Iron deficiency anemia (IDA) is the most common form of anemia worldwide. It can be caused by blood loss or impaired iron absorption. The body needs iron to produce hemoglobin for red blood cell production. Treatment involves treating the underlying cause and replenishing iron stores, usually with oral iron supplements. Parenteral iron may be used for patients unable to tolerate or absorb oral iron. Complications of iron overload include organ damage, so excess iron intake must be avoided.

1. Iron Deficiency Anemia
(IDA)

3. Iron Deficiency Anemia
• Iron deficiency anemia (IDA) is the most
common form of anemia worldwide.
• In men and postmenopausal women the
commonest cause of IDA is blood loss from
lesions in the gastrointestinal tract, making it a
common cause of referral to gastroenterologists.
• Causes of IDA relate either to
blood loss, or
iron mal-absorption

4. Iron deficiency Anemia
• The body needs iron to produce the Hb
necessary for RBC production.
• In general, most people need just 1 milligram
of iron daily.
• Menstruating women need double the dose

5. Iron Deficiency
Successive Stages of Iron Deficiency
• Iron-deficient erythropoiesis,
– or functional iron deficiency
• Depletion of iron stores
• Iron-deficiency anaemia
Grosbois B, et al. Bull Acad Natl Med. 2005;189:1649.

6. Beris P, Tobler A. Schweiz Rundsch Med Prax. 1997;86:1684.
Reprinted from Lambert JF, et al. In C Beaumont, P Beris, Y Beuzard, C Brugnara, eds. Disorders of iron homeostasis,
erythrocytes, erythropoiesis. Forum service editore, Genoa, Italy, 2006 page 73 figure 1, by permission of European
School of Haemotology.
Main Causes of Anaemia
Haemolysis
17.5%
Others
9%
Iron Deficiency
29%
Chronic Disease
27%
Acute
Bleeding
17.5%

7. Iron Deficiency—Aetiology
• Increased demand for iron and/or
haematopoiesis
• Iron loss
• Decreased iron intake or absorption

8. Iron Deficiency—Iron loss
• In physiologic conditions
– Menstruation
• In pathologic conditions
– Surgery, delivery
– Haemoglobinuria,haemoptysis
– Gastrointestinal tract pathology
• In therapeutic procedures
– Phlebotomy
• In blood donation

11. Iron Deficiency
Clinical Manifestations
• Fatigue
• Decreased exercise tolerance
• Tachycardia
• Dermatologic manifestations
• Decreased intellectual performance
• Dysphagia
• Depression, increased incidence of infections
• Restless legs syndrome
Hoffman, ed. Hematology: Basic Principles and Practice, 4th ed. 2005.
Trost LB, et al. J Am Acad Dermatol. 2006;54:824.

12. Iron Deficiency Anemia
• The CVS adaptations of chronic anemia can worsen the
condition of patients with underlying cardiovascular
disease and include:
– Tachycardia
– Increased cardiac output
– Vasodilation
• In the absence of adequate iron, small erythrocytes with
insufficient hemoglobin are formed, giving rise to
microcytic hypochromic anemia.

13. Management
of IDA
• Treatment of iron deficiency anemia consists of correcting the underlying
etiology and replenishing iron stores.
• Oral ferrous iron salts are the most economical and effective form
• Ferrous sulfate is the most commonly used iron salt
• Better absorption and lower morbidity have been claimed for other iron
salts
• Toxicity is generally proportional to the amount of iron available for
absorption
• Reserve parenteral iron for patients who are either unable to absorb oral
iron or who have increasing anemia despite adequate doses of oral iron
• Reserve transfusion of packed RBCs for patients who are experiencing
significant acute bleeding or are in danger of hypoxia and/or coronary
insufficiency

14. IRON
 Iron is among the abundant minerals on earth.

 Of the 87 elements in the earth’s crust, Iron
constitutes 5.6% and ranks 4th
behind Oxygen
(46.4%), Silicon (28.4%) and Aluminum (8.3%).
 In soil, Iron is 100 times more than Ca, Na & Mg and
1000 times more than Zinc and 100,000 times more
than Iodine.

15. Dietary iron:
Iron is present in food as ferric hydroxides (ferric-protein
complexes and hem-protein complexes).
-meat, liver
-vegetables, eggs.
-The average diet contains 10-15mg and only 5-10% is normally
absorbed.
Iron requirements:
It varies depending on sex and age:
Male/female 0.5-1 mg/day
Pregnant female 1-2 mg/day
Children 0.5 mg/day

16. IRON
• Total body iron in a 70-kg man is 4 g.
• Although the body only absorbs 1 mg daily to
maintain equilibrium, the internal requirement
for iron is greater (20-25 mg).
• An erythrocyte has a lifespan of 120 days so
that 0.8% of red blood cells are destroyed and
replaced each day. A man with 5 L of blood
volume has 2.5 g of iron incorporated into the
hemoglobin, with a daily turnover of 20 mg for
hemoglobin synthesis and degradation and
another 5 mg for other requirements.
• Most of this iron passes through the plasma for
reutilization.
• Iron in excess of these requirements is
deposited in body stores as ferritin or
hemosiderin.

17. Iron transport and metabolism
• The average adult iron intake is 10–15 mg per day of which 1–2
mg is absorbed by duodenal enterocytes.
• Ingested iron then undergoes enzymatic reduction from ferric
iron (Fe3 + ) to the more readily absorbed ferrous iron (Fe2 + )
by brush border ferrireductase with the help of low gastric pH.
• Divalent metal transporter 1 (DMT1) on duodenal epithelium
transfers iron across the apical membrane where it is either
transferred across the basolateral membrane to reach plasma
bound to transferrin or stored as ferritin and eventually
excreted as the enterocyte is sloughed.

18. Uses of Iron
• Iron deficiency anemia
• Prophylaxis in pregnancy
• Megaloblastic anemia
• Astringent in throat paint

19. Iron preparations
Oral iron
1. Ferrous sulfate:
Hydrated salt 20% iron,
Dried salt 32% iron 200 mg tab
2. Ferrous gluconate (12% iron) 300 mg Tab
3. Ferrous fumarate (33% iron) 200 mg Tab
4. Ferrous succinate (35% iron)
5. Ferric citrate is an oral iron that has shown efficacy and
gained FDA approval for treatment of iron deficiency
anemia in adults with CKD and not on dialysis.

20. Adverse Effects of Oral Iron
• Epigastric pain,
• heartburn,
• nausea, vomiting,
• Staining of teeth,
• metallic taste,
• bloating,
• Colic

21. Iron preparations
Iron therapy by injection is indicated only when:
1. Oral iron is not tolerated: bowel unset is too
much.
2. Failure to absorb oral iron
3. Non-compliance to oral iron.
4. In presence of severe deficiency with chronic
bleeding

22. PARENTERAL IRON THERAPY
• For patients who cannot be maintained with oral iron
alone, in conditions including:
– Various postgastrectomy conditions
– Previous small bowel resection
– IBD involving the proximal small bowel
– Malabsorption syndromes
– Advanced chronic renal disease including hemodialysis and
treatment with erythropoietin

23. Iron preparations
Parenteral
Iron-dextran :50 mg elemental iron/ml
Iron-sorbitol-citric acid complex: 50 mg iron/ml;

24. Adverse Effects of parenteral Iron
Local
• Pain at site of i.m. injection, pigmentation of skin,
• sterile abscess- especially in old and debilitated
patient.
Systemic
• Fever, headache, joint pains, flushing,
• palpitation, chest pain, dyspnoea,
• lymph node enlargement.

25. CHRONIC IRON TOXICITY
• Aka Iron overload and hemochromatosis.
• Results when excess iron is deposited in the heart, liver, pancreas, and
other organs. It can lead to organ failure and death.
• Most common in patients with inherited hemochromatosis, a disorder
characterized by excessive iron absorption, and in patients who receive
many red cell transfusions over a long period of time.
• In the absence of anemia, it is most efficiently treated by intermittent
phlebotomy where One unit of blood can be removed every week or so
until all of the excess iron is removed.
• Parenteral deferoxamine is much less efficient as well as more
complicated while oral iron chelator deferasirox as effective as
deferoxamine at reducing liver iron concentrations and is much more
convenient.

26. Poisonings
Seen in infants and children (> 60 mg/kg iron)
Precipitates as
• vomiting, abdominal pain,hematemesis,
• diarrhoea, dehydration, acidosis,
• lethargy, cyanosis,convulsions;
• finally shock, cardiovascular collapse
• and death
Antidote: Desferrioxamine (chelating agent)

27. Poisoning-Management
A. Supportive measure: maintain the fluids
& electrolyte balance, vital support & O2
therapy
B. Preventive measure: Induce vomiting by
syrup ipecac or gastric lavage with
sodium bicarbonate or phosphate
solution to render iron insoluble; Egg yolk &
milk to complex

28. Poisoning-Management
C. Pharmacological measure:
• Desferrioxamine [specific antidote]:
binds to remove the iron already absorbed.
• 1 g stat then 500 mg every 4 hours for two
doses orally. Intravenous for the patient with
shock
• Diazepam or phenytoin iv to control
convulsions

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