Iron-Deficiency Anemia

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

  • 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

  • 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

  • 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
  • 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
  • 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
      • 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