Symptoms, Signs And Management of Iron Deficiency Anemia

1. DR. P.GANDIAH, MD
Director
Department of medicine
SVSMC, MBNR

2. GLOBAL BURDEN OF IDA
• Globally 50% of anemias are due to Iron deficiency.
• 8.4 lakhs death annually due to IDA.
• 71% of deaths due to IDA are in Africa and Asian
countries.

4. • First most commonest cause of Anemia is Iron deficiency.
• Second most commonest cause of Anemia is Anemia due
to chronic disease.
• IDA is a type of Anemia where total body iron is reduced.

5. • Anemia is reduction in number of Red cell mass or their
Oxygen carrying capacity that is needed to meet the
metabolic needs of body tissues.
• IDA is a type of anemia where Iron supplied to marrow is
decreased and total body iron is decreased.

6. ANEMIA CUT OUT POINTS
• Adult males < 13gm/dL
• Adult females < 12gm/dL
• Adult pregnant women < 11gm/dL
• Children below 14yrs < 12gm/dL
• Children below 6 yrs < 11gm/dL

7. THREE PARAMETERS ARE USED TO DEFINE
ANEMIA
• Hemoglobin level
• Hematocrit percentage
• RBC count

8. CLASSIFICATION OF ANAEMIA
• Microcytic anemia – MCV < 80 fL
• Normocytic anemia – MCV 80 – 95 fL
• Macrocytic anemia – MCV > 95 – 100 fL
• Some define Macrocytic > 100 fL

9. CAUSE OF MICROCYTIC ANEMIA
• Iron deficiency (relating to blood loss, dietary deficiency and
occasionally malabsorption)
• Anaemia of chronic disease (also associated with
normocytic anaemia)
• Haemoglobinopathies, e.g. thalassaemia
• Sideroblastic anaemias (rare genetic or acquired disorders)

10. DAILY IRON REQUIREMENTS
• < 4 months ………………… 0.5 mg
• Infants < 12months …………………. 1 mg
• Pregnants ………………… 4mg
• Menstruating females ………………. 3mg
• Adult males and post menopausal females …… 1mg

11. • Adult male has ~ 4 gms total body
iron stores

12. • Heme is a porphyrin ring
containing an Iron atom
• Each Hb molecule can
bind 4 oxygen
molecules at haeme site

14. Iron Absorption (% of dose)
0 5 10 15 20 25
Veal muscle
Hemoglobin
Fish muscle
Veal liver
Ferritin
Soy beans
Wheat
Lettuce
Corn
Black beans
Spinach
Rice
Non-heme
iron
Heme
iron

15. IRON ABSORPTION
• Food sources supply: 10 - 25 mg / day
• Absorbed in the brush border of the upper small intestine
• Enhanced by gastric acid
• Inhibited by tannins, systemic inflammation
• Most dietary iron is non-heme form, <5% bioavailability
• < 10% dietary iron is heme form, >25% bioavailability

17. • Transferrin – plasma iron transporter protein.
- Carries less than 1% of total body iron
• Ferritin – intracellular storage of iron
• Hemosiderin – long term iron storage pool

18. IRON STORAGE
Ferritin
multi-subunit protein
primarily intracellular
some in plasma
Hemosiderin
insoluble form of ferritin
visible microscopically

21. IRON LOSSES
• Iron is closely conserved in humans
<0.05% of iron is lost per day normally
1. Very small amounts in urine, bile and sweat
2. Cells shed from skin, intestinal and urinary tracts
3. Menstrual blood loss
4. Pregnancy and lactation
• Humans have NO other physiologic means to excrete excess iron

23. • Blood loss
• Occult or overt GI losses, traumatic or surgical losses
• Failure to meet increased requirements
• Rapid growth in infancy and adolescence
• Menstruation, pregnancy
• Inadequate iron absorption
• Diet low in heme iron
• Gastrointestinal disease or surgery
• Excessive cow’s milk intake in infants

26. 3 STAGES OF IDA
• Stage 1 : Decrease storage of Iron without any other detectable
abnormality.
• Latent IDA : Iron storage exhausted not anemic
Diagnosed by decrease in serum Ferritin
fall in Transferrin level (Normal 30%)
• Iron Deficiency Anemia

28. • Iron deficiency
• Decrease in Ferritin
• Anemia is variable
• Decrease Iron availability due to
- lower plasma Iron level
- increase phagocytosis of RBC by
macrophages
• Increase in Ferritin levels
• Anemia is usually mild (10 – 11 gm%)

30. CAUSES OF IRON DEFICIENCY ANAEMIA
• Obstetric/gynaecological causes
• Gastrointestinal bleeding
• Malabsorption
• Pharmacological
• Increased demand
• Dietary deficiency
• Other – blood donation, blood loss from non-gastrointestinal sources.

31. • Obs & Gynaecological causes – Menorrhagia, Normal menstruation combined with a
deficient diet, Pregnancy.
• Gastrointestinal bleeding – Oesophagitis, Varices, Ulcerated hernia, PUD , IBD,
malignancy, Angiodysplasia.
• Malabsorption – Celiac disease, Atrophic gastritis, H. pylori infection
• Pharmacological – medicines that cause gastric erosions/ulceration, e.g. NSAIDs,
Steroids, Anticoagulants, SSRIs.
• Increased demand – Pregnancy, growth spurts (uncommon)
• Dietary deficiency – vegans, older people, toddlers fed exclusively milk
• Other – blood donation, blood loss from non-gastrointestinal sources, e.g. nosebleeds,
trauma, surgery.

32. RED FLAGS IN IRON DEFICIENCY ANAEMIA
• Upper and lower GI investigations should be considered in all males and post-menopausal
females with iron deficiency anemia unless there is an obvious alternative cause. N.B. fecal
occult blood testing is not beneficial for investigating people with iron deficiency anemia as it is
insensitive and non-specific.
• Patients with gastrointestinal symptoms and unexplained anemia, require urgent referral,
particularly those aged over 50 years or with a family history of colorectal cancer
• Males with Hb < 11 g/dL and non-menstruating females with Hb levels < 10 g/dL require urgent
referral.
• Patients who do not respond to a trial treatment of iron replacement should be referred for
further investigation.

33. CHRONIC DISEASES – ASSOCIATED WITH
MICROCYTIC ANEMIA
• Situations of chronic inflammation
• Chronic infections
• Autoimmune conditions, e.g. rheumatoid arthritis, SLE,
inflammatory bowel disease
• Malignancy
• Chronic heart failure
• Chronic kidney disease

34. LATENT IRON DEFICIENCY ANEMIA
• Iron deficiency without Anemia.
• Iron deficiency does not always develop into anaemia.
• low Iron and normal Hb levels.
• three times more common than iron deficiency
anaemia.

35. INVESTIGATING THE CAUSE OF MICROCYTIC
ANAEMIA
• Serum Ferritin should be done in microcytic anemia.
• Ferritin is an acute phase protein.
• Ferritin is an iron storage protein.
• Keeps iron in a soluble and non-toxic form.
• Ferritin reflects true iron stores in uncomplicated iron deficiency.
• Ferritin might raised in
- Inflammation
- Infection,
- Chronic diseases
- Malignancy
- Liver diseases.

36. • A serum ferritin below 15 – 20 micrograms/L in a person with microcytic anaemia
confirms iron deficiency anaemia

37. Iron deficiency
Anaemia of chronic
disease
Haemoglobinopathies,
e.g. thalassaemia,
Sideroblastic anaemia
Serum ferritin Decreased Increased Increased
Serum iron Decreased Normal or decreased Normal or increased
TIBC Normal or increased Normal or decreased Normal
Transferrin saturation Decreased Normal or decreased Normal or increased
Serum soluble
transferrin receptor
Increased Normal or decreased Increased

38. FEATURES OF IRON DEFICIENCY ANEMIA
•Depends on the degree and the rate of
development of anemia
•Symptoms common to all anemias:
• pallor, fatigability, weakness, dizziness, irritability

39. OTHER FEATURES OF IDA
• Pagophagia - craving ice
• Pica - craving of nonfood substances
• e.g., dirt, clay, laundry starch
• Glossitis - smooth tongue
• Restless Legs
• angular stomatitis - cracking of corners of mouth
• Koilonychia - thin, brittle, spoon-shaped fingernails

40. • Pica

43. • Smooth tongue
• Painless and shiny

47. • Angular Cheilitis

50. • Pedal edema

51. • Peripheral blood smear
• Red cell indices (MCV, MCH)
• Serum ferritin
• Serum iron / transferrin = iron saturation
• Bone marrow iron stain (Prussian blue)

54. Marked
hypochromasia,
microcytosis

55. • Cell size decreases because of decrease in Hb
Heme in IDA
Globin in Thalassemia
• Maturation disorders may result in microcytes if the
cytoplasm is altered.
• Macrocytes because of defect in nucleolus or maturation.

56. Tear Drop Cells

58. Serum
Bone Marrow
N
N
N
Circulation
Reticulocyte
Erythrocyte
Spleen
Macrophage
Low Hgb
Low Serum Fe/TS Low sFt/Liver Fe
High sTfR
Erythroblast
TfR+
Fe
Transferrin

59. FERRITIN
IRON SATURATION
MCV & Hb & Hct

61. • Thalassemia trait (low MCV, normal RDW)
• Imbalance of globin chain production
• Anemia of inflammation
• Decreased iron utilization in the face of adequate iron
stores
• Low ferritin / serum transferrin receptor

62. IRON STAIN OF BONE MARROW
Iron Deficient Marrow
Prussian Blue Stain
Normal Marrow
Prussian Blue Stain

63. TREATMENT
• Most patients are treated initally with oral iron unless there is an absorptive
problem.
• Dietary sources + FeSo4 BID.
• TID is very constipating and causes gastric distress; commonest cause for
noncompliance
• IV iron is no longer ‘dangerous’. The newer formulations such as iron sucrose,
LMW iron dextran and ferric gluconate have minimal risks of infusion reactions
• In very severe cases, RBC transfusion

64. ORAL THERAPY OF IRON DEFICIENCY
• Carbonyl iron (elemental), heme-iron polypeptide
(extracted from porcine RBC), polysaccharide-iron
complex
• Ascorbic acid increases oral iron absorption but
dose is usually not in significant quantity to make a
difference
• Phytates (cereal grains), tannins (tea) and antacid
therapy inhibit oral iron absorption

65. ORAL IRON SUPPLEMENTATION
• 100 – 200 mg elemental iron per day
• In the past, recommended vitamin C tablets, evidence now suggests that the
therapeutic benefit of this is minimal.
• on an empty stomach.
• If gastric symptoms occur, advise the patient to try taking the supplement with food
• Hb should rise by approximately 1 g/L, per day, and 20 g/L higher after 3 - 4 weeks.
• treatment should be continued for a further 3 months to replenish iron stores.
• Ferritin levels should be checked 4 – 6 weeks after completing treatment.

66. Iron salt Dose Elemental iron content
Ferrous fumarate 200 mg 65 mg
Ferrous sulfate (tablet) 325 mg 105 mg
Ferrous sulfate (liquid) 150 mg (in 5 mL) 30 mg ( in 5 mL)

67. RESPONSE TO ORAL IRON THERAPY
• Peak Reticulocyte count 7 - 10 d.
• Increased Hb and Hct 14 - 21 d.
• Normal Hb and Hct 2 months
• Normal Iron stores 4 - 5 months

68. INDICATIONS FOR IV IRON
• Severe symptomatic anemia requiring accelerated erythropoesis
• Failure of oral iron from GI intolerance
• Failure of oral iron due to absorption issues
H pylori infection, autoimmune gastritis, celiac disease, gastric bypass
surgery, inflammatory bowel disease
• Cancer and chemotherapy associated anemia
• Anemia with chronic renal disease (with or without[?] dialysis dependance)
• Heavy ongoing GI or menstrual blood losses

69. INTRAVENOUS IRON FORMULATIONS
• High molecular weight Iron Dextran is not routinely used anymore due to a
much poorer safety profile (anaphalyctoid reactions) in comparison to newer
iron preparations
• Hemoglobin iron deficit (mg) = Body Wt x (14 - Hgb) x (2.145)
(formula dose not account for repletion of body stores)

70. LMW Iron
Dextran
Iron
Sucrose
Ferric
Gluconate
Ferumoxytol Ferric Carboxy
maltose
Administered
Dosage
100mg 200 mg 125 mg 510mg 750mg
Total Dose
Infusion
1000 mg no no 1020 mg 3d
apart
1500mg 7d apart
Cost Inexpensive Inexpensive Inexpensive Expensive Expensive
Indication IDA IDA in CKD IDA in
CKD/HD
+epo
IDA in CKD IDA
+
IDA in CKD
Test dose Yes none none None None
Administration Iv (preferred)
or im
Iv push or
15m
infusion
i.v push or
1hr infusion
17s i.v push or
15 m infusion
7.5 m iv push or
15 m infusion