Iron Deficiency Anemia
Causes & Risk Factors
Findings & Clinical Features
History & Physical Exam
Diagnosis & Management
Screening & Prevention
family medicine presentation and summary
for medical students and residents
2. Dr AbdulRahman Altokhy
Supervised by:
Dr Jamil Alrohil
Iron
Deficiency
Anemia
Causes & Risk Factors
Findings & Clinical Features
History & Physical Exam
Diagnosis & Management
Screening & Prevention
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Contents
3. Anemia is a condition in which Hemoglobin concentration is lower than the normal
level for age and gender which is according to the CDC and WHO:
its is often the presenting sign of a more serious underlying condition.
Deficiency
Anemia
Group Anemia (Hb) Sever Anemia (Hb)
Males < 13.0 g/dl < 8 g/dl
Menstruating Females < 12.0 g/dl < 8 g/dl
Children: 5 - 11 yrs < 11.5 g/dl < 8 g/dl
Children: 6 m - 5 yrs < 11.0 g/dl < 7 g/dl
Pregnant: < 11.0 g/dl < 7 g/dl
4. cy Anemia
Approach
Kinetic
Morphologic Increased RBC loss
Normocytic anemia
(MCV 80-100)
Anemia of chronic diseases
Acute blood loss
Acute hemolysis
Macrocytic anemia
(MCV > 100)
Microcytic anemia
(MCV < 80)
B12 & folate deficiency
Liver disease
Alcohol abuse
Iron deficiency anemia
Thalassemia
Lead poisoning
5. Iron Deficiency Anemia
Occurs when iron deficiency has progressed to iron-deficient erythropoiesis, it’s the
most common cause of anemia worldwide, accounting for about 50% of cases.
Affects over 12% of the world population especially women of childbearing age,
children and individuals living in low- and middle-income countries
doi.org/10.21608/ejhm.2018.9791
6. Iron Deficiency Anemia
Occurs when iron deficiency has progressed to iron-deficient erythropoiesis, it’s the
most common cause of anemia worldwide, accounting for about 50% of cases.
Affects over 12% of the world population especially women of childbearing age,
children and individuals living in low- and middle-income countries
doi.org/10.21608/ejhm.2018.9791
7. Decreased iron intake
Increased iron demand
Decreased iron absorption
Increase iron loss
• Improperly balanced vegan or vegetarian diet
• Iron-poor diet
• Eating disorder
• Exclusive breast feeding after 6 month
Causes & Risk Factors
8. Decreased iron intake
Increased iron demand
Decreased iron absorption
Increase iron loss
• Pregnancy
• Infancy and adolescence
• Menstrual loss
• Blood donation
• Endurance sports
Causes & Risk Factors
9. Decreased iron intake
Increased iron demand
Decreased iron absorption
Increase iron loss
• Celiac disease (5%)
• Gastric and/or intestinal bypass (5%)
• H. pylori colonization (5%)
• Atrophic gastritis
• Inflammatory bowel disease
• Concomitant drug use e.g. PPI
Causes & Risk Factors
10. Decreased iron intake
Increased iron demand
Decreased iron absorption
Increase iron loss
• Abnormal uterine bleeding (25%)
• GI Cancer (15%)
• Chronic NSAIDs (10%)
• Peptic ulcer disease & H. pylori infection (9%)
• Esophagitis
• IBD
• Hookworm infestation
Causes & Risk Factors
11. Clinical features
Findings associated with all anemias:
• Headache (63%)
• Pallor of the skin, conjunctivae, & nail beds (45%)
• Fatigue (44%)
• Palpitations (9%)
• Non-specific pain
• Poor work productivity
• Dyspnea on exertion
• Presyncope & syncope
• Dizziness
• Blurred vision
12. Clinical features
Findings more specific to iron deficiency anemia
• Pica (55%) ingestion of non-nutritive materials
• Restless legs syndrome (RLS) (24%)
• Atrophic glossitis (27%) beefy red appearance
• Angular cheilitis
• Dry or rough skin and damaged hair or Alopecia
• Cold intolerance
• Irritability
Less common findings
• Koilonychia (5.4%) (spoon-shaped fingernails)
• Plummer-vinson syndrome (0.1%) (IDA, esophageal webs & dysphagia)
13. History of presenting illness
Ask about symptoms associated with IDA (including their timing)
• Pica: specifically ask about pica as patients are often reluctant to mention it
• Restless legs syndrome: patients often have difficulty describing their symptoms
Ask about symptoms related to underlying causes of IDA
• Menstrual history (interval, duration, flow, clots) and pregnancy history
• GI history (diarrhea, bleeding, tarry stools)
Exclude Red flags: Rectal Bleeding, Weight Loss, Fever, or Sweating
Assume GI bleeding or Malignancy in older men and postmenopausal women
presenting with IDA while, younger patients usually have a benign condition
14. Past Medical History
Diseases:
• Gastrointestinal diseases e.g. (IBD, celiac diseases, H. Pylori infection, GI cancer)
• Eating disorder or restricted diet (vegetarians and vegans)
• Bleeding disorders or multiple blood donations
Surgery:
• Gastrointestinal surgery e.g. (bariatric surgery or bowel surgery)
Drugs:
• Hypochlorhydria (Antacids, H2 blockers, PPI)
• GI bleeding (Chronic NSAIDs including aspirin)
• Zinc supplements (inhibition of iron bioavailability)
Travel: for Hookworm infection & Occupational: Exposure to benzene (Dyes)
15. Past Medical History
Role out other causes of anemia
Blood loss: Hemoptysis, Urinary Tract Bleeding, Trauma
B12 or folate deficiency: GI Surgery, Metformin, Methotrexate, Alcohol abuse
Anemia of Chronic diseases: RA, SLE, CKD, Liver Failure, Heart Failure, HIV, HCV
Leukemias: Rapid onset and progression, ↑↑↑ WBC
Inherited anemias: (A family Hx is usually present)
• Thalassemia: (Microcytic anemia + Normal or ↑ Iron studies & Normal RDW)
• Sickle cell disease:↑ in south Saudi, Hx of vaso-occlusive crises
• G6PD: Related to medications or ingestion of fava beans
17. Physical examination
Physical examination isn’t reliable to diagnose anemia
• Abnormal findings usually found with severe chronic anemia
• Symptoms such as glossitis, koilonychia, or dysphagia are uncommon in developed
countries
18. Physical examination
General physical examination:
• Skin: look for pallor, dry and rough skin
• HEENT: conjunctival or lingual pallor, glossitis, angular cheilosis
• Cardiac: tachycardia (9%), systolic flow murmur (10%)
• Lungs: pulmonary edema if heart failure is expected
• Abdomen: abdominal mass
• Extremities: koilonychia and poor capillary refill
19. Physical examination
Findings in other anemias:
Hemolysis: Jaundice, Dark Urine, Hepatosplenomegaly
B12 or folate deficiency: Paresthesia, Sensory deficits, Cognitive or Gait effects
Anemia of Chronic diseases:
• Rheumatoid arthritis: Joint Swellings, Deformities
• SLE: Rashes, Petechiae
• Cirrhosis: Spider Nevi, Palmar Erythema, Gynecomastia
• Heart failure: Murmurs, Crackles
Inherited anemias:
• Thalassemia: Bossing of skull & Legs deformities and ulcers
• Sickle cell disease: Leg ulcers and signs of Hemolysis
20. Diagnosis
CBC
• HB: Anemia is diagnosed for males Hb < 13 and for Females Hb < 12
Other CBC indices:
• MCV: Reduced (60.1%)
• MCH: Reduced
• MCHC: Normal to reduced
• RDW: High
• Platelets: Normal/High(13.3%)
Normal CBC indices do not rule out IDA consider Ferritin level in all cases of Anemia
when MCV < 95 μm3 as up to 40% of IDA cases MCV is normal
( N: 80-100 fl)
( N: 27-32 pg)
(N: 30-34 mg)
(N: 11.5-14%)
( N: 150-400 )
21. Diagnosis
Serum Ferritin
Reflects iron stores and is the test of choice to diagnose IDA
• Ferritin ≤ 30 ng has 92% sensitivity and 98% specificity to diagnosis IDA
• Ferritin ≥ 100 ng excludes IDA
• Ferritin 31 to 99 ng consider TIBC, Serum iron level, transferrin saturation
It’s an acute phase reactant, In patients with chronic inflammation or infection, IDA
is likely when ferritin < 50 ng
Hypothyroidism may produce a falsely low ferritin level
Male adults ( N: 30-400 ng)
Female adults ( N: 13-150 ng)
22. Bone marrow biopsy
If suspicion persists
↑ Erythrocyte Protoporphyrin
↑ ↓
Normal
Soluble transferrin receptor
Other Results
↑
↓
↓
↓
↑
↑
TIBC
Serum Iron
Transferrin
IDA
Not
IDA
31 to 99
≤30 ≥100
Ferritin
Anemia & MCV < 95
Diagnosis
24. Management
Treat the underlying cause
Patients with an underlying condition that causes IDA should be treated or referred
to a subspecialist (e.g., gynecologist, gastroenterologist) for definitive treatment
25. Initiate GI workup
Follow up Response
Treat IDA & check Response
No
Initiate workup
for bleeding &
Observe e.g.
transvaginal US
Abnormal uterine bleeding?
Premenopausal women
Management
Yes
No response
26. Consider
to repeat
GI source
Normal
Capsule endoscopy
GI source
No GI source
no response, Repeat endoscopy
Follow up Response
Treat IDA & check Response
Treat
underlying
cause
GI source
No GI source
Upper & Lower endoscopy;
consider celiac serology
Men and postmenopausal women
Management
27. Management
Also consider in the approach of the underlying cause:
• Fecal occult blood testing: positive if GI bleeding is present
• H. pylori test: positive in PUD or Colonization
• Stool microscopy: visualization of worms and eggs
• CT colonography: if colonoscopy is contraindicated
28. Management
Diet
• High iron diet: meat & liver (for Vegetarians: beans, dried fruits, spinach, and
other dark vegetables)
• Milk, coffee and tea. Also, drugs such as H2 blockers, PPI, antacids, can reduce
iron absorption
• Vitamin C (supplements or orange juice) enhances iron absorption
29. Management
Oral iron therapy
The dosage of Elemental Iron required to treat IDA
• Adults: 100 to 200 mg/day
• Children: 3 to 6 mg/kg/day, up to 150 mg/day of liquid preparation
• Best absorbed when taken on an empty stomach with vitamin C
Treatment should be taken until the anemia is corrected in addition to 3 months to
replenish the iron stores
30. Management
Common iron therapy formulations and dosing
Iron formula Elemental iron
Ferrous fumarate 324mg 106 mg
Ferrous sulfate 325mg 65 mg
Ferrous gluconate 300mg 38 mg
Polysaccharide-iron complex 200-50mg 200-50 mg
31. 02-04-2024
Management
Side effects of oral iron therapy
Although side effects are not severe, yet they are frequent like Nausea, Vomiting,
Constipation, Metallic Taste, Diarrhea, Epigastric Distress, Black Or Tarry Stools
• Liquid preparation may stain teeth Hence should be put back on tongue
Improve tolerability
• Increasing the interval to every other day
• Taking iron with food (may reduce absorption up to 40%)
• Switching formula with a lower amount of elemental iron
• Use liquid preparation which is easier to titrate the dose
32. Management
Failure of oral iron therapy
• Noncompliance
• Incorrect dose or diagnosis
• On going blood loss (exceeds the capacity of oral iron to meet needs)
• Absorption problems e.g., Celiac disease or GI surgery
33. Management
Most common indication of parenteral iron therapy:
• GI side effects of oral iron
• Insufficient absorption in patients undergone GI surgery or with celiac disease
• Need for quick recovery (e.g., severe IDA in 2nd or 3rd trimester of pregnancy)
• Worsening symptoms of IBD
• Unresolved bleeding that exceeds the capacity of oral iron therapy
• Renal failure–induced anemia treated with erythropoietin
34. Management
Parenteral iron therapy
Iron deficit Calculation:
• Ganzoni Equation:
Iron deficit [mg] = weight [kg] x ( target Hb - actual Hb g/dl ) x 2.4 + (500 to 1000)*
• Infed® Equation:
Iron deficit [mg] = LBW [kg] x ( target Hb - actual Hb g/dl ) x 2.21 + (13 x LBW [kg])*
• Schrier Equation:
Iron deficit [mg] = weight [kg] x ( target Hb - actual Hb g/dl ) x 2.145 + (500 to 1000)*
*for the repletion of iron stores
35. Management
Parenteral iron can be given as IV or IM
• However, IM iron is not advised as it’s painful and stains the buttocks
Common parenteral iron therapy formula and concentration
Dose in mL = (Iron deficit [mg] + iron stores) / formula concentration (C)
Iron formula Concentration (C) Maximum / Single Infusion
Iron Dextran 50 mg/mL 1000 mg 1-4 hr
Iron Sucrose 20 mg/mL 300 mg 2 hr
Ferric Gluconate 12.5 mg/mL 250 mg 60 min
Ferumoxytol 30 mg/mL 1020 mg 60 min
Ferric Carboxymaltose 50 mg/mL 1000 mg 30 min
36. Management
Transient side effects
IV iron may have transient side effects like transient fever, nausea, vomiting,
pruritus, headache, and flushing; myalgia, arthralgia, back and chest pain which
usually resolve within 48 hours
• Patient should be informed about them and may take NSAIDs as needed
• Decrease infusion rate
• Dilute large doses in 250 mL normal saline
• Separate multiple doses by 7 days or more
• If symptoms develop during the infusion, temporarily hold the infusion and
observe until symptoms are improved, then resume the infusion
37. Management
Premedication to the IV iron is Not done routinely except in:
• Asthma patients: Methylprednisolone 125 mg & H2 receptor blocker
• Inflammatory arthritis patients: Methylprednisolone 125 mg followed by
Prednisone (1 mg/kg OD PO for 4 days)
Serious hypersensitivity reactions and anaphylaxis
Developing of Hypotension, Tachypnea, Tachycardia, Wheezing, Stridor, Or
Periorbital Edema
• Rare (<1 in 200,000)
• Iron Dextran (LMW ID) should be tested with 0.5mL prior to the first dose
• Ferric Gluconate & Iron Sucrose only test if there’s multiple drug allergies
38. Management
Blood transfusion
• For hemodynamically unstable patients or showing signs of end-organ ischemia
(Chest pain or cerebral Hypoxia) or symptomatic patients
• Most patients will present with symptoms when Hb falls to <7
• If hemodynamically stable consider transfusion at a Hb of< 7 to 8
• Transfusion is highly recommended when Hb < 6 specially in pregnancy because of
potentially abnormal fetal development
• If transfusion is performed, 2 units of PRBCs should be given, then reassess the
clinical situation to guide further treatment
• Each unit of PRBCs contains 200 mg of iron and will raise the HB by 1
39. Follow up
An increase in Hb of 1 g/dL after one month of treatment shows an adequate
response to treatment and confirms the diagnosis
• Recheck CBC every three months for one year
• If Hb and RBC indices remain normal, one additional CBC should be obtained12
months later
40. Screening
• For nonpregnant women of childbearing age
• Annually for high risk for IDA
• Every 5-10 years in all others
• AAP and WHO recommend universal screening of anemia at age of1 Year. While
USPSTF graded this as "insufficient"
• ACOG and CDC recommend to screen for IDA using CBC at the First prenatal visit
and at 24 to 28 weeks
41. Prevention
• WHO: Menstruating, Pregnant, and Postpartum women living in areas where
anemia is highly prevalent should take iron supplementation
• CDC: Recommends universal iron supplementation during pregnancy to meet
increased iron demands While USPSTF graded this as "insufficient"
• AAP: Recommends that full term, exclusively breastfed infants start1mg/kg/day of
elemental iron supplementation at 4 months of age until appropriate iron containing
foods are introduced
