IRON DEFICIENCY ANEMIA

Iron deficiency anemia is a common condition affecting diverse age groups and patient populations..

OVERVIEW

Iron deficiency refers to a state in which there is insufficient total body iron to maintain normal physiologic functions, sometimes defined by serum ferritin <15 micrograms/L (or ng/mL) in individuals five years and older.

Anemia is defined as blood hemoglobin values. These hemoglobin values are variable and in general anemia occurs when a person’s hemoglobin is below the mean for a healthy population of the same gender and age.

  • Non-pregnant women – 12 g/dL
  • Pregnant women – 11 g/dL
  • Men ≥15 years – 13 g/dL

 

Anemia has many causes of which Iron deficiency is a common. Iron deficiency can have important consequences to health and development.

 

SYMPTOMS

Those patients who severely reduced iron stores and extremely low serum ferritin but they are not anemic:

  • Weakness, decreased exercise tolerance, fatigue, irritability, or depression
  • Neurodevelopmental delay (children)
  • Consumption of ice or iced drinks (Pica and pagophagia)
  • Beeturia (reddish urine after eating beets)
  • Restless legs syndrome
  • Headache, especially with activity
  • Heavy menstrual blood loss

 

Homogeneous symptoms, mainly fatigue and exercise intolerance, can also be present in individuals who are iron deficient but not anemic.

Subclinical iron deficiency

 

Iron deficiency without anemia is also associated with clinical symptoms in some patients, including effects on fatigue, cognitive function, energy, restless legs syndrome, and pica. These patients are often referred to the hematologist after iron studies reveal iron deficiency. The perspective to therapy is individualized according to etiology and severity of iron deficiency.

Iron deficiency anemia is the second most common cause of anemia in pregnancy after physiologic anemia. Iron requirements increase dramatically during pregnancy due to the expanding blood volume of the mother and the iron requirements for fetal RBC production and feto-placental growth.

DIAGNOSIS

Iron deficiency anemia is identified by reduced or absent iron stores and increased levels of transferrin proteins that facilitate iron uptake and transport to RBC precursors in the bone marrow. Additional tests may be ordered to assess the levels of serum ferritin, iron, total iron-binding capacity, and/or transferrin.

Iron deficiency progresses and the individual becomes anemic; the following findings may be seen on the CBC:

  • Low hemoglobin (Hg) and hematocrit (Hct)
  • Low mean cellular volume (MCV)
  • Low ferritin
  • Low serum iron (FE)
  • High transferrin or total iron-binding capacity (TIBC)
  • Low iron saturation

The low MCV and MCH are reflected on the peripheral blood smear by microcytic, hypochromic RBCs. As anemia progresses, increasingly abnormal forms may be seen. The peripheral smear or blood slide are likely to show small, oval-shaped cells with pale centers. In acute iron deficiency, the white blood count (WBC) may be low and the platelet count may be high or low.

CAUSES AND RISK FACTORS FOR IRON DEFICIENCY

The major causes of iron deficiency are decreased dietary intake, reduced absorption, and blood loss.

Overt bleeding is obvious and not difficult for the clinician to recognize, often by history alone:

  • Traumatic hemorrhage
  • Hematemesis (blood in vomitus) or melena (blood in stool)
  • Hemoptysis (blood in sputum)
  • Heavy menstrual bleeding
  • Pregnancy and delivery
  • Hematuria (blood in urine)

Other sources of blood loss that may be overlooked include:

  • Frequent blood donation
  • Excessive diagnostic blood testing
  • Underestimation of the degree of heavy menstrual bleeding
  • Pregnancy and lactation, with a greater likelihood as the number of pregnancies increases
  • Occult bleeding, typically gastrointestinal (eg, gastritis, malignancy, angio dysplasia) but may also include hemolysis with urinary losses
  • Exercise-induced blood loss, often due to occult gastrointestinal bleeding
  • Gastrointestinal parasites (eg, hookworm, whipworm), especially in developing countries

 

PREVENTION

Choose Iron-rich foods & containing Vitamin C to enhance iron absorption

Iron-rich foods & containing Vitamin C include:

  • Meat: beef, pork, or lamb, especially organ meats such as liver
  • Fish, especially shellfish, sardines, and anchovies
  • Leafy green vegetables including broccoli, kale, turnip greens, and collard greens
  • Legumes, including lima beans, peas, pinto beans, and black-eyed peas
  • Iron-enriched pastas, grains, rice, and cereals
  • Vitamin C (ascorbic acid – some doctors recommend that you take 250 mg of vitamin C with iron tablets)

Intravenous Iron: The patient who does not absorb iron well & with severe iron deficiency or chronic blood loss, those who are receiving supplemental erythropoietin, a hormone that stimulates blood production & cannot tolerate oral iron. You need to be seen by a Hematologist to supervise the iron infusions. It comes in different preparations

  • Iron Dextran
  • Iron Sucrose
  • Ferric Gluconate
  • Ferric Carboxymaltose
  • Ferumoxytol
  • Iron Isomaltoside Ferric Derisomaltose
Drug Side Effects Maximum single dose Infusion time Test dose* Available dose & Costs ($) Premedication 
Ferric carboxymaltose (FCM)

Injectafer, Ferinject

 Skin discolouration, Nausea, Vomiting, dizziness, headache Slow IV push (100mg/min) or an IV infusion §  15minutes Not required §  750mg/15ml – $$$ §  We do not routinely premedication for any of the IV iron products.

 

§  For patients with asthma, multiple drug allergies, or inflammatory arthritis, we often give steroids alone prior to the iron infusion. We may give diphenhydramine.
Ferric gluconate (FG)

Ferrlecit

 Vomiting, Muscle cramps, Dyspnea, diarrhea, tachycardia, headache, dizziness, nausea Slow diluted (12.5mg) §  1-2 hours Not required, but recommended if the patient has a history of multiple drug allergies 12.5mg/ml – $$
Ferumoxytol

Feraheme

 Skin rash, chest pain, constipation, nausea, back pain, muscle spasm, fever Slow IV infusion (510mg) §  15-30min Not required 510mg/17ml – $$
Iron dextran, low molecular weight (LMW ID)

INFeD, CosmoFer

 Chills, abdominal pain, hematuria, shivering, numbness, chest pain, flushing, skin rash, disorientation Slow IV (50mg/min) §  30-60min Yes, 25 mg (0.5 mL) prior to the first dose 50mg/ml – $
Ferric derisomaltose

Monofer, Monoferric

 Skin rash, nausea, diarrhea, fatigue, chest pain, fever Slow IV (1000mg) §  20-30min  Not required 1000mg/10ml – $$$$
Iron sucrose (IS)

Venofer

 Headache, hypotension, nausea, nasopharyngitis, chest pain, dizziness, sepsis Slow IV (200mg) §  15min Not required, but recommended if the patient has a history of multiple drug allergies 20mg/ml – $

Blood Transfusions: Blood transfusion should not be used a treatment for iron deficiency unless the individual has severe anemia with hemodynamic instability. Blood transfusions may be given to patients with severe iron-deficiency anemia who are actively bleeding or have significant symptoms such as chest pain, shortness of breath, or weakness.

Diagnosis-Based Assistance Programs for Iron Deficiency Anemia – Needymeds.org          

Program Name Summary Services Provided Area of Service
Assistant Fund, Inc. – Iron Deficiency Anemia Copay Assistance Program Provides eligible underinsured with iron deficiency anemia with financial assistance to cover all or part of the co-pay. Financial Assistance National
Feraheme assist has favorable non-restricted commercial coverage Eligible uninsured and commercially underinsured patients may receive a single course of therapy at no cost Feraheme Ferumoxytol injection National
Venaccess patient assistance program It helps improve access to Venofer for NDD-CKD patients who lack health insurance and cannot afford therapy Venofer iron sucrose injection, USP National

 

What we can do for you

We are experts in diagnosing and treating anemia using all available options. We will also order workup to figure out the root cause for the anemia. We may be able to offer you copayment assistance to offset your out of pocket expenses for iron treatments.