Kembara Xtra - Medicine - Iron Deficiency Anemia

Medicine - Iron Deficiency Anemia 
ESSENTIAL DESCRIPTION
Low hemoglobin (Hgb) or microcytic, hypochromic red blood cells (RBCs) are linked to low serum iron.
Anemia is defined as a Hgb level two standard deviations below normal for age and sex because normal Hgb fluctuates with age and sex.
Both low Hgb per RBC and fewer RBC in total cause blood oxygen shortage, which can have harmful systemic repercussions. Onset acute (rapid blood loss) or chronic (slow blood loss, insufficient iron intake, or poor absorption).
Hematologic, lymphatic, immunologic, cardiac, and gastrointestinal (GI) systems are among the afflicted system(s).

Aspects of Geriatrics
In older adults, iron deficiency anemia (IDA) is linked to higher hospitalization, morbidity, and mortality rates.
Endoscopy should be performed on older patients with suspected IDA to check for occult GI cancer.

Child Safety Considerations
Low birth weight, a history of preterm, lead exposure, low socioeconomic level, and immigration status are all risk factors for IDA in children. 
Additionally, infants who consume cow's milk before the age of 12 months are more likely to develop IDA.
The Centers for Disease Control and Prevention (CDC) recommend screening high-risk infants at 6 to 12 months, while the American Academy of Pediatrics (AAP) suggests universal screening at 12 months. Should screening be done, include both Hgb and ferritin. The U.S. Preventive Services Task Force (USPSTF) did not find sufficient evidence for screening low-risk infants.

pregnant women's issues
The American College of Obstetricians and Gynecologists (ACOG) recommends screening all pregnant women for IDA and treating those with IDA, while the USPSTF found insufficient evidence to recommend screening pregnant women for IDA. Iron supplements are advised during pregnancy to improve maternal hematologic indexes, though significant clinic improvements have not been observed.

Iron deficiency is the most prevalent nutritional deficit in the world, and IDA is the most typical cause of anemia (causing 50% of cases), according to epidemiology.
All ages, notably children, menstrual women, and pregnant women, are the predominant age groups.

Mexican American and black females make up the majority of the population in both developed and developing nations. 

Incidence
Adults: 2% for men and 15-20% for women annually; 3-5% for infants and toddlers; and up to 20% for pregnant patients. (1)
World population 2 billion; infants and children under the age of 12: 4-7%; men: 2-5%
 Women in menstruation: 30%

 
PATHOPHYSIOLOGY AND ETIOLOGY
Reticulocyte count and Hgb production both decline as iron reserves are depleted. 
Causes:
Blood loss (menstruation, gastrointestinal bleeding, trauma) Poor iron absorption (e.g., atrophic gastritis, post-gastrectomy, celiac disease) Increased demand for iron (e.g., early childhood, puberty, pregnancy, lactation)

RISK FACTORS include being a premenopausal woman, donating blood frequently, being pregnant or nursing a child at a young age, adhering to a strict vegan diet, using NSAIDs while hospitalized, and residing in or traveling to nations where endemic hookworm infection is common.


DURATIONAL PREVENTION
Consider screening high-risk youngsters and asymptomatic pregnant women at 1 year old (recommendations vary).
If a kid is asymptomatic and at risk for IDA (e.g., due to starvation, abuse, or drinking cow's milk before age 12 months), supplementation should be given.

 A diet high in iron and vitamin C for women who are menstruation
Iron 30 mg/day for pregnant women with no symptoms 

COMMONLY ASSOCIATED CONDITIONS Menometorrhagia, hookworm or other parasitic infestations, peptic ulcer disease (PUD), Helicobacter pylori infection, irritable bowel disease, GI tract cancer, pregnancy, obesity treated with gastric bypass surgery, malnutrition, and medications like NSAIDs or antacids

DISEASE HISTORY
The majority of the time asymptomatic; severe anemia may cause symptoms:
- Malaise, weakness, and/or weariness
- Angina with coronary artery disease - Exertional dyspnea
- Migraines or attention issues - Melena
- Pica (chewing ice)

Physical examination findings include: pallor (skin, conjunctivae, sublingual), tachycardia, tachypnea, cool extremities, brittle nails, and heart failure symptoms.

DISTINCTIVE DIAGNOSIS

GI bleeding (such as that caused by gastritis, PUD, carcinoma, varices, and celiac disease); chronic intravascular hemolysis (such as that caused by paroxysmal nocturnal hemoglobinuria or a malfunctioning prosthetic valve); improper use of iron (such as that caused by thalassemia trait, sideroblastosis, or G6PD deficiency); and improper reutilization of iron (such as that caused by infection, inflammation,
Hypoproliferation (e.g., decreased erythropoietin due to hypothyroidism or renal failure) Other anemias, such as thalassemia, lead poisoning, and chronic disease-related anemic

DETECTION & INTERPRETATION OF DIAGNOSIS

Initial examinations (lab, imaging)
Test for anemia symptoms and signs, and if an iron shortage is found, thoroughly evaluate the patient.
Measure your Hgb, HCT, ferritin, serum iron, and total iron-binding capacity (TIBC).

Hgb: 13 g in men and 12 g in women (to define anemia) (6)
- Hgb 2 standard deviations below the age- and sex-normal range (1)
– At greater Hgb levels, patients with comorbidities, such as chronic hypoxemia, smokers, or high altitudes, may still be anemic.
Mean corpuscular volume (MCV): 80 Fl - MCV can be low in moderate anemia or concealed by large cells (reticulocytes, macrocytes).
The most accurate and specific test for determining if anemia is due to an iron shortage is ferritin (6):
- IDA is diagnosed at 15 g/L (with 30 g/L likely) (1).
- A level of >100 g/L excludes iron deficiency.
Iron research
Reduced levels of ferritin, serum iron, and transferrin saturation (TF = total iron-binding capacity / (serum iron) / 100).
- Increased: transferrin, TIBC
When cells in a population are mixed, such as when there is a combined IDA and vitamin B12 deficiency, red cell distribution width (RDW) rises.
CBC with reticulocyte count, index, peripheral smear, and differential
- The reticulocyte production index is poor, and peripheral smear typically exhibits hypochromia and microcytosis but could also be normal.
When there is a strong clinical suspicion of a comorbidity, you should think about testing for G6PD deficiency.
– Look into thalassemia.
 A familial history, a very low MCV (80), an elevated Hgb A2 or Hgb F, and a particularly high or high normal RBC count.
Microcytosis along with ovalocytosis and iron resistance point to a thalassemia trait.
TSH for hypothyroidism Celiac disease: IgA antiendomysial antibodies (IgA anti- EmA) and/or IgA anti-tissue transglutaminase (IgA anti- TTG)
Children with low iron storage may benefit from an empirical trial of iron at 3 mg/kg/day; Hgb climbs >1 g/dL weekly or reticulocytes become raised in 7 to 10 days, both of which indicate iron insufficiency.
 Substances that could affect test results:
- Iron supplements or iron-containing multivitamin-mineral products
Disorders that could affect lab results include:
- Elevated ferritin: solid tumors, acute leukemia, acute or chronic liver disease, acute inflammation, and renal dialysis.
- Elevated Hgb: chronic hypoxemia, smoking, and high altitude


Other/Diagnostic Procedures

Stool guaiac (poor sensitivity; if negative, consider further investigation) Colonoscopy and endoscopy to check for bleeding sites and colorectal and stomach cancer in: - Premenopausal women with negative GYN workup and/or lack of response to iron
- Postmenopausal men and women

 Bone marrow aspiration is hardly carried out


GENERAL TREATMENT MEASURES

Aside from very rare circumstances, avoid transfusions and look for the underlying problem.

MEDICATION: Adults (whether or not pregnant) should take 100 to 200 mg of elemental iron daily.

For children, ferrous sulfate 325 mg TID, ferrous gluconate 300 mg, and elemental iron 3 to 6 mg/kg/day. 1 to 3 pills Ferrous fumarate 324 mg 1 tablet BID-TID or BID-TID on an empty stomach 30 minutes before meals
One-fourth of patients will have constipation. Together with iron, think about a stool softener.
– Iron absorption is decreased by drugs like proton pump inhibitors and H2 antagonists that decrease stomach acid output.
– IV iron is indicated for patients who cannot tolerate the side effects of oral replacement (e.g., pregnant women or patients with GI disorders) or for patients who do not sufficiently respond to oral replacement. Special oral iron formulations, such as enteric-coated iron, are expensive and reduce symptoms only to the extent that they reduce the delivery of iron. In addition, bariatric surgery status, significant uterine bleeding, malabsorption, inflammatory bowel illness, ongoing/severe losses, and malabsorption are indications for IV iron.
Outside of the United States, IV iron is replacing oral iron as the preferred method due to its higher efficacy and toxicity.
The following IV iron preparations are offered in the US:
- Ferric carboxymaltose 750 mg over 15 minutes - Ferumoxytol 510 mg over 3 minutes - Low-molecular-weight iron dextran 1,000 mg over 1 hour
When tablets are not absorbed or a poor tolerance necessitates a dose reduction, adults can also utilize liquid iron preparations, which are often used for youngsters.
- "Failure to respond" to iron can be brought on by ongoing bleeding and untreated hypothyroidism.
– Calculator for the required amount of elemental iron: Elemental iron (mg) = dosage (mL) + (0.26 LBW) + 0.0442 (desired Hgb observed Hgb)
Target Hgb in g/dL = desired Hgb
Current Hgb in g/dL is known as observed Hgb.
Lean body weight in kilograms (LBW)
For males, LBW equals 50 kg plus 2.3 kg for every inch of height above five feet.
 For females, LBW equals 45.5 kg plus 2.3 kg for every inch of height above five feet.
Hgb levels that are considered normal for both sexes are: >15 kg (33 lb) 14.8 g/dL; 15 kg (33 lb) 12.0 g/dL.

 Relative reasons against taking oral iron:
Tetracycline, Allopurinol, Fluoroquinolones, Antacids, Penicillamine, and Vitamin E
For patients with a Hgb level below 6 g/dL, malabsorption, chronic renal disease, or inability to react to larger oral dosages with concurrent vitamin, parenteral iron should be considered.
Parenteral iron formulation problems
- To prevent allergy, administer a test dose of iron dextran prior to the initial dose; ferric gluconate or iron sucrose may be a better choice. Nephrotoxicity risk is increased by dimercaprol.
- The recommended dosage varies per product; consult the particular product for details.

 Safety measures
Iron overload is exceedingly dangerous; absorption is capped at 1 to 2 mg daily; keep pills and liquids out of the reach of young children. Iron may produce black stools and constipation.
Blood transfusion for individuals with severe acute blood loss or severe symptoms (such as ischemia brought on by anemia). By clinical situation and risk variables, Hgb threshold varies. Hgb 6 pregnant women should get transfusions.


QUESTIONS FOR REFERENCE
IDA (Test for colon cancer) in men and postmenopausal women
Men or non-pregnant women with a Hgb level of less than 6 g/dL; Pregnant women with a Hgb level of less than 9 g/dL; Failure to react to an oral iron trial lasting four to six weeks.

ADVANCED THERAPIES

Iron deficiency is mostly influenced by nutrition. Patients should be informed about iron-rich foods.

CONTINUING CARE AFTERCARE RECOMMENDATIONS
patient observation
After Hgb returns to normal, patients should be checked every three months for the next year.
Hgb rises by 1 g/dL every three to four weeks.
After Hgb returns to normal, iron stores may need to be restored for up to 4 weeks.

Red meat, chicken, fish, and eggs are all heme iron sources, which are best absorbed. Non-heme iron sources, such as lentils, beans, dark green vegetables, raisins, tofu, and iron-fortified breads and cereals, are less well absorbed.
When consumed simultaneously, ascorbic acid (vitamin C)-containing foods and beverages such citrus, tomatoes, dark green leafy vegetables, and berries improve iron absorption.
Avoid consuming milk or dairy products within two hours after taking an iron supplement.
Limit adults to 16 ounces of milk each day.
Limit your intake of tea, coffee, and other caffeinated drinks.
To reduce the probability of constipation, increase your intake of fluid and dietary fiber.
Phytates and polyphenols are two substances that should be consumed in moderation.

PROGNOSIS

If the underlying reason is identified and properly addressed, iron treatment can treat IDA.
Treat IDA and concomitant subclinical hypothyroidism together. A poor response to iron therapy occurs from untreated hypothyroidism.

COMPLICATIONS include: Ischemic episodes or heart failure, especially in the elderly; Hidden bleeding, particularly a bleeding cancer; Poor growth, failure to thrive, and motor and cognitive developmental delays in children.