappropriate
• to avoid unnecessary red cell transfusion
• functional iron deficiency e.g. CKD, CCF
• In patients who are at particular risk of iron deficiency anaemia, consider an ongoing prophylactic dose
• Discuss with appropriate specialist

Administration

• Adhere to SOP/SPC
• Observe patients closely during and for 30 min after infusion for allergic reactions
• Ensure resuscitation facilities are available
• Anaphylaxis medications prescribed in advance

RBC transfusion in chronic anaemia 

• Consider a single unit RBC transfusion in patients with:
• moderate/severe symptoms
• haemodynamically stable
• reversible cause of anaemia
• Hb <90 g/L
• Remember each unit transfused is a treatment decision
• See Chronic Anaemia: RBC transfusion

Oral iron

• Review tolerance and compliance to oral iron at 1–2 weeks
• Consider checking reticulocyte count and FBC parameters at 7–10 days for patients on oral iron

IV iron

• Repeat FBC and ferritin at 4 weeks post IV iron to evaluate response

Response expected

• Hb should improve at approximately 10 g/L per week
• Lack of response is defined as an Hb increase <20 g/L after 2–4 weeks treatment

Long-term

• After iron stores replenished, monitor FBC every 3 months for 1 yr
• again at 1 yr or if symptoms of iron deficiency return

• Inform GP of:
• cause
• treatment
• monitoring required