anemia approach and Iron deficiency anemia treatment

1. Approach to Anemia
Dr.Sreeraj.V
MD,DM Clinical Hematology
Department of Medical Oncology
Amala

2. Significant reduction (at least 10 %) in circulating red cell mass or their
hemoglobin content appropriate for the age and sex, leading to corresponding
decrease in the Oxygen - carrying capacity of blood.
WHO criteria - Hb < 13 gm/dl in men & Hb < 12 gm/dl in women
https://www.who.int/health-topics/anaemia#tab=tab_1
Anemia -Definition
Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
2

3. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
3
Anemia –Symptoms depend on
-Depend on Magnitude and rate of reduction in O2 carrying capacity of blood
തലകറക്കം
-Don’t attribute everything to RBC

4. CBC :
Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
4
Coulter Machine: Our Friend
Simple Approach to anemia by
MCV and Reticulocyte count

5. Reticulocyte count:
Number of reticulocyte
in peripheral blood
gives an idea about
marrow erythropoiesis
Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
5
Reticulocytes in blood
indicate
freshly produced
RBC in Marrow
Reticulocyte Production Index :
If Hb 7gram% ,Retic Count 10%
Corrected Reticulocyte %: 7/14 x10=5%
RPI: 5/2: 2.5%
Corrected Reticulocyte %= Patient Hb/Normal Hb x Retic %
Reticulocyte Production Index =Corrected Reticulocyte Count /2

6. BONE MARROW BLOOD
Reticulocytosis: Normal Response to Anemia
Marrow RBC Production
Increased
Reticulocytes
in Blood
Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
6
Reticulocyte RBC

7. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
7
Anemia Casue by
1.Peripheral Destruction
2.Bone Marrow Problem
Peripheral Destruction
Blood loss
Hemolytic anemia
Bone marrow
Decreased production
AA
Bone marrow destruction
Ineffective erythropoiesis
MDS

8. BONE MARROW BLOOD
Decreased Reticulocytosis in peripheral blood
Decreased Response to Anemia
A] Decreased Production in bone marrow
Marrow RBC Production
Decreased
Reticulocytes
in Blood
Eg: Aplastic Anemia
Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
8

9. BONE MARROW BLOOD
Decreased Reticulocytosis in peripheral blood
Decreased Response to Anemia
B] INCREASED DESTRUCTION IN BONE MAARROW
Marrow RBC Production
Decreased
Reticulocytes
in Blood
Iron Deficiency
B12 /Folate Deficiency
MDS
Thalassemia
Ineffective erythropoeisis
Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
9

10. BONE MARROW BLOOD
Increased Reticulocytosis in peripheral blood
Marrow RBC Production
Increased
Reticulocytes
in Blood
Peripheral destruction:Hemolytic anemia
Acute Blood Loss
Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
10

11. Mean Corpuscular Volume
Normocytic
Microcytic
Macrocytic
Mean Corpuscular Hemoglobin
Normochromic
Hypochromic
>100FL
<80FL
Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
11

12. Exercise:…
Normocytic Normochromic
Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
12

13. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
13

14. Approach to Iron Deficiency
Anemia
Dr.Sreeraj.V
MD,DM Clinical Hematology
Department of Medical Oncology
Amala

15. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
15
Iron Metabolism
Transferrin
Ferroportin
Ferritin
Hepcidin
Iron Deficiency:
1.Decreased Absorption
2.Increased Blood Loss
Intestine
Uterus
Urine
Skin

16. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
16
Tests to diagnose
IDA
Test Interpretation
CBC Microcytic
Hypochromic
Reticulocyte
Production Index
Low,<2
S.Iron Low
Total Iron Binding
Capacity
Increased
Transferrin % <20%
Ferritin <15ng/ml
Transferrin Saturation and TIBC
Ferritin: Acute Phase Reactant
Increased in
• CKD
• Inflammation
• Cancer
In these conditions Ferritin <100 is
IDA

17. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
17
Always find out the cause of IDA
GI Loss –Ulcer, Malignancy
Menorrhagia
Inflammatory Bowel Disease
Rarely:Urinary Loss
Menustrual loss resulting in Anemia is always abnormal

18. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
18
Oral Therapy:
Choice of iron compound
N.U. Stoffel, et al.
Traditional Teaching
100 to 200mg elemental
Iron in Divided dose/Day
GI intolerability:
Unabsorbed Iron :
Irritant to mucosa

19. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
19
Oral Therapy:
Problem with multiple daily dosing:
Poor Absorption = Increased GI toxicity
Once a Day or Alternate day dosing
is safe,tolerable and effective
Nicole U Stoffel,Lancet Haematol 2017;4: 524–33

20. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
20
Oral Therapy:
Time of Iron
Intake
If GI side effects :
Take with Food
+
Vitamin C juice /Tablets

21. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
21
Oral Therapy:
Response
Hb increase at least 2gram% at 3 weeks
Total therapy duration:3 to 6
months

22. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
22
Domenico Girelli,International Journal of Hematology volume 107, pages16–30 (2018)
IV Iron

23. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
23
Domenico Girelli,International Journal of Hematology volume 107, pages16–30 (2018)
IV Iron

24. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
24
Domenico Girelli,International Journal of Hematology volume 107, pages16–30 (2018)
IV Iron

25. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
25
Richard Dillon,Clinical Study | Open AccessVolume 2012 | Article ID 473514 | https://doi.org/10.1155/2012/473514
Domenico Girelli,International Journal of Hematology volume 107, pages16–30 (2018)
IV Iron

26. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
26
Summary
Anemia evaluation: Minimum Reticulocyte & MCV
Macrocytic Anemia: Marrow Pathology : Low Threshold for bone marrow study
Single morning dose of Oral Iron or Alternate Day dosing is safe & Effective
Oral Iron duration of Rx: 6month
IV iron : Indication ,FCM or F-Isomaltose safe

27. Dr.Sreeraj.V."Approach to anemia:IMA
Kunnmkulam,12/11/22"
27