For medical

1. ‫الرحیم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
Conference
on
IRON DEFICIENCY ANEMIA
Prepared by: Dr Abdul Wadood Raza Mujahid
Coordinator trainer: Dr Mirwais Habibi
Chief trainer: Proff Dr Mohammad Ismail Alam

2. Anemia
• Definition:
• Anemia is defined as a reduction in the
number of circulating erythrocytes
Any condition that can impair the production
or increase the rate of destruction or loss of
erythrocytes can result in anemia if the bone
marrow is unable to compensate for the rate
of loss of red blood cells

3. Classification
by pathophysiology:
Decreased production
Hemoglobin synthesis lesion: iron deficiency,
thalassemia, anemia of chronic disease
DNA synthesis lesion: megaloblastic anemia
Stem cell lesion: aplastic anemia,
myeloproliferative leukemia
Bone marrow infiltration: carcinoma,
lymphoma Pure red cell aplasia

4. Increased destruction Blood loss Hemolysis (intrinsic)
Membrane lesion: hereditary spherocytosis, elliptocytosis
Hemoglobin lesion: sickle cell, unstable hemoglobin
Glycolysis: pyruvate kinase deficiency, etc
Oxidation lesion: glucose-6-phosphate dehydrogenase
deficiency Hemolysis (extrinsic)
Immune: warm antibody, cold antibody
Microangiopathic: thrombotic thrombocytopenic
purpura, hemolytic-uremic syndrome, mechanical
cardiac valve, paravalvular leak
Infection: clostridial
Hypersplenism

5. Measurement Unit Normal Range
Hemoglobin g/dL Males: 13.5–17.5
Females: 12–16
Hematocrit % % Males: 40–52
Females 36–48
(RBC) count × 106
/μL of blood Males: 4.5–6.0
Females: 4.0–5.4
(MCV) fL 81–99
(MCH) pg 30–34

6. Physiologic Compensatory Mechanisms
First
in acute-onset anemia with
severe loss of intravascular
volume, peripheral
vasoconstriction and central
vasodilatation preserve blood
flow to vital organs

7. Second over time and with
increasingly severe anemia,
systemic small vessel vasodilatation
results in increased blood flow to
ensure better tissue oxygenation

8. .
Third
an increased level of 2,3-
diphosphoglycerate accumulates in
RBCs and interacts with hemoglobin
molecules to cause a rightward shift of
the hemoglobin oxygen dissociation
curve, which in turn enhances the
release of oxygen to tissues at any
given partial pressure of oxygen

9. Fourth
in chronic anemia there is a
compensatory increase in plasma
volume that maintains total blood
volume and enhances tissue
perfusion.

10. The fifth
compensatory response in
otherwise normal individuals
is stimulation of EPO
production, which in turn
stimulates new erythrocyte
production.

11. IRON DEFICIENCY ANEMIA
IDA is one of the MICROCYTIC AND
HYPOCHROMIC ANEMIAS
Iron deficiency is by far the most common
cause of anemia worldwide
Essentials of Diagnosis
• Serum ferritin < 12 mcg/L.
• Caused by bleeding unless proved otherwise.
• Responds to iron therapy.

12. Epidemiology
affecting 2 billion people worldwide
Age incidence Infant&young children
(dietary)
Young woman/ preg (blood loss)
Old age(hemorrhoid,pud,Hiatus H,Colon
cancer)

13. Major location of iron in the
body
circulating red blood cells
storage pool as ferritin
or as hemosiderin

14. Body Iron Distribution
Iron Content, mg
Adult Male 80( kg) - Adult Female( 60 kg)
Hemoglobin 2500 - 1700
Myoglobin/enzymes 500 - 300
Transferrin iron 3 - 3
Iron stores 600-1000 - 0-300

15. The hemoglobin content of
erythrocytes is determined by the
coordinated production of globin
protein, the heme porphyrin ring,
and the availability of iron. A
deficiency in any of these three
critical components of hemoglobin
results in hypochromic and/or
microcytic anemia.

16. Iron Metabolism
Iron is a critical element in the function of all
cells,
The major role of iron in mammals is to carry O2
as part of hemoglobin.
Iron is a critical element in iron-containing
enzymes, including the cytochrome system in
mitochondria. Without iron, cells lose their
capacity for electron transport and energy
metabolism. In erythroid cells, hemoglobin
synthesis is impaired, resulting in anemia and
reduced O2 delivery to tissue.

17. Regulation of Body Iron
In general, iron metabolism is balanced between
absorption of 1-2 mg/d and loss of
1-2 mg/d
Physiological demands Normally, an adult male will
need to absorb at least 1-2 mg of elemental iron
daily to meet needs
since requirements increase to 2–5 mg of iron per day
during pregnancy and lactation
red cells turn over each day0.8–1%
each milliliter of red cells contains 1 mg of elemental
iron, the amount of iron needed to replace those red
cells lost through senescence amounts to 20 mg/d

18. Cont…
Any additional iron required for daily red cell
production comes from the diet.
There is no regulated excretory pathway for
iron, and the only mechanisms by which iron
is lost are
blood loss (via gastrointestinal bleeding,
menses, or other forms of bleeding)
and the loss of epithelial cells from the skin,
gut, and genitourinary tract.

19. Absorption
Gastric acid is required to release iron from food and
helps to keep iron in the soluble ferrous state
Hypochlorhydria in the elderly or that due to
drugs(ppi)
may contribute to the lack of iron availability from the
diet
Absorption occurs in the stomach, duodenum, and
upper jejunum
Iron bioavailability is affected by the nature of the
foodstuff(oxalates, phosphates, carbonates,
tannates, phytates)

20. heme iron (e.g., red meat) being most readily
absorbed
the average iron intake in an adult male is 15
mg/d with 6% absorption;
the average female, the daily intake is 11 mg/d
with 12% absorption. An individual with iron
deficiency can increase iron absorption to
approximately 20% of the iron present in a
meat-containing diet but only 5–10% in
vegeterians

21. cont…
one-third of the female population in the
United States has virtually no iron stores
During the last two trimesters of pregnancy,
daily iron requirements increase to 5–6 mg.
That is the reason why iron supplements are
strongly recommended for pregnant women
in developed countries.
Infants, children, and adolescents may be
unable to maintain normal iron balance
because of the demands of body growth and
lower dietary intake of iron.

22. iron in vegetables is only about
one-twentieth as available,
egg iron one-eighth
liver iron one-half
and heme iron one-half to
two-thirds

23. Stages of Iron Deficiency
The first stage is negative iron
balance(storege I decreased , serum IRON
normal ,,Hb normal)
This stage results from a number of
physiologic mechanisms, including blood
loss, pregnancy (in which the demands for
red cell production by the fetus outstrip
the mother's ability to provide iron), rapid
growth spurts in the adolescent, or
inadequate dietary iron intake

24. Blood loss in excess of 10–20
mL of red cells per day is
greater than the amount of
iron that the gut can absorb
from a normal diet

25. normal - negative iron B - I D erythropoisis - IDA
M ironst - 1-3+ 0-1+ 0 0
S ferritin - 50-200 <20 <15 <15
(Mcg/l)
TIBC - 300-600 >360 >360 >400
( mcg/dl)
SI - 50-150 NL <50 <30
(Mcg/dl)
T Sat% - 30-50 NL <20 <10
Morph - NL NL NL Mic/Hypoc
PTP Lev - 30-50 NL >100 >200
mcg/dl

26. Causes of Iron Deficiency
Menstrual blood loss
pregnancy
or gastrointestinal blood loss is
the most common etiology.

27. • Increased Demand for Iron
• Rapid growth in infancy or adolescence
• Pregnancy
• Erythropoietin therapy
Increased Iron Loss
. Chronic blood loss
• Menses
• Acute blood loss
• Blood donation
• Phlebotomy as treatment for polycythemia
vera

28. CONT…
Decreased Iron Intake or Absorption
• Inadequate diet
• Malabsorption from disease (sprue, Crohn's
disease)
• Malabsorption from surgery
(postgastrectomy)
• Acute or chronic inflammation

29. Clinical Presentation of Iron Deficiency
The signs and symptoms of anemia can vary
widely from patient to patient with the same
degree and tempo of anemia.
The major factors that determine the specific
response of each individual to anemia
include the severity of the anemia, the
rapidity of onset of the anemia, the age of
the patient
the patient's overall physical condition, and
comorbid events or disorders.

30. cont…
Weakness, fatigue, lethargy, palpitations,
Dyspnea on exertion, and orthostatic light-
headedness are common symptoms (chronic
anemia)
Occasional patients with slowly developing or
long-standing anemia may report being
asymptomatic with hemoglobin levels of 5 or
6 g/dL

31. Cont…
comorbid conditions(coronary artery disease,
anemia may result in the onset or worsening
of angina or may precipitate myocardial
infarction
cerebrovascular disease may experience
decreased cognition and more frequent or
severe transient ischemic attacks or strokes.
New or worsening claudication may develop
in anemic patients with significant peripheral
arterial disease.

32. Anemia of rapid onset
In a patient with severe acute hemolysis or
blood loss, prominent early symptoms include
resting or orthostatic hypotension along with
subsequent light-headedness or syncope,
exertional or resting tachycardia (or both)
palpitations
diaphoresis
anxiety, agitation
generalized severe weakness and lethargy, and
possibly decreased mental function.

33. Cont…
most frequently elderly women, may have
dysphagia due to an esophageal stricture or
web (Plummer-Vinson syndrome).
A clinical manifestation unique to iron
deficiency is pica{craving for ice
(pagophagia), or less commonly for clay
(geophagia) or starch (amylophagia)}
pagophagia is believed to be the most
specific to iron deficiency.

34. Physical findings
Pallor
tachycardia
hypotension
dizziness
tinnitus
headaches
loss of concentration
fatigue
weakness
glossitis and angular stomatitis

35. Cont…
less common but highly specific abnormal
findings in iron deficiency are spooning of the
fingernails (koilonychia) and blue-tinged
sclerae
Plummer-Vinson's syndrome (glossitis,
dysphagia, and esophageal webs)

36. Laboratory Findings
Plasma ferritin is a measure of iron stores and the best
single test to confirm iron deficiency
ferritin is the primary storage form for iron in the liver
and bone marrow and is the best surrogate marker of
iron stores,
Normal range is 50-200micg/L
ferritin level of < 10 ng/mL in women or 20 ng/mL in
men is a specific marker of low iron stores
Serum iron and Total Iron-Binding Capacity(The TIBC is
an indirect measure of the circulating transferrin
normal range for TIBC is 300–360 microg/dl IDA>360

37. .
soluble transferrin receptor . Normal values are 4–9
g/L determined by immunoassay.
Red Cell Protoporphyrin Levels Normal values are <30
g/dL of red cells In iron deficiency, values in excess
of 100 g/dL are seen

38. Evaluation of Bone Marrow Iron Stores
• Iron Stores Sr Ferritin mcg/l Marrow Iron Stain, 0-4+
• 0 <15 0
• 1–300 mg Trace to 1+
15–30
• 300–800 mg 2+
30--60
• 800–1000 mg 3+
60--150
• 1–2 g 4+
>150

39. Diagnostic Procedures
A BM biopsy that shows absent
staining for iron is the definitive
test for establishing iron
deficiency and is helpful when
the serum tests fail to confirm
the diagnosis.

40. Differential Diagnosis
USE OF THE PERSONAL AND FAMILY MEDICAL
HISTORY IN DIAGNOSIS OF ANEMIAS
Known normal complete blood cell count in the
past(Probably not a hereditary/congenital
disorder)
Anemia known since childhood
{Inherited/congenital hemolytic anemia or
(less likely) bone marrow hypoplasia}

41. Cont…
Splenectomy, gallstones, and/or jaundice
(Chronic hemolytic anemia, liver disease)
Family history of splenectomy, gallstones,
and/or jaundice
{ Hereditary hemolytic anemia (RBC enzyme or
membrane disorder, thalassemia, or
hemoglobinopathy)}
Poor or unconventional diet, malnutrition, or
severe alcoholism( Bone marrow hypoplasia,
folate deficiency)

42. Paresthesias, foot numbness, loss of
balance, altered mental
status{ Cobalamin (vitamin B12)
deficiency}
Gastrectomy, surgical removal of the
ileum, chronic malabsorption
disorder{ Cobalamin (vitamin B12)
deficiency}

43. Cont…
Chronic rheumatologic, immunologic, infectious, or
neoplastic disease
( Anemia of inflammation, autoimmune hemolytic
anemia)
Decreased urine output (Anemia secondary to renal
insufficiency)
Dark urine {Hemolytic anemia (intravascular
hemolysis)}
Recent onset of infections, mucosal and skin
bleeding, easy bruising, oral ulcerations( Bone
marrow aplasia/hypoplasia, acute leukemia,
myelodysplasia, myelophthisis)

44. Cont…
Occupational/environmental toxin exposure
(benzene, ionizing radiation, lead) { Bone
marrow aplasia/hypoplasia, acute leukemia,
myelodysplasia, lead poisoning }
Penicillin, cephalosporin, procainamide,
quinidine, quinine, sulfonamide (Drug-
induced immune hemolytic anemia)
Chloramphenicol, gold salts, sulfonamides,
anti-inflammatory drugs( Bone marrow
aplasia/hypoplasia)

45. Methotrexate, azathioprine,
pyrimethamine, trimethoprim,
zidovudine, sulfa drugs,
hydroxyurea, antimetabolites
( Bone marrow
aplasia/hypoplasia,
megaloblastic anemia)

46. Cont…
Chronic gastritis, peptic ulcer disease,
chronic use of ASA or NSAIDs,
recurrent epistaxis or rectal
bleeding, melena, menorrhagia,
metrorrhagia, multiple pregnancies,
duodenal surgery, gastrectomy
( Iron deficiency)

47. Iron Deficiency
Smear Micro/hypo
SI <30
TIBC >360
Percent saturation <10
Ferritin (g/L) <15
Hemoglobin pattern
on electrophoresis Normal
Inflammation
Smear Normal micro/hypo
• SI <50
• TIBC <300
• Percent saturation 10–20
• Ferritin (g/L 30–200
• Hemoglobin pattern on
Electrophoresis Normal

48. Thalassemia
Smear Micro/hypo with targeting
SI Normal to high
TIBC Normal
Percent saturation 30–80
Ferritin (g/L) 50–300
Hemoglobin pattern on electrophoresis
Abnormal with thalassemia; can be
normal with alpha thalassemia
Sideroblastic
Anemia
Variable
Normal to high
Normal
30–80
50–300
Normal

49. Treatment: Iron-Deficiency Anemia
Red Cell Transfusion
Transfusion therapy is reserved for individuals
who have symptoms of anemia
cardiovascular instability
continued and excessive blood loss from
whatever source and require immediate
intervention.
Surgery
HB<7MG/DL

50. Oral Iron
The preferred route of iron
administration
(enteric coated and prolong release
preparation should be avoided)
Ferrous sulfate, 325 mg three times daily,
which provides 180 mg of iron daily of
which up to 10 mg is absorbed is the
preferred therapy

51. Iron is best absorbed on an empty
stomach
Oral iron ingestion may induce a number
of GI side effects, including epigastric
distress, bloating, and constipation,
diarrhea is common problems
Compliance is improved by introducing
the medicine more slowly in a gradually
escalating dose with food

52. – Ferrous gluconate(300m/bd and fumarate
at a similar dose(325/td) may be better-
tolerated alternative therapies.
–Iron polysaccharide complex contains 150
mg of elemental iron, given twice daily, is
as effective as other preparations at a
similar cost and seems to have fewer GI
side effects.
–Administration of vitamin C(250mg) along
with the iron improves absorption by
maintaining the iron in the reduced state

53. The goal of therapy in individuals with iron-
deficiency anemia is not only to repair the
anemia, but also to provide stores of at least
0.5–1 g of iron.
Sustained treatment for a period of 6–12
months after correction of the anemia will be
necessary to achieve this.
Indeffinetely(menorrhagia, HHT, HIATAL
HERNIA)

54. The response to iron therapy varies
the reticulocyte count should begin to increase within 4-
7 days after initiation of therapy and peak at 7-12days
2weaks Hct increased,normal after 4-5w
The absence of a response may be due to
poor absorption
noncompliance (which is common)
or a incorrect diagnosis (anemia of chronic disease,
thalassemia),
Celiac disease
Ongoing gastrointestinal blood loss
Normal absorption will result in an increase in the serum
iron of at least 100 mcg/dL

55. If iron deficiency persists despite adequate
treatment, it may be necessary to switch to
parenteral iron therapy.
Parenteral Iron Therapy The indications are
intolerance to oral iron
refractoriness to oral iron
gastrointestinal disease (usually inflammatory
bowel disease)
precluding the use of oral iron
continued blood loss(Very high iron
requirements that cannot be met with oral
supplementation)

56. Because of the possibility of anaphylactic
reactions
parenteral iron therapy has been advocated
only for use in cases of persistent anemia
after a reasonable course of oral therapy.
Methylprednisolone, diphenhydramine,
and 1:1,000 epinephrine 1-mg ampule (for
subcutaneous administration) should be
immediately available at all times during
the infusion

57. CONT…
Sodium ferric gluconate(Ferrlecit)
and iron sucrose (Venofer) that have
much lower rates of adverse effects,
is available and has been shown to
result in a lower incidence of severe
anaphylaxis, allowing wider use of
parenteral therapy.

58. CONT…
Delayed reactions to IV iron, such as
arthralgia
Myalgia
fever
pruritus
and lymphadenopathy may be seen
within 3 days of therapy and usually
resolve spontaneously or with NSAIDs.

59. Acute Iron poisoning
Occurred by accidental ingestion of iron containing
medication by infants or small children's
The earliest manifestation is vomiting
There maybe
heamatemesis & melana
Restlessness ,hypotention ,
tachypnea&cyanosis
Coma&death

60. The initial Rx is evacuation of the stomach
In home induce digital stimulation of the pharyngeal
gag reflex
Baking soda may provoke emesis and Hco3 bind with
iron
60mg/kgbw……hospital treatment is indicated
Gastric Leavage with 4g sodium bi carbonate.
5-10g desferrioxamine,60ml SBC
Rx shock&metabolic acidosis
Desferrioxamine 1g….0,5g(4h)…(8h)…12h
1g iv …<15mg/kg…4h….12h….

61. Parenteral iron is used in two ways:
one is to administer the total dose of iron
required to correct the hemoglobin deficit and
provide the patient with at least 500 mg of
iron stores;
the second is to give repeated small doses of
parenteral iron over a protracted period
The amount of iron needed by an individual
patient is calculated by the following formula:
Body weight (kg) x 2.3 x (15–patient's
hemoglobin, g/dL) + 500 or 1000 mg (for
stores).

62. Total body iron ranges between 2 g and 4 g: approximately
50 mg/kg in men and 35 mg/kg in women
One milliliter of packed red blood cells (not whole blood)
contains approximately 1 mg of iron
. In men, red blood cell volume is approximately 30 mL/kg.
A 70-kg man will therefore have approximately 2100 mL
of packed red blood cells and consequently 2100 mg of
iron in his circulating blood. In women, the red cell
volume is about 27 mL/kg; a 50-kg woman will thus
have 1350 mg of iron circulating in her red blood cells.
Thus, a woman whose hemoglobin is 9 g/dL would be
treated with a total of 1315 mg of parenteral iron, 315
mg for the increased red blood cell mass and 1000 mg to
provide iron stores. The entire dose may be given as an
intravenous infusion over 4–6 hours

63. Dosage
Iron dextran 2ml(100mg) im/iv
– The recommended dosage of sodium ferric
gluconate is 125 mg diluted in 100 mL of NS
infused IV over 1 hour or as a slow IV push over
10 minutes (12.5 mg/min). This can be repeated
weekly until circulating iron (to a normal Hct) and
storage iron (1 to 3 g) are replenished and a total
dose of 500 to 2000 mg is usually required for
adequate repletion.
– Iron sucrose is administered as a 100 to 200 mg
IV push or up to 400 mg over a 2.5-hour IV
infusion.

64. Prognosis
In most cases, iron deficiency anemia can be
corrected rapidly by either oral or parenteral
replacement, but the long-term prognosis
ultimately depends on the clinical course of the
underlying cause.
It is critical that the patient undergo a full
evaluation to determine the underlying cause of
the iron deficiency, especially because an occult
GI lesion, often malignant, may be present,
particularly in patients older than 50 years of age

65. The END
Tank you for your active
attention

66. References
CMDT 20I2
HARRISON’S PRINCEPLES OF INT MEDICINE 18th
e 2012
Cecil MEDICINE 23rd
e
Williams' heamatology 6th
e 2011
Washington M Medical Therapeutics 33rd
e 2011
Davidson’s Medicine 20th
e
WWW.eMEDICEN.com