Iron Deficiency Anaemia
Tariq Ahmad
07739 858203
Sarah - 01392 406218
Interests
•
•
•
•
•
Inflammatory bowel disease
Nutrition
Colonoscopy
Paediatric and adolescent Endoscopy
Serious adverse drug reactions
Iron Deficiency Anaemia
Dull topic – Why talk about IDA?
• IDA is common
– Prevalence in adult men and PM women
• IDA: 2%
• ID: 7%
• Most common indication for referral
• High risk of malignancy
– 13% (6.3% colonic, 3.6% gastric, 1.0% renal)
– RR of malignant diagnosis < 2 yrs ~ 33 (9-107)
• “Hands off” approach by Gastro team
James EJGH 2005
Diagnosis
• Ferritin < 15ng/mL
– Specificity 99%, Sensitivity 59%
• Exclude acute phase response
– If CRP elevated divide Ferritin by 3
• Red cell morphology
– Normal in 50% of patients with IDA
– 20-30% of patients with MCV < 75 will not have IDA
– Low MCV: Think before prescribing iron
• Trial of iron if ferritin ≤ 40 μg/l (or ≤ 70 μg/l in
presence of chronic inflammation)
IDA – 5 minute assessment
History
• Age
• Menopause
• Diet
• Colour blind?
• Prosthetic heart valve?
• Blood donor
• FH Colorectal cancer, Bleeding disorder
IDA – 5 minute assessment
Examination
• Lips
• Abdominal mass
• Urine dip
Investigations
• Ferritin
• CRP
• Creat
• TTG / IgA
IDA – Who to refer?
• All men
• Post-menopausal women
• Pre-menopausal women if
– > 50 years old
– Strong family history of colorectal cancer
– GI symptoms which meet criteria for upper or
lower 2WW referral
– Raised CRP or calprotectin
– Persistent IDA following iron supplementation
& correction of potential causes of losses
DO NOT START IRON UNTIL AFTER INVESTIGATIONS
Should I refer this elderly / frail
patient?
Consider:
1. Duration of anaemia
2. First episode vs. recurrence
3. Fitness to withstand investigations
4. Fitness to withstand possible surgery
5. Patient wishes following frank discussion
Risk factors for malignancy in
patients with IDA
• Prospective UK study 550,000 population
• 695 cases over 2 years
• 13.1% cancer
– 6.3% colonic, 3.6% gastric, 1.0% renal
>50 years
Male
Hb < 9.0
NSAIDs, Warfarin, Aspirin
OR (95% CI) for Cancer
7.0 (1.7-29.3)
3.0 (1.8-4.9)
2.2 (1.3-3.9)
NS
James EJGH 2005
ID without anaemia
US Prospective cohort study
• 9024 participants aged 25-74 with IDA
• Follow-up 2 years
• Men and post-menopausal women 0.9%
cancers
• Pre-menopausal women 0%
Investigate men > 50 years and post-menopausal women
Ioannou GN, Am J Med 2002
2WW misuse
• “I have taken blood tests – results to
follow”
• Failure to mention previous investigations
for same problem
• Long-standing anaemia
• Patient not fit for a hair cut
Colonic imaging 2011
• ≤ 80 years
– 1st choice – Colonoscopy
– 2nd choice – CT pneumocolon
• > 80 years
– Minimal prep CT colon
• Barium enema RIP
CT Colonography (CTC)
(CT Pneumocolon, Virtual colonoscopy)
•
•
•
•
•
•
•
Low residue diet 48-24 hrs pre
Fluid only 24 hrs pre
Oral contrast 48hrs
No sedation
Rectal gas
Supine / prone
6-7 secs acquistion time
Advantages
• Superior to DCBE
• Sensitivity >90% for polyps
>10mm
• Well tolerated
• Extra-luminal information
Normal OGD & Colon – what next?
Reassurance for most patients
• IDA recurrence after OGD + duodenal
biopsy & Colonoscopy – 10%
• Risk of malignancy in next 5 years < 5%
Normal OGD & Colon – what next?
•
•
•
•
•
•
Repeat IDA 5 minute assessment
Check duodenal biopsies taken?
Erradicate H.pylori
Consider Giardia
Stop NSAIDs, PPI
Check CRP / Calprotectin ?Small bowel
Crohn’s
• If asymptomatic 3+ months oral iron
Oral iron preparations
• Avoid enteric coated or SR iron
• Avoid giving with food
• 250 mg ascorbic acid enhances
absorption
• Ferrous sulphate, fumarate gluconate
equal efficacy and side effect profile
• Low dose as efficacious with fewer side
effects
• Use in patients with IBD controversial
Monitoring response
•
•
•
•
•
Pica disappears within 24 hours
Check FBC at 2-3 weeks and 3 months
No indication to repeat Ferritin
Expect Hb rise 0.7g/dL per week
Continue oral iron for 3 months after
normalisation of Hb
Indications for outpatient review
• Significant GI symptoms.
• Elevated CRP or calprotectin.
• Recurrent anaemia.
Faecal Calprotectin
• Acute phase protein
– Neutrophil cytosolic protein
– Neutrophil activation leads to release in
serum & stool
• Clinical utility
– Differentiating IBD from IBS
– Monitoring disease activity in IBD
Screening of patients with
suspected IBD by faecal calprotectin
• Calprotectin outperforms
– ESR, CRP, ASCA, p-ANCA
Van Roon Am J Gastro 2007
Meta-analysis
of 13 studies
Sensitivity
(95% CI)
Specificity
(95% CI)
Reduction in
endoscopy
False
negative test
Adults
0.93
(0.85-0.97)
0.96
(0.79-0.99)
67%
6%
Children
0.92
(0.84-0.96)
0.76
(0.62-0.86)
35%
8%
Van Rheenen BMJ 2010
Capsule endoscopy
Parenteral iron
Advantages
Disadvantages
Gut not needed
Rare lethal side effects
Rapid
Expensive
No adherence issues
Facilities required
Single dose
Infrequent side effects
Parenteral iron preparations
Trade
name
Max dose
Infusion time
SAE per million
infusions
LWM iron dextran
Cosmofer
20mg / kg
Test dose 4 hrs
3.3
Iron sucrose
Venofer
500 mg
30 mins
0.6
Iron gluconate
Ferrlecit
125 mg
30 mins
0.9
Iron
carboxymaltose
Ferrinject
1000mg
15 mins
?
Iron isomaltoside
1000
Monofer
20mg / kg
60 mins
?
ID and prognosis in CHF
Jankowska et al. Eur Heart J 2010
ID and chronic heart failure
FAIR-HF trial
• 459 patients ID(A)
• Iv iron carboxymaltose vs. placebo
• Patient global assessment 50% vs. 28%
OR 2.51 (CI 1.75–3.61)
• Improvement in NYHA class
• Improvement in 6 min walk test
• Improvement in QoL
Anker N Engl J Med 2009
2011 Electronic
IBD registry
• Facilitates cancer surveillance
• Facilitates electronic drug monitoring
• Allows accurate assessment of service
needs
• Allows audit of quality of care
Colorectal Cancer surveillance in IBD
• Longstanding colitis is associated with an
increased risk of colorectal cancer (7.6 18% at 30 yrs)
• Surveillance colonoscopy is recommended
• Challenges include endoscopic and
histologic diagnosis, and interval cancers
Exeter Audit
• Identify avoidable shortcomings in CRC
surveillance
• All patients with a diagnosis of IBD and
colorectal cancer 1999 - 2009.
• 1969 IBD patients
• 39 patients had IBD and CRC
• 18/26 (70%) patients not surveyed
according to 2004 BSG guidelines.
Reasons for no surveillance
• 9 managed exclusively in primary care
• 8 not considered in secondary care
– 3 surgical clinic
– 5 gastroenterology clinic
• 1 refused
IBD cancer surveillance
BSG Guidelines 2010
Vaccination / chemoprophylaxis
strategy
At diagnosis of IBD
Varicella vaccine
Hepatitis B
Pneumococcal polysaccharide vaccine
Influenza (trivalent inactivated)
Human papilloma virus
Annually
Influenza (trivalent, inactivated)
Booster
Pneumococcal polysaccharide vaccine (3–5 years)
Discretionary
Travel vaccines: live vaccines (eg, yellow fever, oral poliomyelitis)
should be avoided if on immunomodulators
Chest x ray, interferon release assay prior to anti-TNF therapy
Before starting a
third
immunomodulator
Trimethoprim–sulfamethoxazole 80/400 mg daily, or 160/800 mg
three times a week as prophylaxis against Pneumococcus
jiroveci
European evidence-based Consensus on the prevention, diagnosis and management of opportunistic infections in IBD. J
Crohn’s Colitis 2009;3:47–91