Iron-Deficiency Anemia
History
History
- Diet, drug
- Bleed, blood donation, menstrual history (pregnancy in all women)
- Recent illness, weight loss
- GI symptoms
- Travel history (hookworm)
- Consider screen (immigrant) women and children for anemia
- Family history of iron-deficiency (?iron absorption), hematological (thalassemia), bleeding
- If severe anemia, ask about cardiac (angina, palpitations, leg swelling)
- May have symptoms even if non-anemic but iron-deficient (iron needed in all cells, not just RBC)
- May not have symptoms if chronic anemia (adaptation)
Exam
Exam
- Pallor, atrophic glossitis, angular cheilosis
- Nail changes: Longitudinal ridging and kolionychia
- Tachycardia, murmurs, cardiac enlargement, heart failure
- CVS r/o heart failure
- Abdo: Masses, organomegaly, lymphadenopathy
- Rectal exam (if hx bleed/tenesmus)
Investigations
Investigations
- CBC + ferritin +/- TIBC
- Consider reticulocytes
- Consider Hb Electrophoresis, Blood Smear
- Screen all for celiac (Anti-TTG, IgA)
- Consider complete iron studies (serum ferritin, total iron binding capacity [TIBC]), and serum iron
- Diagnostic trial of iron treatment x3 weeks in premenopausal women with history of menorrhagia or pregnant women
- All men/postmenopausal women screened for GI malignancy
- B12/folate should be checked in normocytic, inadequate response to iron treatment, or suspected (malnutrition, malabsorption, elderly - pernicious anemia)
- Consider SPEP
Treatment
Treatment
- Find underlying cause (intake vs. loss)
- Refer to appropriate specialty (GI, gyne)
- Consider G/C-scope, stool for parasites if travel
- If negative and persistent iron-deficiency anemia despite treatment, Consider H pylori
- Consider UA
- Consider G/C-scope, stool for parasites if travel
- Iron-replacement
- Iron-rich foods (dark green vegetables, iron-fortified bread, meat, apricots, prunes, raisins), dietition referral
- Absorption increased if high intake of fish, red/white meat, vitamin C
- Absorption reduced if phytate (whole grade cereals), polyphenols (tea/coffee), calcium, antacids/PPIs
- Oral ferrous sulfate consider 300mg PO daily (or even q2 days)
- If not tolerated, consider ferrous fumarate (highest iron content) or ferrous gluconate
- IV If inadequate iron absorption, non compliance, intolerance
- Consider transfusion if Hb<70 and symptomatic
- Iron-rich foods (dark green vegetables, iron-fortified bread, meat, apricots, prunes, raisins), dietition referral
- Monitor
- Re-check hemoglobin 2-4w on iron treatment
- Lack of response, assess compliance
- Address adverse effects
- Laxative, reassurance for black stools, take iron with meals, reduce dose frequency, ferrous gluconate (lower elemental iron)
- Consider continued blood loss/malabsorption, or incorrect diagnosis
- Address adverse effects
- Response, follow-up at 2-4 months to ensure normalized
- Once normalized continue 3 months then stop
- Consider monitor periodically (eg. q3 months x 1 y, then yearly)
- Consider prophylaxis
- Once normalized continue 3 months then stop
- Lack of response, assess compliance
- Re-check hemoglobin 2-4w on iron treatment
References:
- AAFP 2013. Iron Deficiency. http://www.aafp.org/afp/2013/0115/p98.html
- BC Guidelines 2010. Iron Deficiency. http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/iron-deficiency
- Transfusion 1997. https://www-ncbi-nlm-nih-gov.proxy3.library.mcgill.ca/pubmed?term=9191816