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