1. Understanding Iron
Deficiency Anaemia (IDA)
Lab Test & management
with focus on
Parenteral Iron therapy
Dr. Sharda Jain

2. ANAEMIA
FREE
INDIA
ANAEMIA FREE
WOMEN & GIRLS
is our AIM

3. Objectives
• Basic of Anemia in India
• key aspects of lab evaluation
• Systematic approach to Parenteral
Iron therapy in anemia

4. India has largest no of
• Anaemic women
• Anaemic girls
• Anaemic children
Anaemic MOTHERS make Anaemic BABIES
Few facts
Hard to swallow

5. 8 out of 10
Children, adolescent and women
are anaemic.
BUT
The silver lining is
50% are only mildly anaemic

6. Anaemia drains all our energy
&
makes us “Lazy Race”

7. Lets Pledge in 2015 to make
• Anaemia Free India
• Anamia Free School
• Anaemia Free Family
• Anaemia Free Children

8. Hb of GIRLS AND WOMEN should not
be less than 12gm%

9. In India our AIM is
12gm by 12 yrs
where as
in West AIM is for Hb 14-15gm

10. It is doable
&
we can do it

11. CHINA Role Model
• Once they brought one child norm, they
concentrated on saving this child and making
him/her healthy.
• Their incidence of anaemia in children, adolescent
has markedly decreased.
• They have increased the height of their
children by 4-6 inc.
If they can do it, why can’t we do it.

12. • There are 1 million GOOD TEACHERS and 20 million
highly placed WORKING WOMEN in India.
Each should work hard to make their class
Student’s and co workers :Anaemia Free”.
• Every parent should take pledge to make their
family “Anaemia Free”
There are 8 lacs Doctors & 8 lacs nurses

13. •Bone Marrow
Pluripotent stem cells
– Life span
•Reticulocyte- 4 days
•RBC –120 days
Few facts about lab tests

14. The Important Players
• Hemoglobin
–
Transports 02from lungs to tissues
–4 globin chains & iron

15. The important players
• IRON
–key element in the production of
hemoglobin
–absorption is poor
• TRANSFERRIN
–iron transporter
• FERRITIN
–iron binder, measure of iron stores,

17. Definitions
• Anemia-values ofAnemia-values of HEMOGLOBIN,
HEMATOCRIT or RBC counts which are moreor RBC counts which are more
than 2 standard deviations below the meanthan 2 standard deviations below the mean
– HGB<13.5 g/dL (men)HGB<13.5 g/dL (men) <12 (women)<12 (women)
– HCT<41% (men)HCT<41% (men) <36 (women)<36 (women)

18. Infants 6-12 months & children 1-2 years < 11 gm%
Adolescent girls < 12 gm%
Pregnant women < 11 gm%
Lactating women < 12 gm%
Women in reproductive age group < 12 gm%
Adult men < 13 gm%
Moderate anaemia 7 - 10.0 gm%
Severe anaemia < 7 gm%
WHO GUIDELINES
HAEMOGLOBIN CUT OFF LEVELS
FOR DETERMINING ANAEMIA

19. ALGORITHM FOR EVALUATION OF ANEMIAALGORITHM FOR EVALUATION OF ANEMIA
ANEMIC PATIENT
Hyper-regenerative
Evaluate for hemolysis
and bleeding
Hypo-regenerative
Rule out treatable
nutritional deficiency (IDA , FA – B12)
endocrinopathy, etc
Low-EPO High-EPO
Trial of EPO Consider BMBxContinue EPO
Retic index
Epo level
Response No
response

20. Laboratory Evaluation
• Initial Testing
–CBC w/ differential (includes RBC indices)
–Reticulocyte count
–Peripheral blood smear

21. Laboratory Evaluation
• Bleeding *Iron Deficiency
– Serial HCT or HGB - Iron Studies
• Hemolysis
– Serum LDH,
– indirect bilirubin,
– haptoglobin,
– coombs,
– coagulation studies
• Bone Marrow Examination
• Others-directed by clinical
indication
hemoglobin
electrophoresis
B12/folate levels

22. Information from CBC
Parameters
1. HB/PCV : Degree of anaemia. Correlates
with patient’s symptoms.
HB : PCV ----- 1 : 3
2. MCV, MCH, Peripheral Smear: allow
Morphological Classification of anemia,
guide workup and allow assessment of
response to therapy

23. Peripheral smear: Shape, size, degree of
pigmentation of cell types, presence of abnormal
cells and blood parasites aid diagnosis of type of
anemia
Reticulocyte count : An appropriate response
(after correction) shows appropriate erythropoietin
release, a marrow capable of producing red cell
precursors, and sufficient iron stores.

24. Normal Polychromasia
PBS

25. Normal rbc Microcytosis, hypochromia

26. Normal
Macrocytic/
megaloblastic

27. Microangiopathic
hemolytic anemia
Spur cell anemia
(liver disease)

28. Hereditary spherocytosis

29. CBC PARAMETERS IDA THALASSEMIA
RBC count < 5 million/ml >5 million /ml
RDW >14 <14
Mentzer’s Index >14 <14
MCV
MCH
MCHC NORMAL
IDA / THALASSEMIA

30. IDA VERSUS THALASEMIA
MENTZER’S INDEX
MCV/ RBC
< 14 THALASEMMIA
> 14 IDA

31. SPECIFIC INVESTIGATIONS
• SERUM FERRITIN
• HPLC --- if needed
UK Guidelines on the management of iron deficiency in pregnancy 2012

32. NOT ROUTINELY
RECOMMENDED
• SERUM IRON
• TIBC
• % TRANSFERRIN SATURATION
Only when serum Ferritin is normal but
clinical and morphological picture strongly
suggestive of Iron Deficiency Anaemia

33. SERUM FERRITIN
• Serum ferritin is the best single indicator of
storage iron.
Adults (ug/L)
– less than 12→ diagnostic of iron deficiency
– 15 - 50 → probable iron deficiency
– 50 - 100 → possible iron deficiency
– more than 100 → iron deficiency unlikely
– persistently more than 1000 → consider test for iron
overload

34. TESTS OF IRON STATUS
Practical aspectsPractical aspects
• Low serum ferritin almost always indicates iron
deficiency
• Low serum iron and high TIBC almost always
indicate iron deficiency
• Ferritin > 100 rarely found in iron deficiency
– Exception - liver inflammation/necrosis
• Normal serum iron rarely found in iron
deficiency
–Exception - iron deficiency recently treated
with oral iron

35. TESTS OF IRON STATUS
Practical aspectsPractical aspects
• When TIBC is low or normal, low serum iron not a
reliable indicator of iron deficiency!
• IRON DEFICIENCY may be HARD TO DIAGNOSE via
blood tests in setting of INFLAMMATION (eg, low iron,
low TIBC, intermediate ferritin level)
– Therapeutic trial of iron +/- EPO a reasonable alternative to
marrow biopsy

36. Treatment PlansTreatment Plans

37. Remember 5 A’s
• Ask what is your Hb
• Ask when was it done last
• Ask what is the normal Hb
• Ask to get it done right away
• Advise : Diet
: Tablet
: Deworming

38. DIET --- IRON AND PROTEINS

39. SOURCES OF IRON
Green leafy vegetables
Legumes, Nuts
Jaggery , Dried Fruits
Meat , Liver ,
Poultry , Fish
SOURCES OF FOLIC ACID
Green leafy vegetables
Legumes, Nuts
Milk , Fruits
Meat , Liver , Eggs

40. WHO (deworming)
•Drug of choice is Mebendazole 100mg BD for 3
days
OR Albendazole 400mg
•In pregnant women with anaemia after 12
weeks of pregnancy

42. REASONS FOR FAILURE TO ORAL IRONREASONS FOR FAILURE TO ORAL IRON
THERAPYTHERAPY

43. Reasons for failure to oral iron therapyReasons for failure to oral iron therapy

44. 44
Ferric Carboxymaltose Injection
For the use of a Registered Medical Practitioner or a Hospital or a Laboratory only
Parenteral Iron Therapy &
medical@emcure.co.in

45. Parenteral Introduction of Iron
• in severe iron deficiency anemiain severe iron deficiency anemia
• intolerance of oral preparationsintolerance of oral preparations
• Gynae Conditions - before surgery ,Gynae Conditions - before surgery ,
After Delivery ,After Delivery ,
AUB/ DUB with moderate anamiaAUB/ DUB with moderate anamia
Pregnancy AnamiaPregnancy Anamia
• diseases of gastro-intestinal tractdiseases of gastro-intestinal tract
• continuous blood losscontinuous blood loss
• not compensated by oral methodnot compensated by oral method

46. Recent Advance in Parenteral Iron -
Ferric Carboxymaltose Injection
Injection Iron Sucrose

47. Properties of
an ideal parenteral iron
Property
Type
Molecular weight
Complex stability
Half life
pH
Osmolality
Antigenicity
Test dose
Time for inj.
Max dose
Ideal
I (robust)
>100 kD
High
Long
Neutral
Isotonic
Low
No
Short
High
Iron dextran
I (robust)
>100 kD
High
3-4 days
Neutral
Isotonic
High
Yes
4 - 6 h for 20mg/kg
20mg/kg
Iron sucrose
II (semi-robust)
34-60 kD
Moderate
6 hours
High
High
Low
No
15 min for100mg
600 mg/week
Ferric
carboxymaltose
I (robust)
150 kD
High
16 hours
Near-Neutral
Isotonic
Low
No
15 min for 1000mg
1000 mg/infusion /week

48. Iron usage over years

49. Dosage
• For IV use only
• Conventionally calculated using Ganzoni formula: Cumulative iron deficit
[mg] = body weight [kg] x (target Hb - actual Hb) [g/dl] x 2.4 + iron storage
depot [mg]
• Use simpler regimen as used in FERGIcor study [Gastroenterology 2011]
Cumulative iron dose of 500 mg should not be exceeded for patients with body
weight < 35 kg

50. Dilution for Infusion
• In case of drip infusion Ferric Carboxymaltose Injection must be diluted only in
sterile 0.9% sodium chloride solution as follows:
Iron Maximum volume of
normal saline
Minimum time
for
administration
200 to < 500 mg 100 ml 6 min
500 to <1000
mg
250 ml 15 min
How critical is speed of infusion?
What could be the consequence of excessive dilution (<2mg/ml)?

51. FERRIC CARBOXYMALTOSE INJECTION
FERIUM INJECTION
Allaying the fear
of an injectable iron…..

52. Adverse effects*
System Common
(>1%- <10%)
Uncommon
(>0.1% - <1%)
Immune system hypersensitivity
Nervous system headache (3.3%); dizziness paraesthesia
Vascular hypotension, flushing
Gastrointestinal nausea, abdominal pain,
constipation, diarrhoea
dysgeusia, vomiting, dyspepsia, flatulence
Skin rash pruritus, urticaria
Musculoskeletal myalgia, back pain, arthralgia
General injection site reactions pyrexia, fatigue, chest pain, rigors, malaise,
oedema peripheral
Investigational transient blood phosphorus
decreased, alanine
aminotransferase increased
aspartate aminotransferase increased,
gamma-glutamyltransferase increased,
blood lactate dehydrogenase increased
* UK-MHRA approved Prescribing Information

54. FERRIC CARBOXYMALTOSE INJECTION
FERIUM INJECTION
Allaying the fear
of an injectable iron…..

55. Contraindications
• Known hypersensitivity to Ferric
Carboxymaltose Injection or to any of its
excipients
• Anaemia not attributed to iron deficiency
• Evidence of iron overload or disturbances in
iron utilization of iron
• First trimester pregnancy
• Children below 14 yrs

56. Comparative Efficacy of
3 Parenteral Irons
Journal of Blood Transfusion Volume 2012, Article ID
473514 Adob
Do

57. Perioperative anemia
• There is a high incidence of preoperative and postoperative anemia in
surgical patients, with a coincident increase in blood utilization.
• These factors are associated with increased risk for perioperative infection
and adverse outcome (mortality) in surgical patients.
Journal of Surgical Research 102, 237–244 (2002)

58. LIFECARE EXPERIENCE
IRON SUCROSE
• USED IN OVER 500 CASES
• ALL PREGNANT WOMEN
• 6 PATIENTS HAD REACTIONS
• THOUGH NOT MAJOR BUT SCARY ENOUGH
• DEFINITE RISE IN HB IS NOT ASSURED
Severe Reaction if Occurs Recovery is Difficult
Company itself is withdrawing

59. FERRIC CARBOXYMALTOSE
• USED IN 304 CASES
• 256 NON PREGNANT AND 48 *PREGNANT
• 3 PATIENTS HAD REACTIONS (Rashe 2 , swollen lips 1)
• AGAIN THOUGH NOT MAJOR BUT SCARY
ENOUGH
• RISE IN 2 gm HB SEEN IN 1 MONTH IN 90% OF
CASES
*Pregnancy not approved by drug controller of India

60. Our Protocol
• COUNSELING AND CONSENT
• EMERGENCY TRAY
• RESUSCITATION FACILTIES
• ENOUGH EXPERIENCED MANPOWER –
DOCTORS, NURSES

61. Conclusion
• Major benefits of FCM inj
over iron sucrose Inj.
• Safe
• Rapid infusion rate – 1000 mg
in 15 minutes
• Low antigenicity
• No test dose required

62. Thank You

63. Thank
You