Describe Pathophysiology of Iron absorption and elimination
Define Iron Deficiency Anemia
Describe Causes, Laboratory and Diagnoses of Iron Deficiency Anemia in Adults
Discuss Non-Pharmacological Treatment
Discuss Pharmacological Treatment and Management of Iron Deficiency
1. Treatment of
Iron Deficiency Anemia
in Adults
Dieu LinhThiVo. CaliforniaTouro University. COP2019
Kaiser San Jose. Fall 2017 - Community Practice Rotation
5. Learning Objectives
• Describe Pathophysiology of Iron absorption and elimination
• Define Iron Deficiency Anemia
• Describe Causes, Laboratory and Diagnoses of Iron Deficiency Anemia in
Adults
• Discuss Non-Pharmacological Treatment
• Discuss PharmacologicalTreatment and Management of Iron Deficiency
12. Goals ofTreatment
• Restore RBC Hgb concentration
• Reestablish RBC indices (MCV, MCH, MCHC)
• Replenish iron stores
• Treat Underlying causes
MATTHEWW. SHORT, “Iron Deficiency Anemia: Evaluation and Management”. 2013 American Academy of Family Physicians.
13. Non-Pharmacologic
Treatment Recommended Dietary Allowances (RDAs) for Iron
Age Male Female Pregnancy Lactation
Birth to 6
months
0.27mg 0.27mg
7–12 months 11 mg 11 mg
1–3 years 7 mg 7 mg
4–8 years 10 mg 10 mg
9–13 years 8 mg 8 mg
14–18 years 11 mg 15 mg 27 mg 10 mg
19–50 years 8 mg 18 mg 27 mg 9 mg
51+ years 8 mg 8 mg
Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes forVitamin A,Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon,
Vanadium, and Zinc : a Report of the Panel on Micronutrients.Washington, DC: National Academy Press; 2001.
Consider foods with iron-rich
sources:
• E.g. Breakfast cereals, oysters, white
beans, chocolate, beef liver, lentils,
spinach, tofu, kidney beans, sardines,
chickpeas, tomatoes, beef, potatoes,
cashew nuts
Avoid Foods impaired absorptions of
Iron:
• E.g. tannates, phosphates, phytates
(usually founds in grains, and seeds) or
food high in calcium
• Medications impaired absorption of Iron:
Acid reducers (e.g. PPI, H2RA, antacids)
14. Source of Iron-Rich Food
Food
Milligrams
per serving Percent DV*
Breakfast cereals, fortified with 100% of the DV for iron, 1 serving 18 100
Oysters, eastern, cooked with moist heat, 3 ounces 8 44
White beans, canned, 1 cup 8 44
Chocolate, dark, 45%–69% cacao solids, 3 ounces 7 39
Beef liver, pan fried, 3 ounces 5 28
Lentils, boiled and drained, ½ cup 3 17
Spinach, boiled and drained, ½ cup 3 17
Tofu, firm, ½ cup 3 17
Kidney beans, canned, ½ cup 2 11
Sardines, Atlantic, canned in oil, drained solids with bone, 3 ounces 2 11
Chickpeas, boiled and drained, ½ cup 2 11
Tomatoes, canned, stewed, ½ cup 2 11
Beef, braised bottom round, trimmed to 1/8” fat, 3 ounces 2 11
Potato, baked, flesh and skin, 1 medium potato 2 11
Cashew nuts, oil roasted, 1 ounce (18 nuts) 2 11
Non-PharmacologicTreatment (Cont.)
U.S. Department of Agriculture, Agricultural Research Service. USDA National Nutrient Database for Standard Reference, Release 26. Nutrient Data Laboratory Home Page, 2013.
15. PharmacologyTreatment
MATTHEWW. SHORT, “Iron Deficiency Anemia: Evaluation and Management”. 2013 American Academy of Family Physicians.
Guideline: Daily iron supplementation in adult women and adolescent girls. Geneva:World Health Organization; 2016.
2016 World Health Organization Guidelines for Daily Iron Supplementation in
Menstruating AdultWomen “non-pregnant females in a reproductive age” and
Adolescent girls
• 30 to 60mg of elemental iron per day for 3 months
• An ↑ hemoglobin of 1g/dL after 1 month of treatment show an adequate response and
confirms the diagnoses
• Continue treatment for 3 months after anemia is corrected for adequate replenish of
iron stores
2013 American Academy of Family Physicians (AAFP) guidelines for Adults
• 120 mg of elemental iron per day for 3 months
• An ↑ hemoglobin of 1g/dL after 1 month of treatment show an adequate response and confirms the
diagnoses
• Continue treatment for 3 months after anemia is corrected for adequate replenish of iron stores
16. Oral Iron Supplements
FERROUS GLUCONATE FERROUS SULFATE FERROUS FUMARATE
Strength 300mg 325mg 324mg
% element iron ~11% ~20% ~33%
Elemental iron/tablet ~38mg ~65mg ~106mg
Dosing 1 to 3 tab BID orTID 1 tabTID 1 tab BID
ADME Onset: hematologic response: ~3-10days
Time to Peak:
↑RBC ~ 5-10days
↑hemoglobin within 2-4wks
Absorption: occurs at upper intestine
(duodenum, and upper jejunum)
In person with normal serum iron stores:
~10%
In person with deficit serum iron stores:
~20 to 30%
Common SEs Nausea, epigastric pain, dark stools, constipation, teeth staining (liquid preparation)
Common DDIs • PPIs or other factors decrease gastric secretion (e.g. Antacids, H2RA), cholestyramine ↓absorption of iron
• ↓Absorption of Fluoroquinolones, Tetracycline, Levothyroxine, Mycofenolate mofetil and Penicillamine,
Levodopa and Methyldopa
• Chloramphenicol, Vitamin E may ↓ hematological response
Counseling Points • Take on Empty Stomach (w/ Food may ↓ absorption by 40%)
• Vitamin C ↑ absorption up to 30% (Take w/ orange juice or ascorbic acid 250-500mg BID w/ iron)
• Avoid Antacids, Coffee, Tea, Dairy products, Eggs, or whole-grain cereals or breads 1 hour before or 2 hour
after
MATTHEW W. SHORT, “Iron Deficiency Anemia: Evaluation and Management”. 2013 American Academy of Family Physicians.
17. IV Iron Supplements
FERRIC GLUCONATE
(FERRLECIT)
FERROUS SUCROSE
(VENOFER)
FERUMOXYTOL
(FERAHEME)
FERRIC CARBOXYMALTOSE
(INJECTAFER)
IRON DEXTRAN
(INFED OR DEXFERRUM)
Element iron 12.5mg/mL 20mg/mL 30mg/mL 50mg/mL 50mg/mL
Administration
Route
IV IV IV IV IM or IV
Test Dose Not required, but
recommended if hx of
drug allergies
Not required, but
recommended if hx of
drug allergies
Not required Not required 0.5mL (0.25mg) IV over 30 seconds,
observed x1hr
Dosing 125mg/10-60min
Max: 250mg/60min
100-400mg/2-90min
Max: 300mg/2hr
510mg/5min
Max: 510-1020/15-60min
750-1000mg/15-30min
Max:
750-1500mg/15-30min
Multiple doses of 100 mg, or
Single dose of 1000 mg diluted in
250 mL normal saline) given
over one hour
Total Iron Deficit in
mg
Dosing needed = weight (Kg) x 2.3 x hemoglobin deficiency + 500 to 1000mg iron
Hemoglobin deficiency =Target hemoglobin level – patient hemoglobin level
BBW None None None None Anaphylaxis
Common SEs Headache, nausea, diarrhea, hypoTN or hyperTN, injection site rxn, rash
Myalgia, arthralgia, back and chest pain is usually resolved in 48 hours
Hypersensitivity, severe or life threatening are RARE. Usually occurs due to rapid infusion
Clinical Pearls • Benefits for anemia patients with CKD requiring ESA (since iron supplement helps delay ESA administration)
• IV Iron is preferred when high level of HEPCIDIN that may create a refractory to oral iron supplement
• IV iron should be avoided in 1st
trimester pregnancy because lack of safety data
• IV iron significantly improve physical performance and QoL in patients with CHF (1 yr treatment reduce in hospitalization)
• Premedication with antihistamine is no longer advises because it may cause hypotension and tachycardia
• Larger RCTs are required to determined risk of iron related infections inT2DM or metabolic syndrome
MATTHEW W. SHORT, “Iron Deficiency Anemia: Evaluation and Management”. 2013 American Academy of Family Physicians.
Dan L. Longo, “Iron-Deficiency Anemia”. May 7, 2015DOI: 10.1056/NEJMra1401038
18. Take Home Points
• Iron is an important element in helping Production of Hemoglobin In RBC
• Risk Factors include: ↑ demands, ↓ intake, ↓ absorption, and Drugs induced iron-deficiency
• Early Sign and Symptoms: Fatigue, weakness, headache, irritability, exercise intolerance,
exertional dyspnea, vertigo, angina pectoris (rare)
• Complications: pallor, dry or rough skin, blue sclerae, Loss ofTounge Papillae, Spoon Nails, and
possible precipitating infections, induce heart failure, and restlessness leg syndrome
• Laboratory Diagnoses: First lab decreases will be serum Ferritin then serum iron once iron
stores deficit
• Treatment Goals: Restore RBC hemoglobin concentration, replenish iron stores and prevent
complications
• Dosing strategy recommendation is EVERY OTHER DAY
• Pick the oral formulation that’s best fit for the patients, less AEs and increase adherence
20. Iron DeficiencyTrending
• Un-absorbed iron might alter the intestine microbiota which may increase
concentration of pathogens.
• Dosing may be appropriate with EVERY OTHER DAY RATHERTHAN EVERY DAY.
IL-6 mediates hypoferremia of inflammation by inducing the synthesis of the iron regulatory hormone hepcidin”. J. Clin. Invest. 113:1271–1276 (2004). doi:10.1172/JCI200420945.
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