Iron Deficiency Anemia

IRON DEFICIENCY ANEMIA

  • About 3.5 millions, people in the US have anemia, making the most common blood disorder.
  • There are several different types of anemia, but as much as 50% of people with the condition are iron- deficient, making iron diet–deficiency anemia the most common type of anemia.
  • Cardiologists have noted that anemia is a powerful an independent predictor of cardiovascular problems for patients. 

Anemia is a decreased in the content of red blood cells (RBC) or a decreased in the in the hemoglobin inside the RBC–hemoglobin is the oxygen-carrying iron protein that attaches to oxygen in the lungs and carries it to tissues throughout the body.

Anemia is diagnosed when a blood test shows a hemoglobin value of less than 13.5 g/dL in a man or less than 12 g/dL in woman.  Children have values that vary with age.

 

What are the symptoms of anemia?

At the beginning of the deficiency, symptoms of anemia can be very difficult to detect.  But as it gets worse or progresses, oxygen becomes very deficient in your body and patients may experience severe fatigue and weakness.  All other symptoms include:

 

  • Weakness
  • Shortness of breath
  • Dizziness
  • Fast or irregular heartbeat
  • Pounding or “whooshing” in your ears
  • Headache
  • Cold hands or feet
  • Pale or yellow skin
  • Chest pain

 

Not having enough iron, vitamin B12, folate the body cannot produce enough of a specific type of protein call hemoglobin, which is inside the red blood cells and is very important in capturing the oxygen in the lungs and distributing into the tissues.  As a result of the insufficiency, some parts of the body do not receive the oxygen they need.  And this explains one of the most common symptoms of anemia… is that you are out of breath easily, and sometimes getting so little oxygen to your head you feel dizzy or lightheaded.

one of the most prominent symptoms of anemia is a general feeling of exhaustion, fatigue is one of the most predominant symptoms in many patients.  Some simply will fill more tired, all others will fill it while engaging in an activity.  The tiredness is caused by the same process that leads to shortness of breath and dizziness: Without enough iron or vitamin B12, there is not enough hemoglobin, and without enough hemoglobin, there is not enough oxygen to feel the body.

Some patients with anemia complain that their skin is looking to pale.  As your red blood cells become deficient and not healthy to fuel your organs with oxygen, you cannot expect your largest organ, your skin, to look healthy.  Without iron or vitamin B12, there might not be enough blood supply to the skin, resulting in a paler, and even yellow–looking appearance.

Anemia can also manifest with chest pain.  When there are few were healthy red blood cells circulating the heart.  As a result, the heart beats faster than normal and you may start to feel the strain as chest pain.  Patients with coronary heart disease and anemia may have increased adverse cardiovascular events or even death.  Cardiologists have noted that anemia is a powerful an independent predictor of cardiovascular problems for patients.

 Some patient soon anemia experience an unusual craving for ice cubes and other strangers snacks such as dirt and picking on bricks.  It is your body’s instinctive survival mechanism that is denominated in the medical literature as Pica– the tendency to crave non-nutritional items like ice cubes, baking soda, clay, or even pencils or dried paint. Patients crave chewing or eating such unusual food substances and it’s a very common symptom of iron-deficiency anemia.

 

What are some of the key considerations in the risks for anemia?

Many people are at risk for anemia because of poor diet, intestinal disorders, chronic diseases, infections, and other conditions. Women who are menstruating or pregnant and people with chronic medical conditions are most at risk for this disease. The risk of anemia increases, as people grow older.

If you have any of the following chronic conditions, you might be at greater risk for developing anemia:

  •  Rheumatoid arthritis or another autoimmune disease
  • Kidney disease
  • Cancer
  • Liver disease
  • Thyroid disease
  • Inflammatory bowel disease (Crohn disease or ulcerative colitis)

The signs and symptoms of anemia can easily be overlooked. In fact, many people do not even realize that they have anemia until it is identified in a routine blood test.

  

What are the causes of anemia?

There are many forms of anemia.  Some people like those suffering from conditions like sickle cell anemia and thalassemia, or anemic from birth; the bodies genetically inherited difficulty producing red blood cells or a specific portion of red blood cells.  But the greatest portion patient suffering from anemia become anemic over it time through not consuming enough iron or vitamin B12, both of which, along with folate, are necessary for the production of healthy red blood cells.

Iron and Vitamin Sources

 

Pregnant women are especially susceptible to anemia because the body must produce much more blood than normal to support the growth and development of a baby, and without enough iron, vitamin B12, or folate, there are fewer healthy red blood cells that can be made resulting in less oxygen to feel the organs of the mother and the baby. however, women who aren’t pregnant, men, and even children experiencing gastrointestinal conditions, such as ulcers, hemorrhoids, inflammation of the stomach, and cancer can have increased risk of anemia if their health conditions cause chronic bleeding.

 

What are the common types of anemia?

There are numerous types of anemia which include:
1.  Iron deficiency anemia is most common type of anemia.  Iron deficiency is usually due to blood loss, poor absorption of iron, pregnancy, gastric bypass surgery.
2.  Vitamin deficiency anemia, which results from low levels of vitamin B12 folate, in most cases due to a poor dietary intake.  Pernicious anemia is a disorder in which vitamin B12 cannot be normally absorbed in the gastrointestinal tract due to gastric or small intestinal problems..
3.  Anemia of pregnancy.
4.  Aplastic anemia, myelodysplastic syndrome, or myeloproliferative disorders are rare blood cell disorder that affects the Bone marrow, as a result there is insufficient or no production of red blood cells, white blood cells, and platelets.  There is a failure of the stem cells in the bone marrow.
5.  Hemolytic anemia results when red blood cells are destroyed in the bloodstream or in the  spleen.  There are numerous causes of hemolytic anemia such as infections, autoimmune disorder shoulders, and congenital abnormalities in the red blood cells, inherited abnormalities that affect the hemoglobin or the structure of the red blood cells.  Even mechanical causes like the ones found on leaky heart valves or aneurysms
6.  Sickle cell anemia and similar hemoglobin disorders such as hemoglobin C, thalassemia alpha, thalassemia beta.  Very often, in these disorders, the red blood cells are deformed and rigid, and  as a consequence, they clogged the circulation because they are unable to flow through the small vessels.

7. Anemia caused by cancer. Most cancers of the gastrointestinal system may initially present with anemia

8. Anemia caused by kidney disorders leading to deficiency of the hormone erythropoietin–this hormone secreted by the kidneys stimulate the bone marrow to produce red blood cells.

 

 What is the treatment for anemia?

Your diet might have something to do with the iron levels or bodies sort iron in animal–base foods like chicken and fish.  If you do not eat meat, substitute foods that are high in iron such as beings, spinach or tofu.

Because iron is in soybeans, dark green leafy vegetables, and tofu in addition to lean red meat, vegans and vegetarians can still consume the amount of iron their body needs. However, Dr. Koduri says it’s impossible to get vitamin B12 from plant sources. As a result, the only way for those with vegan diets to consume an adequate amount of vitamin B12 is to regularly take a supplement,

Iron supplementation is important in iron deficiency anemia. If a patient cannot tolerate oral iron treatments, a viable option is IV iron infusion.

Other nutritional anemias, such as folate or B-12 deficiency, may result from poor diet or from an inability to absorb vitamins in the gastrointestinal tract. Treatment varies from changing your diet to taking dietary supplements.

If your anemia is due to a chronic disease, treatment of the underlying disease will often improve the anemia. Under some circumstances, such as chronic kidney disease, your doctor may prescribe medication such as erythropoietin injections to stimulate your bone marrow to produce more red blood cells.

If you are diagnosed with aplastic anemia, your doctor may refer you to a hematologist for a bone marrow biopsy to determine the cause of the anemia. Medications and blood transfusions may be used to treat aplastic anemia, myelodysplastic syndrome, or myeloproliferative disorders

Hemolytic anemia occurs when red blood cells are destroyed in the bloodstream. This may be due to mechanical factors (a leaky heart valve or an aneurysm), infection, or an autoimmune disease. The cause can often be identified by special blood tests and by looking at the red blood cells under a microscope. The treatment will depend upon the cause and may include referral to a heart or vascular specialist, antibiotics, or drugs that suppress the immune system.

Talk with your doctor if you believe you may be at risk for anemia. Your doctor will determine your best course of treatment and, depending on your condition, may refer you to a hematologist, a doctor who specializes in blood disorders.

If you’re experiencing some of these symptoms of anemia and think that you might be anemic, it’s important to consult a doctor for an evaluation to discern exactly which type of anemia you have, and what you should do to cure it. Dr. Koduri warns against purchasing any over-the-counter anemia combatant because there is not a catch-all cure for all forms of anemia. The key is understanding the cause and the deficiency, so you can work with your doctor or hematologist to find the most effective treatment.

 

Iron infusion Therapy

Oral iron supplementation is usually the first choice for the treatment of iron deficiency anemia (IDA) because of its effectiveness and low cost. But unfortunately in many iron deficient conditions, oral iron is a less than the ideal treatment mainly because of adverse events related to the gastrointestinal tract as well as the long course required to treat anemia and replenish body iron stores.

The first iron product for intravenous use was high-molecular-weight iron dextran. However, dextran-containing intravenous iron preparations are associated with an elevated risk of anaphylactic reactions, which made physicians reluctant to prescribe intravenous iron in the treatment of iron deficiency anemia for many years. In 1999 and 2001, two new intravenous iron preparations (ferric gluconate and iron sucrose) were introduced into the market as safer alternatives to iron dextran. Over the last five years, three new intravenous iron dextran-free preparations have been developed and have better safety profiles than the more traditional intravenous compounds, as none require test doses and all these products are promising in respect to a more rapid replacement of body iron stores (15-60 minutes/infusion) as they can be given at higher doses (from 500 mg to more than 1000 mg/infusion).

Iron is an essential element as it plays an important role in many vital biological processes such as the synthesis of heme which forms the basis of hemoglobin (Hb) the oxygen-carrying protein of the blood, the formation of myoglobin, energy metabolism, neurotransmitter production, the formation of collagen and immune system function. Lack of iron is one of the principal causes of anemia in the general population. It is not surprising that iron deficiency anemia (IDA) is associated with increased morbidity and mortality.

Treatment with oral iron supplements is simple, inexpensive and a relatively effective way of treating iron deficiency conditions. Ferrous iron salts (sulfate, fumarate, succinate, and gluconate) are the most commonly used oral iron preparations

On the other hand, it is very well known that oral iron is a less than ideal treatment mainly because of gastrointestinal adverse events (particularly when using ferrous iron compounds), lack of adherence to therapy or insufficient length of therapy for the degree of iron deficiency, poor duodenal absorption due to concomitant gastrointestinal pathologies (inflammatory bowel disease [IBD], gastric bypass surgery or any other cause of chronic inflammation, malignancy) conditions and the long course of treatment needed to resolve anemia (1-2 months) and replenish body iron stores (another 3-6 months). Noncompliance with a prescribed course of oral iron is common and even in compliant patients, poor intestinal absorption fails to compensate for the iron need in the presence of ongoing blood losses or in inflammatory conditions.

In 1999, Ferric gluconate (FG) (Ferrlecit), after having been available in Europe for many years, was introduced into the American market as a safer alternative to iron dextran

A historical review of the use of FG in Europe and iron dextrans in the United States found no deaths attributable to FG, but at least 31 to iron dextran. The authors concluded that FG was a safer therapeutic option to iron dextran and its safety was related to the lack of the dextran envelope and therefore associated with a lower risk of anaphylactoid reactions.

The maximum recommended dose of FG is 125 mg given as a bolus or short infusion; it has been reported that an infusion of 250 mg given over 1 hour is safe.

A double-blind, placebo-controlled crossover study of single-dose administration of FG in 2338 hemodialysis patients reported only one serious allergic reaction and no deaths. They further reported that, in patients previously sensitive to iron dextran, reactions to FG were uncommon, but 7-fold more common than those without prior iron sensitivities.

In November 2000, Iron sucrose (IS) (Venofer) was approved in the United States although it had also been used for a long time in Europe. By far, the greatest experience in published literature is with this formulation.

IS can be safely administered as a 15-30 minute infusion in doses of 200-300 mg; the maximum weekly dose should not exceed 600 mg. If higher-than-recommended doses are not infused, adverse events are rarely observed.

IS is a dextran-free formulation with a safety profile similar to FG. The efficacy and safety of IV IS has been shown in the treatment of anemia including in CKD patients on hemodialysis.(34,35) Furthermore, IS is also effective in the treatment of IDA patients combined with IBD, whereas oral iron is potentially harmful to the intestinal epithelium. It has been shown that IS is an important alternative option to blood transfusion in a variety of surgery settings leading to significant reduction of blood transfusion requirements.

The incidence of serious life-threatening anaphylaxis with IS is 0.002% When doses higher than 250 mg of FG or 300 mg of IS are administered, infusion reactions occur probably due to free iron release from the less tightly bound carbohydrate carriers. Black box warnings do not appear in the directions for use of either FG or IS and a test dose is not required.

Based on the current state of knowledge, FG and IS largely replaced the use of iron dextrans in US patients.

In spite of being the most frequently used IV iron compound in published studies, the main disadvantage of IS is the need for multiple infusions as the maximum weekly dose should not exceed 600 mg (200 mg IV, 1-3 times/week).

These restrictive and time-consuming administration requirements may contribute to the underuse of IV iron in the treatment of IDA. Consequently, there was a clear need for a cost-effective IV iron therapy with favorable administration regimen that could potentially help to increase its use and improve outcomes.

Ferumoxytol (FeraHeme®)

This formulation was approved by the FDA in 2009 for iron replenishment in CKD patients with IDA. It can be administrated as a relatively large dose (max 510 mg) in a rapid (< 20 seconds) session without test dose requirement.

However, this product is not currently approved in Europe and the FDA is continuing to evaluate Ferumoxytol due to reports of serious cardiac disorders In addition, ferumoxytol administration may transiently interfere with diagnostic ability of magnetic resonance imaging which is frequently used for the diagnosis and follow-up of Inflammatory Bowel Disease, IBD; consequently this does not seem to be an appropriate IV iron compound for IBD patients.

Conclusion

Oral iron supplements are an inexpensive and effective way of treating IDA patients and their administration, in the absence of inflammation or significant ongoing blood loss, can correct anemia.

Oral iron is a less than ideal treatment because of the high gastrointestinal adverse events rate, particularly when using ferrous iron compounds; a long treatment course is needed to resolve anemia and to achieve replenishment of the body iron stores.

In cases where oral iron is ineffective, associated with adverse events or cannot be used, IV iron compounds are treatment options.

IV iron therapy is clearly better and presents several advantages over oral iron treatment.

Given the proven effectiveness as well as safety profile of IV iron, particularly of IS in a broad spectrum of diseases associated with IDA, the current paradigm that oral iron is first-line therapy should be reconsidered.

Based on the preponderance of the published evidence, with the exception of high-molecular-weight iron dextran, the differences in safety profile among IV iron products are small when given at the recommended doses and respecting the correct infusion time.

Clinical trials in nephrology, gynecology, gastroenterology, oncology, and hematology evaluating the more rapid administration of larger doses of iron are needed. So, until reliable comparative data becomes available, one product cannot, and should not, be considered superior in terms of safety profile.

IV iron is safe and probably much safer than most physicians realize. Proper utilization of this important therapeutic modality offers significant clinical benefits by reducing morbidity and mortality from many pathological conditions associated with iron deficiency.

 

At Hematology Oncology Care infusions are done in the privacy and harmony of our on-site suites.

On-site infusion has been proven a safe and effective alternative to inpatient care for many disease states and therapies.  For many patients, receiving treatment outpatient infusion suite setting is preferable to inpatient care.  Our infusion therapy suites which are ideally suited for certain patient-therapy situations.

The On-site infusion Patient approach to care offers numerous advantages such as medication use for appropriateness, effectiveness, safety, and adherence, with consideration of accessibility and cost; a collaborative approach to on-site infusion that involves the patient, oncologist, and other healthcare providers; and a focus on improving health outcomes

 

 

The information in this document does not replace a medical consultation. It is for personal guidance use only. We recommend that patients ask their doctors about what tests or types of treatments are needed for their type and stage of the disease.
Sources:

  • American Cancer Society
  • The National Cancer Institute
  • National Comprehensive Cancer Network
  • National Institute of Health
  • American Academy of Gastroenterology
  • National Institute of Health
  • MD Anderson Cancer Center
  • Memorial Sloan Kettering Cancer Center
  • American Academy of Hematology

 

 

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