Scope - Home - Province of British Columbia



DRAFT: Iron Deficiency – Investigation and ManagementDRAFT FOR EXTERNAL REVIEW: The online questionnaire is available at guideline provides recommendations for the investigation and management of iron deficiency in patients of all ages. An underlying disorder may be the cause of an iron deficiency. If so, this needs to be identified and managed. The investigation for the cause of iron deficiency is beyond the scope of this guideline. Diagnostic codes: 280 (Iron Deficiency Anemias) Key RecommendationsHaving first identified patients at risk of iron deficiency and iron deficiency anemia, use a case-finding approach by testing ferritin and complete blood count (CBC) respectively.Serum iron, iron binding capacity, transferrin saturation/fraction saturation are not routinely useful for investigation of iron deficiency anemia. Determine the cause of iron deficiency. Consider age and clinical presentation when investigating for cause. Take thorough dietary history and provide dietary counselling to caregivers of infants and toddlers with iron deficiency, including maximum daily cow’s milk intake, and selection of iron-rich solid foods. In cases where there is an obvious cause, a trial of treatment and monitoring response may be appropriate.Regular blood donation increases the risk of iron deficiency.Menorrhagia is the most frequent cause of iron deficiency and iron deficiency anemia among pre-menopausal women.Even when there is an obvious cause, consider serious co-contributors (e.g. colon cancer in adult males and post-menopausal females). Consider prescribing IV iron when there is: inadequate response to oral iron (malabsorption or ongoing blood loss), or intolerance to oral iron therapy. Do not prescribe intramuscular (IM) iron, due to high frequency of unacceptable side effects.Identification of Patients with Iron Deficiency and Iron Deficiency AnemiaIron deficiency is common throughout the lifespan. Iron deficiency may develop from decreased dietary intake, increased requirements for iron, decreased iron absorption, or increased iron loss. Screening of the general population for iron deficiency is not recommended ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"lfJ3vpHM","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":111,"uris":[""],"uri":[""],"itemData":{"id":111,"type":"article-journal","title":"Screening for Iron Deficiency Anemia, Including Iron Supplementations for Children and Pregnant Women: Recommendation Statement","container-title":"American Family Physician","page":"461","volume":"74","issue":"3","source":"","abstract":"This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for iron deficiency anemia and the supporting scientific evidence.","ISSN":"0002-838X, 1532-0650","shortTitle":"Screening for Iron Deficiency Anemia, Including Iron Supplementations for Children and Pregnant Women","journalAbbreviation":"AFP","language":"en","issued":{"date-parts":[["2006",8,1]]}}}],"schema":""} 1. Use a case-finding approach to investigate all patients at high risk of iron deficiency and iron deficiency anemia (Table 1) by testing ferritin and complete blood count (CBC) respectively.Table 1: Causes of and risk factors for iron deficiency and iron deficiency anemia (IDA) in adultsNote: refer to Iron Deficiency in Children and Iron Deficiency in Obstetrics on page 5 for causes and risk factors in children, pregnancy and the perinatal period.Increased RequirementsDecreased IntakeMenstruating girls and women ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0gsrick2","properties":{"formattedCitation":"\\super 2,3\\nosupersub{}","plainCitation":"2,3","noteIndex":0},"citationItems":[{"id":113,"uris":[""],"uri":[""],"itemData":{"id":113,"type":"article-journal","title":"Iron-deficiency anaemia and physical performance in adolescent girls from different ethnic backgrounds","container-title":"The British Journal of Nutrition","page":"427-433","volume":"72","issue":"3","source":"PubMed","abstract":"One hundred and fourteen 11-14-year-old schoolgirls from Wembley, Middlesex, were assessed for Fe status (haemoglobin (Hb), packed cell volume and mean corpuscular Hb concentration, height, weight, eating habits, and ethnic origin, and undertook a step test to assess physical performance. Overall, 20% of girls had Hb less than 120 g/l, ranging from 11% in White girls to 22-25% in girls of Asian origin. Prevalence of low Hb was 20% in vegetarians, higher in White vegetarians compared with non-vegetarians (23 v. 4%), but lower in the Indian vegetarians compared with non-vegetarians (17 v. 32%). Low Hb was present in 25% of girls who had tried to lose weight in the previous year, and was more common in girls from manual social class backgrounds than non-manual (24 v. 10%). At the start of the step test the twenty-three girls with low Hb had heart rates similar to those with normal Hb, but heart rates in the low Hb group were significantly elevated immediately after the step test, and still significantly elevated 1 min later. The present results confirm the findings of a previous study in White girls, and suggest that physical performance may be compromised at mild levels of anaemia.","ISSN":"0007-1145","note":"PMID: 7947657","journalAbbreviation":"Br. J. Nutr.","language":"eng","author":[{"family":"Nelson","given":"M."},{"family":"Bakaliou","given":"F."},{"family":"Trivedi","given":"A."}],"issued":{"date-parts":[["1994",9]]}}},{"id":115,"uris":[""],"uri":[""],"itemData":{"id":115,"type":"article-journal","title":"Iron and zinc status of young women aged 14 to 19 years consuming vegetarian and omnivorous diets","container-title":"Journal of the American College of Nutrition","page":"463-472","volume":"14","issue":"5","source":"PubMed","abstract":"OBJECTIVE: To assess the iron and zinc status of young females, aged 14 to 19 years, consuming vegetarian and omnivorous diets.\nMETHODS: Dietary intakes (via 3-day weighed food records), BMI, and laboratory indices of iron and zinc status were compared in a convenience sample of 79 lacto-ovo-vegetarians (LOV), 16 semi-vegetarians (SV), and 29 omnivorous (OM) females.\nRESULTS: Twenty-nine percent LOV, 44% SV, and 17% OM had low iron stores (i.e., plasma ferritin < 12 micrograms/L); only 3% had anemia. As well, 24% LOV, 33% SV, and 18% OM had serum zinc < 10.71 mumol/L and 14% LOV, 14% SV, and 17% OM had hair zinc < 1.68 mumol/g. Intakes of iron and ascorbic acid from the weighed food records were associated with serum iron (p < 0.04) and total iron binding capacity (negatively; p < 0.02), respectively, whereas Phy:Zn molar ratios were associated with serum zinc (negatively; p < 0.04). Z-scores for BMI were associated with serum zinc (p < 0.02) and diet type (p < 0.001); serum AP activity was associated with age (p < 0.0001) and oral contraceptive use (p < 0.04).\nCONCLUSIONS: Suboptimal iron and zinc status was attributed to low intakes of poorly available iron and zinc in all dietary groups.","ISSN":"0731-5724","note":"PMID: 8522725","journalAbbreviation":"J Am Coll Nutr","language":"eng","author":[{"family":"Donovan","given":"U. M."},{"family":"Gibson","given":"R. S."}],"issued":{"date-parts":[["1995",10]]}}}],"schema":""} 2,3 (at least 10% are estimated to have iron deficiency) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ud7ITSaX","properties":{"formattedCitation":"\\super 4\\nosupersub{}","plainCitation":"4","noteIndex":0},"citationItems":[{"id":192,"uris":[""],"uri":[""],"itemData":{"id":192,"type":"article-journal","title":"Iron sufficiency of Canadians","container-title":"Health Reports","page":"41-48","volume":"23","issue":"4","source":"PubMed","abstract":"BACKGROUND: Iron deficiency is the most common nutritional deficiency in the world, but little is known about the iron status of people in Canada, where the last estimates are from 1970-1972.\nDATA AND METHODS: The data are from cycle 2 (2009 to 2011) of the Canadian Health Measures Survey, which collected blood samples from a nationally representative sample of Canadians aged 3 to 79. Descriptive statistics (percentages, arithmetic means, geometric means) were used to estimate hemoglobin and serum ferritin concentrations, and other markers of iron status. Analyses were performed by age/sex group, household income, self-perceived health, diet, and use of iron supplements. World Health Organization reference values (2001) were used to estimate the prevalence of iron sufficiency and anemia.\nRESULTS: The overall prevalence of anemia was low in the 2009-to-2011 period--97% of Canadians had sufficient hemoglobin levels. Generally, hemoglobin concentration increased compared with 1970-1972; however, at ages 65 to 79, rates of anemia were higher than in 1970-1972. Depleted iron stores were found in 13% of females aged 12 to 19 and 9% of females aged 20 to 49. Lower household income was associated with a lower prevalence of hemoglobin sufficiency, but was not related to lower serum ferritin sufficiency. Self-perceived health and diet were not significantly associated with hemoglobin and serum ferritin levels.\nINTERPRETATION: The lack of a relationship between iron status and diet may be attributable to the use of questions about food consumption frequency that were not specifically designed to estimate dietary iron intake. Factors other than iron intake might have contributed to the increase in the prevalence of anemia among seniors.","ISSN":"0840-6529","note":"PMID: 23356044","journalAbbreviation":"Health Rep","language":"eng","author":[{"family":"Cooper","given":"Marcia"},{"family":"Greene-Finestone","given":"Linda"},{"family":"Lowell","given":"Hélène"},{"family":"Levesque","given":"Johanne"},{"family":"Robinson","given":"Stacey"}],"issued":{"date-parts":[["2012",12]]}}}],"schema":""} 4MultiparityLow socioeconomic statusVegetarian or vegan dietLack of balanced diet or poor intakeAlcohol use disorderMen and women > age 65 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"JA4oIvMp","properties":{"formattedCitation":"\\super 4\\nosupersub{}","plainCitation":"4","noteIndex":0},"citationItems":[{"id":192,"uris":[""],"uri":[""],"itemData":{"id":192,"type":"article-journal","title":"Iron sufficiency of Canadians","container-title":"Health Reports","page":"41-48","volume":"23","issue":"4","source":"PubMed","abstract":"BACKGROUND: Iron deficiency is the most common nutritional deficiency in the world, but little is known about the iron status of people in Canada, where the last estimates are from 1970-1972.\nDATA AND METHODS: The data are from cycle 2 (2009 to 2011) of the Canadian Health Measures Survey, which collected blood samples from a nationally representative sample of Canadians aged 3 to 79. Descriptive statistics (percentages, arithmetic means, geometric means) were used to estimate hemoglobin and serum ferritin concentrations, and other markers of iron status. Analyses were performed by age/sex group, household income, self-perceived health, diet, and use of iron supplements. World Health Organization reference values (2001) were used to estimate the prevalence of iron sufficiency and anemia.\nRESULTS: The overall prevalence of anemia was low in the 2009-to-2011 period--97% of Canadians had sufficient hemoglobin levels. Generally, hemoglobin concentration increased compared with 1970-1972; however, at ages 65 to 79, rates of anemia were higher than in 1970-1972. Depleted iron stores were found in 13% of females aged 12 to 19 and 9% of females aged 20 to 49. Lower household income was associated with a lower prevalence of hemoglobin sufficiency, but was not related to lower serum ferritin sufficiency. Self-perceived health and diet were not significantly associated with hemoglobin and serum ferritin levels.\nINTERPRETATION: The lack of a relationship between iron status and diet may be attributable to the use of questions about food consumption frequency that were not specifically designed to estimate dietary iron intake. Factors other than iron intake might have contributed to the increase in the prevalence of anemia among seniors.","ISSN":"0840-6529","note":"PMID: 23356044","journalAbbreviation":"Health Rep","language":"eng","author":[{"family":"Cooper","given":"Marcia"},{"family":"Greene-Finestone","given":"Linda"},{"family":"Lowell","given":"Hélène"},{"family":"Levesque","given":"Johanne"},{"family":"Robinson","given":"Stacey"}],"issued":{"date-parts":[["2012",12]]}}}],"schema":""} 4Recent immigration from developing countries ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rdnRZO3P","properties":{"formattedCitation":"\\super 5\\nosupersub{}","plainCitation":"5","noteIndex":0},"citationItems":[{"id":254,"uris":[""],"uri":[""],"itemData":{"id":254,"type":"article-journal","title":"Evidence-based clinical guidelines for immigrants and refugees. Appendix 15: Iron-deficiency anemia: evidence review for newly arriving immigrants and refugees.","container-title":"Canadian Medical Association Journal","page":"E824-E925","volume":"183","issue":"12","source":"Crossref","DOI":"10.1503/cmaj.090313","ISSN":"0820-3946, 1488-2329","language":"en","author":[{"family":"Pottie","given":"K."},{"family":"Greenaway","given":"C."},{"family":"Feightner","given":"J."},{"family":"Welch","given":"V."},{"family":"Swinkels","given":"H."},{"family":"Rashid","given":"M."},{"family":"Narasiah","given":"L."},{"family":"Kirmayer","given":"L. J."},{"family":"Ueffing","given":"E."},{"family":"MacDonald","given":"N. E."},{"family":"Hassan","given":"G."},{"family":"McNally","given":"M."},{"family":"Khan","given":"K."},{"family":"Buhrmann","given":"R."},{"family":"Dunn","given":"S."},{"family":"Dominic","given":"A."},{"family":"McCarthy","given":"A. E."},{"family":"Gagnon","given":"A. J."},{"family":"Rousseau","given":"C."},{"family":"Tugwell","given":"P."},{"literal":"coauthors of the Canadian Collaboration for Immigrant and Refugee Health"}],"issued":{"date-parts":[["2011",9,6]]}}}],"schema":""} 5, especially in Southeast Asia, Africa ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"5ub9JCBh","properties":{"formattedCitation":"\\super 6\\nosupersub{}","plainCitation":"6","noteIndex":0},"citationItems":[{"id":257,"uris":[""],"uri":[""],"itemData":{"id":257,"type":"article","title":"The global prevalence of anaemia in 2011","publisher":"World Health Organization","URL":"","author":[{"family":"World Health Organization","given":""}],"issued":{"date-parts":[["2015"]]},"accessed":{"date-parts":[["2018",7,19]]}}}],"schema":""} 6Increased LossDecreased AbsorptionMenorrhagiaGI bleedingcolon cancerpeptic ulcer diseaseinflammatory bowel diseaseRegular blood donationPost-operative patients with significant blood lossHematuria (overt or microscopic)Intravascular hemolysisExtreme physical exercise (endurance athletes)Pathological (hemolytic anemias)Upper GI pathology:Chronic gastritis (incl. H pylori gastritis, atrophic gastritis/pernicious anemia)Gastric lymphomaCeliac diseaseCrohn’s diseaseMedications that decrease gastric acidity or bind iron, e.g. antacid/PPI use Gastrectomy or intestinal bypassDuodenal pathologyChronic renal failureSigns and Symptoms in Adults The clinical consequences of iron deficiency are both due to anemia and to non-anemic iron deficiencies. Early stage iron deficiency can exist without overt anemia, but with other non-hematological symptoms ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ueQEisR8","properties":{"formattedCitation":"\\super 7\\nosupersub{}","plainCitation":"7","noteIndex":0},"citationItems":[{"id":127,"uris":[""],"uri":[""],"itemData":{"id":127,"type":"article-journal","title":"Diagnosis and management of iron-deficiency anaemia","container-title":"Best Practice & Research. Clinical Haematology","page":"319-332","volume":"18","issue":"2","source":"PubMed","abstract":"Anaemia is typically the first clue to iron deficiency, but an isolated haemoglobin measurement has both low specificity and low sensitivity. The latter can be improved by including measures of iron-deficient erythropoiesis such as the transferrin iron saturation, mean corpuscular haemoglobin concentration, erythrocyte zinc protoporphyrin, percentage of hypochromic erythrocytes or reticulocyte haemoglobin concentration. However, the changes in these measurements with iron deficiency are indistinguishable from those seen in patients with the anaemia of chronic disease. The optimal diagnostic approach is to measure the serum ferritin as an index of iron stores and the serum transferrin receptor as a index of tissue iron deficiency. The treatment of iron deficiency should always be initiated with oral iron. When this fails because of large blood losses, iron malabsorption, or intolerance to oral iron, parenteral iron can be given using iron dextran, iron gluconate or iron sucrose.","DOI":"10.1016/j.beha.2004.08.022","ISSN":"1521-6926","note":"PMID: 15737893","journalAbbreviation":"Best Pract Res Clin Haematol","language":"eng","author":[{"family":"Cook","given":"James D."}],"issued":{"date-parts":[["2005",6]]}}}],"schema":""} 7, due to deficiency of iron containing cellular enzymes. Non-hematologic symptoms include decreased aerobic work performance, hair loss, adverse pregnancy outcome, and impaired immune function.Investigate based on clinical suspicion, not only on presence of anemia. Other symptoms include: hair loss, fatigue, cold intolerance, restless leg syndrome, irritability/depression, nail changes, angular chelitis, pica/phagophagia (ice craving).Refer to Iron Deficiency in Children on page 5 for signs and symptoms in children.Diagnosis/InvestigationIdentify patients at risk of iron deficiency based upon a directed history (including dietary history and history of blood loss, including blood donation, and family history including colorectal cancer ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"3cxZ6FDM","properties":{"formattedCitation":"\\super 8\\nosupersub{}","plainCitation":"8","noteIndex":0},"citationItems":[{"id":133,"uris":[""],"uri":[""],"itemData":{"id":133,"type":"article-journal","title":"Guidelines for the management of iron deficiency anaemia","container-title":"Gut","page":"1309-1316","volume":"60","issue":"10","source":"Crossref","DOI":"10.1136/gut.2010.228874","ISSN":"0017-5749","language":"en","author":[{"family":"Goddard","given":"A. F."},{"family":"James","given":"M. W."},{"family":"McIntyre","given":"A. S."},{"family":"Scott","given":"B. B."},{"literal":"on behalf of the British Society of Gastroenterology"}],"issued":{"date-parts":[["2011",10,1]]}}}],"schema":""} 8), symptom review, and physical examination. Iron deficiency anemia in adult men and postmenopausal women is most likely to have a serious underlying cause of blood loss including malignancy. Consider upper and lower endoscopy ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MaTJ3s7U","properties":{"formattedCitation":"\\super 8\\nosupersub{}","plainCitation":"8","noteIndex":0},"citationItems":[{"id":133,"uris":[""],"uri":[""],"itemData":{"id":133,"type":"article-journal","title":"Guidelines for the management of iron deficiency anaemia","container-title":"Gut","page":"1309-1316","volume":"60","issue":"10","source":"Crossref","DOI":"10.1136/gut.2010.228874","ISSN":"0017-5749","language":"en","author":[{"family":"Goddard","given":"A. F."},{"family":"James","given":"M. W."},{"family":"McIntyre","given":"A. S."},{"family":"Scott","given":"B. B."},{"literal":"on behalf of the British Society of Gastroenterology"}],"issued":{"date-parts":[["2011",10,1]]}}}],"schema":""} 8. Bleeding from the gastrointestinal tract accounts for approximately two-thirds of all causes in iron deficient patients ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MpyGXkWZ","properties":{"formattedCitation":"\\super 9,10\\nosupersub{}","plainCitation":"9,10","noteIndex":0},"citationItems":[{"id":123,"uris":[""],"uri":[""],"itemData":{"id":123,"type":"article-journal","title":"Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia","container-title":"The New England Journal of Medicine","page":"1691-1695","volume":"329","issue":"23","source":"PubMed","abstract":"BACKGROUND: Idiopathic iron-deficiency anemia in adults is assumed to be the result of occult chronic blood loss from the gastrointestinal tract. The aim of this study was to determine an effective clinical strategy for managing this common clinical problem.\nBACKGROUND: We prospectively studied 100 consecutive patients with iron-deficiency anemia, using colonoscopy and esophagogastroduodenoscopy and, in patients with negative endoscopic studies, enteroclysis (radio-graphic examination of the small intestine).\nRESULTS: Gastrointestinal endoscopy revealed at least one lesion potentially responsible for blood loss in 62 of the 100 patients. Endoscopic examination of the upper gastrointestinal tract showed a bleeding source in 36 patients, and colonoscopy showed a lesion in 25; 1 patient had lesions in both the upper and lower gastrointestinal tracts. The most common abnormality in the upper gastrointestinal tract was peptic ulceration (duodenal ulcer in 11 patients, gastric ulcer in 5, and anastomotic ulcer in 3). Cancers, detected in 11 patients, were the most common colonic lesions. Enteroclysis was performed in 26 of the 38 patients with negative endoscopic studies, and the results were normal in all instances. Symptoms at a specific site in the gastrointestinal tract were predictive of disease in the corresponding portion of the bowel. In addition, the combination of positive tests for fecal occult blood and symptoms in the lower gastrointestinal tract had a positive predictive value of 86 percent for detecting a lesion in the lower gastrointestinal tract.\nCONCLUSIONS: Gastrointestinal lesions (in both the upper gastrointestinal tract and the colon) are frequently found in patients with iron-deficiency anemia. Since site-specific symptoms are predictive of abnormalities in the corresponding portion of the bowel, the initial evaluation should be directed by the location of the symptoms. Concomitant lesions of the upper and lower gastrointestinal tract are rare; thus, detection of a likely source of blood loss during the initial examination may obviate the need for further procedures.","DOI":"10.1056/NEJM199312023292303","ISSN":"0028-4793","note":"PMID: 8179652","journalAbbreviation":"N. Engl. J. Med.","language":"eng","author":[{"family":"Rockey","given":"D. C."},{"family":"Cello","given":"J. P."}],"issued":{"date-parts":[["1993",12,2]]}}},{"id":125,"uris":[""],"uri":[""],"itemData":{"id":125,"type":"article-journal","title":"Guidelines for the management of iron deficiency anaemia. British Society of Gastroenterology","container-title":"Gut","page":"IV1-IV5","volume":"46 Suppl 3-4","source":"PubMed","ISSN":"0017-5749","note":"PMID: 10862605\nPMCID: PMC1766761","journalAbbreviation":"Gut","language":"eng","author":[{"family":"Goddard","given":"A. F."},{"family":"McIntyre","given":"A. S."},{"family":"Scott","given":"B. B."}],"issued":{"date-parts":[["2000",6]]}}}],"schema":""} 9,10. Menorrhagia is the most frequent cause of iron deficiency among pre-menopausal women. Testing for malabsorption is recommended if small bowel disease is clinically suspected, or if oral iron supplementation results in refractory response despite compliance.TestingFirst, determine the cause of iron deficiency. The etiology is often multifactorial; even when there is an obvious cause, investigation of serious underlying causes (e.g. colon cancer in adults) is recommended.Individualize disease-specific management depending on underlying cause ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"laPHTAud","properties":{"formattedCitation":"\\super 11\\nosupersub{}","plainCitation":"11","noteIndex":0},"citationItems":[{"id":134,"uris":[""],"uri":[""],"itemData":{"id":134,"type":"article-journal","title":"Iron deficiency anemia","container-title":"Nutrition in Clinical Practice: Official Publication of the American Society for Parenteral and Enteral Nutrition","page":"128-141","volume":"23","issue":"2","source":"PubMed","abstract":"The most severe consequence of iron depletion is iron deficiency anemia (IDA), and it is still considered the most common nutrition deficiency worldwide. Although the etiology of IDA is multifaceted, it generally results when the iron demands by the body are not met by iron absorption, regardless of the reason. Individuals with IDA have inadequate intake, impaired absorption or transport, physiologic losses associated with chronological or reproductive age, or chronic blood loss secondary to disease. In adults, IDA can result in a wide variety of adverse outcomes including diminished work or exercise capacity, impaired thermoregulation, immune dysfunction, GI disturbances, and neurocognitive impairment. In addition, IDA concomitant with chronic kidney disease or congestive heart failure can worsen the outcome of both conditions. In this review, the prevalence of IDA related to confounding medical conditions will be described along with its diverse etiologies. Distinguishing IDA from anemia of chronic disease using hematologic measures is reviewed as well. In addition, current diagnostic strategies that are inclusive of clinical presentation, biochemical tests, and differential diagnosis will be outlined, followed by a discussion of treatment modalities and future research recommendations.","DOI":"10.1177/0884533608314536","ISSN":"0884-5336","note":"PMID: 18390780","journalAbbreviation":"Nutr Clin Pract","language":"eng","author":[{"family":"Clark","given":"Susan F."}],"issued":{"date-parts":[["2008",5]]}}}],"schema":""} 11. Consider age and clinical presentation when investigating for cause; refer to Table 1 for common causes.The initial recommended tests for iron deficiency and for iron deficiency anemia are serum ferritin and CBC respectively. Table 2: Initial Investigational TestsInvestigationApplicationNotesHematology Profile (CBC)Hemoglobin value is required to assess severity of anemiaCan suggest iron deficiencyNot diagnostic test of choice for iron deficiencyA constellation of the following findings on CBC and peripheral smear is highly suggestive of iron deficiency:anemiamicrocytosishypochromiaSerum Ferritin Diagnostic test of choice for iron deficiency ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"shc5AdiU","properties":{"formattedCitation":"\\super 12\\nosupersub{}","plainCitation":"12","noteIndex":0},"citationItems":[{"id":129,"uris":[""],"uri":[""],"itemData":{"id":129,"type":"article-journal","title":"Iron deficiency anemia in the elderly: the diagnostic process","container-title":"CMAJ: Canadian Medical Association journal = journal de l'Association medicale canadienne","page":"435-440","volume":"144","issue":"4","source":"PubMed","abstract":"OBJECTIVE: To determine the effectiveness of physician probability estimates calculated on the basis of findings from history-taking and physical examination in the diagnosis of iron deficiency anemia in elderly patients.\nDESIGN: Prospective study.\nSETTING: Two community hospitals offering secondary and tertiary care.\nPATIENTS: A total of 259 patients over 65 years of age found to have previously undiagnosed anemia.\nMEASURES: Physician estimates of the likelihood of iron deficiency before (pretest probability) and after (post-test probability) the laboratory test results were available. The hemogram was available to the physicians when they made their pretest probability estimates. Because the serum ferritin level proved to be the most powerful of the laboratory test results studied, the likelihood ratios associated with the post-test estimates were compared with the ratios associated with the serum ferritin level.\nMAIN RESULTS: The post-test probability estimates were influenced by the serum ferritin level and the pretest estimates. The post-test estimates derived from the findings obtained through history-taking and physical examination and the laboratory test results (including the serum ferritin level) were slightly less accurate in predicting iron deficiency than the serum ferritin level alone. Nevertheless, a model in which the pretest estimates were used in addition to the serum ferritin level to predict iron deficiency proved to be more powerful than the serum ferritin level alone (p = 0.006). This indicated that the limitations of the post-test estimates were due to a misinterpretation of the serum ferritin level and that the findings from history-taking and physical examination added important diagnostic information.\nCONCLUSIONS: Physicians must be aware of test properties to provide optimal care to their patients. If test results are properly interpreted, pretest probabilities derived from findings obtained through history-taking and physical examination can add useful information that will lead to more accurate diagnoses.","ISSN":"0820-3946","note":"PMID: 1993290\nPMCID: PMC1452779","shortTitle":"Iron deficiency anemia in the elderly","journalAbbreviation":"CMAJ","language":"eng","author":[{"family":"Patterson","given":"C."},{"family":"Guyatt","given":"G. H."},{"family":"Singer","given":"J."},{"family":"Ali","given":"M."},{"family":"Turpie","given":"I."}],"issued":{"date-parts":[["1991",2,15]]}}}],"schema":""} 12Adults (ug/L) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wfaRaK9z","properties":{"formattedCitation":"\\super 13\\uc0\\u8211{}15\\nosupersub{}","plainCitation":"13–15","noteIndex":0},"citationItems":[{"id":280,"uris":[""],"uri":[""],"itemData":{"id":280,"type":"article-journal","title":"Diagnosis of iron-deficiency anemia in the elderly","container-title":"The American Journal of Medicine","page":"205-209","volume":"88","issue":"3","source":"PubMed","abstract":"PURPOSE: To determine the value of serum ferritin, mean cell volume, transferrin saturation, and free erythrocyte protoporphyrin in the diagnosis of iron-deficiency anemia in the elderly.\nPATIENTS AND METHODS: We prospectively studied consecutive eligible and consenting anemic patients over the age of 65 years, who underwent blood tests and bone marrow aspiration. The study consisted of 259 inpatients and outpatients at two community hospitals in whom a complete blood count processed by the hospital laboratory demonstrated previously undiagnosed anemia (men: hemoglobin level less than 12 g/dL; women: hemoglobin level less than 11.0 g/dL).\nRESULTS: Thirty-six percent of our patients had no demonstrable marrow iron and were classified as being iron-deficient. The serum ferritin was the best test for distinguishing those with iron deficiency from those who were not iron-deficient. No other test added clinically important information. The likelihood ratios associated with the serum ferritin level were as follows: greater than 100 micrograms/L, 0.13; greater than 45 micrograms/L but less than or equal to 100 micrograms/L, 0.46; greater than 18 micrograms/L but less than or equal to 45 micrograms/L, 3.12; and less than or equal to 18 micrograms/L, 41.47. These results indicate that values up to 45 micrograms/L increase the likelihood of iron deficiency, whereas values over 45 micrograms/L decrease the likelihood of iron deficiency. Seventy-two percent of those who were not iron-deficient had serum ferritin values greater than 100 micrograms/L, and in populations with a prevalence of iron deficiency of less than 40%, values of greater than 100 micrograms/L reduce the probability of iron deficiency to under 10%. Fifty-five percent of the iron-deficient patients had serum ferritin values of less than 18 micrograms/L, and in populations with a prevalence of iron deficiency of greater than 20%, values of less than 18 micrograms/L increase the probability of iron deficiency to over 95%.","ISSN":"0002-9343","note":"PMID: 2178409","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Guyatt","given":"G. H."},{"family":"Patterson","given":"C."},{"family":"Ali","given":"M."},{"family":"Singer","given":"J."},{"family":"Levine","given":"M."},{"family":"Turpie","given":"I."},{"family":"Meyer","given":"R."}],"issued":{"date-parts":[["1990",3]]}}},{"id":282,"uris":[""],"uri":[""],"itemData":{"id":282,"type":"article-journal","title":"Prospective evaluation of a clinical guideline for the diagnosis and management of iron deficiency anemia","container-title":"The American Journal of Medicine","page":"281-287","volume":"113","issue":"4","source":"PubMed","abstract":"PURPOSE: We examined the effect of introducing an evidence-based clinical guideline on the diagnosis and evaluation of iron deficiency anemia.\nSUBJECTS AND METHODS: The guideline recommended measurement of serum ferritin levels for all anemic patients with a mean corpuscular volume (MCV) </=95 fL and endoscopic evaluation for those with a serum ferritin level less than 45 ng/mL. Physicians practicing in the general medicine inpatient and outpatient services of two university-affiliated hospitals were informed about the guideline and the data supporting it. Clinical evaluations during the 9 months before (\"control period,\" n = 3341 patients) and the 9 months after (\"intervention period,\" n = 3173 patients) the introduction of the guideline were compared.\nRESULTS: There was a 30% increase (95% confidence interval [CI]: 22% to 39%) in the proportion of anemic patients who underwent serum ferritin evaluation in the intervention period (41% [n = 1284]) compared with in the control period (31% [n = 1040]), and a 24% increase (95% CI: 4% to 48%) in the proportion with a serum ferritin level <45 ng/mL (8.1% [n = 256] vs. 6.5% [n = 217]). The proportion of anemic patients who underwent endoscopic evaluation within 4 months of measurement of low serum ferritin level in the intervention period (3.3% [n = 106]) was 67% higher (95% CI: 23% to 125%) than in the control period (2.0% [n = 67]), and the proportion with serious gastrointestinal lesions found as a result of endoscopy was 62% (95% CI: 8% to 145%) higher (1.8% [n = 57] vs. 1.1% [n = 37]).\nCONCLUSIONS: Introduction of a guideline describing appropriate evaluation of iron deficiency anemia led to an increase in the proportions of patients evaluated for iron deficiency anemia and found to have serious gastrointestinal lesions.","ISSN":"0002-9343","note":"PMID: 12361813","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Ioannou","given":"George N."},{"family":"Spector","given":"Jeremy"},{"family":"Scott","given":"Kevin"},{"family":"Rockey","given":"Don C."}],"issued":{"date-parts":[["2002",9]]}}},{"id":285,"uris":[""],"uri":[""],"itemData":{"id":285,"type":"article-journal","title":"Clinical utility of the soluble transferrin receptor and comparison with serum ferritin in several populations","container-title":"Clinical Chemistry","page":"45-51","volume":"44","issue":"1","source":"PubMed","abstract":"Soluble transferrin receptor (sTfR) and ferritin concentrations were measured in a variety of clinical settings to compare the ability of these two tests to identify iron deficiency. Among 62 anemic patients who either had a bone marrow aspirate performed or had a documented response to iron therapy, the diagnostic sensitivity and specificity of sTfR (at a diagnostic cutoff of > 2.8 mg/L) were 92% and 84%, respectively, with a positive predictive value of 42% in this population. Ferritin (< or = 12 microg/L) had a sensitivity of 25% and a specificity of 98%. However, the sensitivity and specificity of ferritin could be improved to 92% and 98%, respectively, by using a diagnostic cutoff value of < or = 30 microg/L, resulting in a positive predictive value of 92%. Ferritin and sTfR were also measured in 267 outpatient samples and 112 medical students. In the outpatient group, the two tests agreed in 73% of the samples; however, 25% of the samples had ferritin values > 12 microg/L and increased sTfR. Among the medical students, there was 91% agreement between the two tests, but 7% of the samples had ferritin < or = 12 microg/L and normal sTfR. Together, these data suggest that measurement of sTfR does not provide sufficient additional information to ferritin to warrant routine use. However, sTfR may be useful as an adjunct in the evaluation of anemic patients, whose ferritin values may be increased as the result of an acute-phase reaction.","ISSN":"0009-9147","note":"PMID: 9550557","journalAbbreviation":"Clin. Chem.","language":"eng","author":[{"family":"Mast","given":"A. E."},{"family":"Blinder","given":"M. A."},{"family":"Gronowski","given":"A. M."},{"family":"Chumley","given":"C."},{"family":"Scott","given":"M. G."}],"issued":{"date-parts":[["1998",1]]}}}],"schema":""} 13–15less than 15 → diagnostic of iron deficiency15-45 probable iron deficiencymore than 45 → iron deficiency unlikelyChildren (ug/L) less than 12 → diagnostic of iron deficiencyThese values occur on a continuum; cut-offs are suggested:The likelihood of iron deficiency increases with lower ferritin concentrations, including those that overlap with the normal reference interval. The normal reference interval is derived from healthy outpatients without signs of iron deficiency or chronic illness.In adults, iron deficiency is unlikely if ferritin >45 ug/L (or >70 in a patient with chronic inflammatory disease) Ferritin is an acute phase reactant. May be unreliable in patients with chronic disease, active inflammation, or malignancyNon-hematologic symptoms can occur when the serum ferritin is in the low normal range (less than 45 ug/L)Note: In most situations, there is no benefit to ordering serum iron, transferrin, transferrin saturation, or total iron binding capacity. An investigation for anemia of chronic disease (ACD) as a co-contributor to anemia begins with a clinical assessment for an underlying (inflammatory) disorder. ManagementThe objective of treatment is to replenish iron stores: normalize hemoglobin levels and ferritin ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ZTdC85iq","properties":{"formattedCitation":"\\super 16\\nosupersub{}","plainCitation":"16","noteIndex":0},"citationItems":[{"id":171,"uris":[""],"uri":[""],"itemData":{"id":171,"type":"article","title":"Guidelines for the management of iron deficiency anaemia","author":[{"family":"Goddard","given":"AF"},{"family":"James","given":"MW"},{"family":"McIntyre","given":"AS"}],"issued":{"date-parts":[["2005"]]}}}],"schema":""} 16.Iron replacement therapy may begin as soon as iron deficiency is detected, whether or not anemia is also present; however, it is essential to determine and correct the underlying causes of iron deficiency (see Appendix B and Table 1) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"QKsbUuqf","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":111,"uris":[""],"uri":[""],"itemData":{"id":111,"type":"article-journal","title":"Screening for Iron Deficiency Anemia, Including Iron Supplementations for Children and Pregnant Women: Recommendation Statement","container-title":"American Family Physician","page":"461","volume":"74","issue":"3","source":"","abstract":"This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for iron deficiency anemia and the supporting scientific evidence.","ISSN":"0002-838X, 1532-0650","shortTitle":"Screening for Iron Deficiency Anemia, Including Iron Supplementations for Children and Pregnant Women","journalAbbreviation":"AFP","language":"en","issued":{"date-parts":[["2006",8,1]]}}}],"schema":""} 1.Certain medications, such as anticoagulants, non-steroidal anti-inflammatory drugs (NSAIDs), and selective serotonin reuptake inhibitors (SSRIs), may increase the risk of gastrointestinal bleeds. Evaluate the patient's overall risk of bleeding. Evaluate the risk-benefit ratio of continuing these medications in an iron-deficient patient. Lifestyle ModificationEncourage all individuals to consume a diet with sufficient iron to prevent iron deficiency. Refer to Patient and Caregiver Resources for recommended daily intake and foods high in iron.Treatment with Oral IronOral iron replacement is almost always preferred to intravenous (IV) therapy. It is safer, more cost-effective, and convenient when compared to IV therapy. Refer to Appendix for a list of commonly used oral iron preparations, doses, and costs.Oral iron intolerance is very common:Oral iron preparations may cause nausea, vomiting, dyspepsia, constipation, diarrhea or dark stools.Strategies to minimize these effects include: start at a lower dose and increase gradually over 4 to 5 days; giving divided doses or the lowest effective dose, or taking supplements with meals (note: iron absorption is enhanced if supplements are taken on an empty stomach; however, it may not be tolerated).Although sustained release iron preparations tend towards less gastrointestinal side effects, they may not be as effective as standard film coated products due to reduced/poor iron absorption ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"PvTngVWX","properties":{"formattedCitation":"\\super 17\\nosupersub{}","plainCitation":"17","noteIndex":0},"citationItems":[{"id":139,"uris":[""],"uri":[""],"itemData":{"id":139,"type":"article","title":"Comparison of oral iron supplements","publisher":"Therapeutic Research Center","URL":"","author":[{"family":"Pharmacist's Letter","given":""}],"issued":{"date-parts":[["2008",8]]},"accessed":{"date-parts":[["2018",5,10]]}}}],"schema":""} 17.Iron absorption can be decreased by various medications and supplements; space dosing apart by at least 2 hours.Iron absorption from iron salts can be enhanced by taking them on an empty stomach (at least 1.5 to 2 hours after a meal), with acidic juices or vitamin C, and not with other multivitamin, calcium, or antacid tablets. This does not apply to other types of iron preparations such as polypeptides, which are more easily absorbed.Monitoring Response to Oral IronThe frequency of subsequent monitoring depends upon the severity of the anemia, the underlying cause of the iron deficiency, and the clinical impact on the patient. Reassess patients with moderate to severe anemia by testing CBC as early as 2-4 weeks. Hemoglobin should increase by 10-20 g/L by 4 weeks. Hemoglobin will correct within 2 to 4 months if appropriate iron dosages are administered and underlying cause of iron deficiency is corrected.Continue iron therapy an additional 4 to 6 months (adults) after correction of anemia to replenish the iron stores ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rohpuUKF","properties":{"formattedCitation":"\\super 18\\nosupersub{}","plainCitation":"18","noteIndex":0},"citationItems":[{"id":140,"uris":[""],"uri":[""],"itemData":{"id":140,"type":"book","title":"Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc","publisher":"National Academies Press (US)","publisher-place":"Washington (DC)","source":"PubMed","event-place":"Washington (DC)","abstract":"This volume is the newest release in the authoritative series issued by the National Academy of Sciences on dietary reference intakes (DRIs). This series provides recommended intakes, such as Recommended Dietary Allowances (RDAs), for use in planning nutritionally adequate diets for individuals based on age and gender. In addition, a new reference intake, the Tolerable Upper Intake Level (UL), has also been established to assist an individual in knowing how much is \"too much\" of a nutrient. Based on the Institute of Medicine's review of the scientific literature regarding dietary micronutrients, recommendations have been formulated regarding vitamins A and K, iron, iodine, chromium, copper, manganese, molybdenum, zinc, and other potentially beneficial trace elements such as boron to determine the roles, if any, they play in health. The book also: Reviews selected components of food that may influence the bioavailability of these compounds. Develops estimates of dietary intake of these compounds that are compatible with good nutrition throughout the life span and that may decrease risk of chronic disease where data indicate they play a role. Determines Tolerable Upper Intake levels for each nutrient reviewed where adequate scientific data are available in specific population subgroups. Identifies research needed to improve knowledge of the role of these micronutrients in human health. This book will be important to professionals in nutrition research and education.","URL":"","ISBN":"978-0-309-07279-3","call-number":"NBK222310","note":"PMID: 25057538","language":"eng","author":[{"literal":"Institute of Medicine (US) Panel on Micronutrients"}],"issued":{"date-parts":[["2001"]]},"accessed":{"date-parts":[["2018",5,10]]}}}],"schema":""} 18. Target normal ferritin >100 ?g/L.If ferritin and hemoglobin are not responding as anticipated, consider adherence, ongoing bleeding, malabsorption, or alternate diagnosis. If the patient’s clinical status is compromised by moderate to severe anemia, consider admission to an acute care facility and blood transfusion. Once the patient is stable, iron replacement can commence. IV TherapyComplete or partial failure of oral iron therapy trial (in compliant patients) may be due to insufficient absorption, inadequate dosing, or ongoing loss (e.g. hemorrhage). Intravenous therapy may be initiated when there is: inadequate iron absorption, continued blood loss, intolerance to oral iron therapy, urgent surgery in an iron-deficient patient/pre-operative indication, chronic kidney disease, including dialysis patients ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cgpHMY6g","properties":{"formattedCitation":"\\super 19\\nosupersub{}","plainCitation":"19","noteIndex":0},"citationItems":[{"id":168,"uris":[""],"uri":[""],"itemData":{"id":168,"type":"article-journal","title":"Intravenous versus oral iron supplementation for the treatment of anemia in CKD: systematic review and meta-analysis","container-title":"American Journal of Kidney Diseases: The Official Journal of the National Kidney Foundation","page":"897-906","volume":"52","issue":"5","source":"PubMed","abstract":"BACKGROUND: Iron supplementation is essential for the treatment of patients with anemia of chronic kidney disease (CKD). It is not clear which is the best method of iron administration.\nSTUDY DESIGN: Systematic review and meta-analysis. A search was performed until January 2008 of MEDLINE, Cochrane Central Register of Controlled Trials, conference proceedings in nephrology, and reference lists of included trials.\nSETTING & POPULATION: Patients with CKD (stages III to V). We included dialysis patients and patients with CKD not on dialysis therapy (hereafter referred to as patients with CKD).\nSELECTION CRITERIA FOR STUDIES: We included all randomized controlled trials regardless of publication status or language.\nINTERVENTION: Intravenous (IV) versus oral iron supplementation.\nOUTCOMES MEASURES: Primary outcomes assessed: absolute hemoglobin (Hb) level or change in Hb level from baseline. We also assessed all-cause mortality, erythropoiesis-stimulating agent requirement, adverse events, ferritin level, and need for renal replacement therapy in patients with CKD.\nRESULTS: 13 trials were identified, 6 including patients with CKD and 7 including dialysis patients. Compared with oral iron, there was a significantly greater Hb level in dialysis patients treated with IV iron (weighted mean difference, 0.83 g/dL; 95% confidence interval, 0.09 to 1.57). Meta-regression showed a positive association between Hb level increase and IV iron dose administered and a negative association with baseline Hb level. For patients with CKD, there was a small but significant difference in Hb level favoring the IV iron group (weighted mean difference, 0. 31 g/dL; 95% confidence interval, 0.09 to 0. 53). Data for all-cause mortality were sparse, and there was no difference in adverse events between the IV- and oral-treated patients.\nLIMITATIONS: There was significant heterogeneity between trials. Follow-up was limited to 2 to 3 months.\nCONCLUSIONS: Our review shows that patients on hemodialysis therapy have better Hb level response when treated with IV iron. For patients with CKD, this effect is small.","DOI":"10.1053/j.ajkd.2008.05.033","ISSN":"1523-6838","note":"PMID: 18845368","shortTitle":"Intravenous versus oral iron supplementation for the treatment of anemia in CKD","journalAbbreviation":"Am. J. Kidney Dis.","language":"eng","author":[{"family":"Rozen-Zvi","given":"Benaya"},{"family":"Gafter-Gvili","given":"Anat"},{"family":"Paul","given":"Mical"},{"family":"Leibovici","given":"Leonard"},{"family":"Shpilberg","given":"Ofer"},{"family":"Gafter","given":"Uzi"}],"issued":{"date-parts":[["2008",11]]}}}],"schema":""} 19 Intramuscular (IM) TherapyIntramuscular (IM) iron therapy is not recommended because risks include unpredictable absorption, anaphylaxis, and local complications (e.g. pain, permanent staining of the skin, sarcoma formation) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mG06hHF1","properties":{"formattedCitation":"\\super 20\\nosupersub{}","plainCitation":"20","noteIndex":0},"citationItems":[{"id":146,"uris":[""],"uri":[""],"itemData":{"id":146,"type":"article-journal","title":"Intravenous Iron Therapy: A Summary of Treatment Options and Review of Guidelines","container-title":"Journal of Pharmacy Practice","page":"431-443","volume":"21","issue":"6","source":"Crossref","DOI":"10.1177/0897190008318916","ISSN":"0897-1900, 1531-1937","shortTitle":"Intravenous Iron Therapy","language":"en","author":[{"family":"Silverstein","given":"Scott B."},{"family":"Gilreath","given":"Jeffrey A."},{"family":"Rodgers","given":"George M."}],"issued":{"date-parts":[["2008",12]]}}}],"schema":""} 20.Iron supplementation: ongoing careOnce anemia has corrected and iron stores have normalized, a low maintenance dose may be prescribed if there is an ongoing need for additional iron (e.g. menorrhagia, growth spurt, regular blood donation). Dietary modification may also be considered (refer to Appendix A). Consider similar supplementation for patients who have iron depletion but not anemia.Iron Deficiency and Iron Deficiency Anemia in Infants, Children and AdolescentsIron deficiency and iron deficiency anemia in children is associated with motor and cognitive deficits which may be irreversible ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MuPbwPJM","properties":{"formattedCitation":"\\super 21\\nosupersub{}","plainCitation":"21","noteIndex":0},"citationItems":[{"id":147,"uris":[""],"uri":[""],"itemData":{"id":147,"type":"article-journal","title":"Clinical inquiries. What is appropriate management of iron deficiency for young children?","container-title":"The Journal of Family Practice","page":"629-630","volume":"55","issue":"7","source":"PubMed","abstract":"Infants and toddlers with suspected iron-deficiency anemia should begin treatment with oral ferrous sulfate (3 mg/kg/d of elemental iron). A rise in hemoglobin >1 g/dL after 4 weeks supports the diagnosis of iron deficiency, and supplementation should continue for 2 additional months to replenish iron stores. Recheck hemoglobin at the end of treatment and again 6 months later (strength of recommendation [SOR]: C, based on expert opinion). For primary prevention, counsel parents on the use of iron-fortified formula for non-breastfed infants until the age 12 months (SOR: B, based on randomized controlled study), and introduce iron-rich foods between 4 and 6 months to breastfed babies (SOR: C, based on expert opinion).","ISSN":"0094-3509","note":"PMID: 16822452","journalAbbreviation":"J Fam Pract","language":"eng","author":[{"family":"Bhargava","given":"Sital"},{"family":"Meurer","given":"Linda N."},{"family":"Jamieson","given":"Barbara"},{"family":"Hunter-Smith","given":"Dan"}],"issued":{"date-parts":[["2006",7]]}}}],"schema":""} mon causes and risk factors All ages: Increased requirements due to growth, bleeding from any source, e.g. frequent nosebleeds, GI diseases including short gut syndrome, cow’s milk protein colitis Infants < 6 months: maternal iron deficiency, fetal-maternal hemorrhage, twin-twin transfusion, prematurity (low blood volume at birth, phlebotomy)Toddlers (age 1-3 years): cow’s milk before 12 months, bottle use beyond 12-15 months, excessive cow’s milk, exclusive breastfeeding beyond 6 months, picky eating (insufficient intake or diversity of solid food), prematurity, obesity ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"vcMrNXvf","properties":{"formattedCitation":"\\super 22\\nosupersub{}","plainCitation":"22","noteIndex":0},"citationItems":[{"id":188,"uris":[""],"uri":[""],"itemData":{"id":188,"type":"article-journal","title":"Iron deficiency is a public health problem in Canadian infants and children","container-title":"Paediatrics & Child Health","page":"347-350","volume":"15","issue":"6","source":"PubMed","ISSN":"1918-1485","note":"PMID: 21731416\nPMCID: PMC2921732","journalAbbreviation":"Paediatr Child Health","language":"eng","author":[{"family":"Hartfield","given":"Dawn"}],"issued":{"date-parts":[["2010",7]]}}}],"schema":""} 22Adolescents: disordered eating, menorrhagia, low body weight, extreme physical exercise/endurance athletes, vegetarian diet (refer to Vegetarian and Vegan Diets on page 6)Signs and symptomsNote that some patients may be asymptomaticAll ages: tiredness, restless legs, inattention, poor school performance, irritability/depression, growth retardation, unexplained cognitive and intellectual impairment, pica/phagophagia, breath-holding spells , developmental delayInfants: poor feeding, lethargy, failure to thrive, cardiomegaly, tachypneaAdolescents: presyncope, syncope, headache, irritability, fatigue, exercise intolerance, restless legsDiagnosisSerum ferritin is the diagnostic test of choice for iron deficiency. Ferritin <12 ug/L is diagnostic of iron deficiency. Refer to Table 2 for guidance on interpreting ferritin levels.Treatment Consider the introduction of iron rich foods/formula or routine iron supplementation for asymptomatic children aged 6-12 months who are at increased risk for iron deficiency anemia ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"z6Ux9QV0","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":111,"uris":[""],"uri":[""],"itemData":{"id":111,"type":"article-journal","title":"Screening for Iron Deficiency Anemia, Including Iron Supplementations for Children and Pregnant Women: Recommendation Statement","container-title":"American Family Physician","page":"461","volume":"74","issue":"3","source":"","abstract":"This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for iron deficiency anemia and the supporting scientific evidence.","ISSN":"0002-838X, 1532-0650","shortTitle":"Screening for Iron Deficiency Anemia, Including Iron Supplementations for Children and Pregnant Women","journalAbbreviation":"AFP","language":"en","issued":{"date-parts":[["2006",8,1]]}}}],"schema":""} 1. Take a thorough dietary history and provide dietary counselling to all pediatric patients with iron deficiency. For children aged 1-3, provide specific guidance on recommended daily amounts of cow’s milk and introduction of iron-rich solid foods. Consider referral to a dietician. Infants 6-24 months should not consume more than 750 mL per day of cow’s milk ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ZY5SiAQC","properties":{"formattedCitation":"\\super 23\\nosupersub{}","plainCitation":"23","noteIndex":0},"citationItems":[{"id":290,"uris":[""],"uri":[""],"itemData":{"id":290,"type":"webpage","title":"Nutrition for healthy term infants, six to 24 months: An overview | Canadian Paediatric Society","abstract":"Nutrition for Healthy Term Infants is a joint statement by Health Canada, the Canadian Paediatric Society, Dietitians of Canada and the Breastfeeding Committee for Canada. It was republished in September 2012, with recommendations on infant feeding from birth to six months of age. The statement was most recently updated in April 2014, with recommendations for feeding older infants and young children from six to 24 months of age. The present practice point outlines the statement development…","URL":"","shortTitle":"Nutrition for healthy term infants, six to 24 months","language":"en","author":[{"family":"Society","given":"Canadian Paediatric"}],"accessed":{"date-parts":[["2018",10,5]]}}}],"schema":""} 23 because its volume can displace other iron rich foods, and large amounts may lead to intestinal blood loss due to cow’s milk protein colitis.Recommend infants and toddlers with suspected iron deficiency anemia begin treatment with oral ferrous sulphate. Recommended treatment dose for infants and children is 3 to 6 mg of elemental iron/kg/day in either once a day or divided doses. For optimal absorption, oral iron should be taken on an empty stomach with water or juice, and not with dairy. If this is not tolerated (e.g. constipation), try administering oral iron with food.Advise patients that iron can be toxic to children and should always be safely stored.Blood transfusion is very rarely required for iron deficiency anemia in children. Judicious transfusion is indicated for very severe anemia in the setting of hemodynamic compromise / severe signs of anemia requiring emergent correction. In this case, transfused blood should be administered in small aliquots of 5 mL / kg over 4 hours with close monitoring, for prevention of fluid overload / cardiac failure.Monitoring responseRefer to adult Monitoring Response section for guidance.Reticulocyte count may be helpful in monitoring response. Consider switching formulations is oral iron preparation is not tolerated.If hemoglobin is correcting by 4 weeks, continue oral iron and check CBC and ferritin at three months.Iron Deficiency and Obstetrics There is an increase in iron requirement (about 1000 mg total) during pregnancy, parturition and lactation. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"iCIEZt7h","properties":{"formattedCitation":"\\super 24,25\\nosupersub{}","plainCitation":"24,25","noteIndex":0},"citationItems":[{"id":117,"uris":[""],"uri":[""],"itemData":{"id":117,"type":"article-journal","title":"Iron requirements in pregnancy and strategies to meet them","container-title":"The American Journal of Clinical Nutrition","page":"257S-264S","volume":"72","issue":"1 Suppl","source":"PubMed","abstract":"Iron requirements are greater in pregnancy than in the nonpregnant state. Although iron requirements are reduced in the first trimester because of the absence of menstruation, they rise steadily thereafter; the total requirement of a 55-kg woman is approximately 1000 mg. Translated into daily needs, the requirement is approximately 0.8 mg Fe in the first trimester, between 4 and 5 mg in the second trimester, and >6 mg in the third trimester. Absorptive behavior changes accordingly: a reduction in iron absorption in the first trimester is followed by a progressive rise in absorption throughout the remainder of pregnancy. The amounts that can be absorbed from even an optimal diet, however, are less than the iron requirements in later pregnancy and a woman must enter pregnancy with iron stores of >/=300 mg if she is to meet her requirements fully. This is more than most women possess, especially in developing countries. Results of controlled studies indicate that the deficit can be met by supplementation, but inadequacies in health care delivery systems have limited the effectiveness of larger-scale interventions. Attempts to improve compliance include the use of a supplement of ferrous sulfate in a hydrocolloid matrix (gastric delivery system, or GDS) and the use of intermittent supplementation. Another approach is intermittent, preventive supplementation aimed at improving the iron status of all women of childbearing age. Like all supplementation strategies, however, this approach has the drawback of depending on delivery systems and good compliance. On a long-term basis, iron fortification offers the most cost-effective option for the future.","ISSN":"0002-9165","note":"PMID: 10871591","journalAbbreviation":"Am. J. Clin. Nutr.","language":"eng","author":[{"family":"Bothwell","given":"T. H."}],"issued":{"date-parts":[["2000",7]]}}},{"id":119,"uris":[""],"uri":[""],"itemData":{"id":119,"type":"article-journal","title":"Treatments for iron-deficiency anaemia in pregnancy","container-title":"The Cochrane Database of Systematic Reviews","page":"CD003094","issue":"2","source":"PubMed","abstract":"BACKGROUND: Iron deficiency, the most common cause of anaemia in pregnancy worldwide, can be mild, moderate or severe. Severe anaemia can have very serious consequences for mothers and babies, but there is controversy about whether treating mild or moderate anaemia provides more benefit than harm.\nOBJECTIVES: To assess the effects of different treatments for iron-deficiency anaemia in pregnancy (defined as haemoglobin less than 11 g/dl) on maternal and neonatal morbidity and mortality.\nSEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE (1976 to December 2005), LILACS (1982 to 40 edition), BIOSIS Previews (1980 to June 2002) and ongoing clinical trial registers.\nSELECTION CRITERIA: Randomised controlled trials comparing treatments for iron-deficiency anaemia in pregnancy.\nDATA COLLECTION AND ANALYSIS: We identified 17 trials, involving 2578 women. We assessed trial quality.\nMAIN RESULTS: The trials were small and generally methodologically poor. They covered a very wide range of differing drugs, doses and routes of administration, making it difficult to pool data. Oral iron in pregnancy showed a reduction in the incidence of anaemia (one trial, 125 women; relative risk 0.38; 95% confidence interval 0.26 to 0.55). It was not possible to assess the effects of treatment by severity of anaemia. A trend was found between dose and reported adverse effects. We found that most trials had no assessments on relevant clinical outcomes and a paucity of data on adverse effects, including some that are known to be associated with iron administration. Although the intramuscular and intravenous routes produced better haematological indices in women than the oral route, no clinical outcomes were assessed and there were insufficient data on adverse effects, for example, on venous thrombosis and severe allergic reactions.\nAUTHORS' CONCLUSIONS: Despite the high incidence and burden of disease associated with this condition, there is a paucity of good quality trials assessing clinical maternal and neonatal effects of iron administration in women with anaemia. Daily oral iron treatment improves haematological indices but causes frequent gastrointestinal adverse effects. Parenteral (intramuscular and intravenous) iron enhances haematological response, compared with oral iron, but there are concerns about possible important adverse effects. Large, good quality trials, assessing clinical outcomes (including adverse effects) are required.","DOI":"10.1002/14651858.CD003094.pub2","ISSN":"1469-493X","note":"PMID: 17443522","journalAbbreviation":"Cochrane Database Syst Rev","language":"eng","author":[{"family":"Reveiz","given":"L."},{"family":"Gyte","given":"G. M. L."},{"family":"Cuervo","given":"L. G."}],"issued":{"date-parts":[["2007",4,18]]}}}],"schema":""} 24,25Iron is essential for normal fetal development. It is important to prevent iron deficiency in the fetus by preventing iron deficiency in pregnant women ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7LWwxarL","properties":{"formattedCitation":"\\super 26\\nosupersub{}","plainCitation":"26","noteIndex":0},"citationItems":[{"id":131,"uris":[""],"uri":[""],"itemData":{"id":131,"type":"article-journal","title":"Prepartum anaemia: prevention and treatment","container-title":"Annals of Hematology","page":"949-959","volume":"87","issue":"12","source":"PubMed","abstract":"This review focuses on the occurrence, prevention and treatment of anaemia during pregnancy in Western societies. Iron deficiency anaemia (IDA) is the most prevalent deficiency disorder and the most frequent form of anaemia in pregnant women. Minor causes of anaemia are folate and vitamin B12 deficiency, haemoglobinopathy and haemolytic anaemia. Anaemia is defined as haemoglobin of <110 g/L in the first and third trimester and <105 g/L in the second trimester. The diagnosis relies on haemoglobin, a full blood count and plasma ferritin, which can be supported by plasma transferrin saturation and serum soluble transferrin receptor. Among fertile, non-pregnant women, approximately 40% have ferritin of <or=30 microg/L, i.e. small or absent iron reserves and therefore an unfavourable iron status with respect to upcoming pregnancy. The prevalence of prepartum anaemia in the third trimester ranges 14-52% in women taking placebo and 0-25% in women taking iron supplements, dependent on the doses of iron. In studies incorporating serum ferritin, the frequency of IDA in placebo-treated women ranges 12-17% and in iron-supplemented women 0-3%. Requirements for absorbed iron increase during pregnancy from 0.8 mg/day in the first trimester to 7.5 mg/day in the third trimester, on the average approximately 4.4 mg/day, and dietary measures are inadequate to reduce the frequency of prepartum IDA. However, IDA is efficiently prevented by oral iron supplements in doses of 30-40 mg ferrous iron taken between meals from early pregnancy to delivery. Treatment of IDA should aim at replenishing body iron deficits by oral and/or intravenous administration of iron. In women with slight to moderate IDA, i.e. haemoglobin of 90-105 g/L, treatment with oral ferrous iron of approximately 100 mg/day between meals is the therapeutic option in the first and second trimester; haemoglobin should be checked after 2 weeks and provided an increase of >or=10 g/L, oral iron therapy has proved effective and should continue. Treatment with intravenous iron is superior to oral iron with respect to the haematological response. Intravenous iron is considered safe in the second and third trimester, while there is little experience in the first trimester. Intravenous iron of 600-1,200 mg should be considered: (1) as second option if oral iron fails to increase haemoglobin within 2 weeks; (2) as first option at profound IDA, i.e. haemoglobin of <90 g/L in any trimester beyond 14 weeks gestation; and (3) as first option for IDA in third trimester. Profound IDA has serious consequences for both woman and foetus and requires prompt intervention with intravenous iron. This is especially important for the safety of women who for various reasons oppose blood transfusions.","DOI":"10.1007/s00277-008-0518-4","ISSN":"1432-0584","note":"PMID: 18641987","shortTitle":"Prepartum anaemia","journalAbbreviation":"Ann. Hematol.","language":"eng","author":[{"family":"Milman","given":"Nils"}],"issued":{"date-parts":[["2008",12]]}}}],"schema":""} 26. Assess risk of iron deficiency among women planning pregnancy, especially women in high-risk groups (Table 1).Iron supplementation for non-anemic pregnant womenMost pregnant women need to take a supplement to get enough iron ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2tAD8FHJ","properties":{"formattedCitation":"\\super 27\\nosupersub{}","plainCitation":"27","noteIndex":0},"citationItems":[{"id":205,"uris":[""],"uri":[""],"itemData":{"id":205,"type":"book","title":"Prenatal nutrition guidelines for health professionals: iron","publisher":"Health Canada","publisher-place":"Ottawa","source":"Open WorldCat","event-place":"Ottawa","URL":"","ISBN":"978-1-100-12207-6","note":"OCLC: 458724707","shortTitle":"Prenatal nutrition guidelines for health professionals","language":"en","author":[{"literal":"Canada"},{"literal":"Health Canada"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",7,9]]}}}],"schema":""} 27. An increase in iron consumption by about 15-30 mg elemental iron/day is recommended for non-anemic women, an amount readily met by most prenatal vitamin formulations. Health Canada recommends that pregnant women take a daily multivitamin that includes B12, 0.4mg of folic acid, and 16-20 mg of iron ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wS6J60xR","properties":{"formattedCitation":"\\super 27\\nosupersub{}","plainCitation":"27","noteIndex":0},"citationItems":[{"id":205,"uris":[""],"uri":[""],"itemData":{"id":205,"type":"book","title":"Prenatal nutrition guidelines for health professionals: iron","publisher":"Health Canada","publisher-place":"Ottawa","source":"Open WorldCat","event-place":"Ottawa","URL":"","ISBN":"978-1-100-12207-6","note":"OCLC: 458724707","shortTitle":"Prenatal nutrition guidelines for health professionals","language":"en","author":[{"literal":"Canada"},{"literal":"Health Canada"}],"issued":{"date-parts":[["2009"]]},"accessed":{"date-parts":[["2018",7,9]]}}}],"schema":""} 27. For more information including advice on optimizing dietary iron intake and iron absorption, refer to: Health Canada Prenatal Nutrition Guidelines for Health Professionals: Iron and Prenatal Nutrition Guidelines for Health Professionals – Frequently Asked Questions. Iron deficiency anemia in pregnant womenIron deficiency anemia is the most frequent form of anemia in pregnant women. Anemia in pregnancy is defined as ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0Xq6ZnML","properties":{"formattedCitation":"\\super 28\\uc0\\u8211{}30\\nosupersub{}","plainCitation":"28–30","noteIndex":0},"citationItems":[{"id":273,"uris":[""],"uri":[""],"itemData":{"id":273,"type":"article-journal","title":"Reference intervals for haematological variables during normal pregnancy and postpartum in 434 healthy Danish women","container-title":"European Journal of Haematology","page":"39-46","volume":"79","issue":"1","source":"PubMed","abstract":"AIM: To report reference intervals for haematological variables during normal pregnancy and postpartum.\nMATERIAL AND METHODS: The series comprised 434 healthy ethnic Danish women with a normal pregnancy > or =37 wk duration and a normal delivery with newborns weight >2500 g. Blood samples were obtained at 18, 32 and 39 wk gestation and at 8 wk postpartum. The following variables were analysed: Haemoglobin (Hb), haematocrit (Hct), blood erythrocyte count, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, white cell count, platelet count, erythrocyte folate, plasma folate, plasma cobalamin, plasma methylmalonic acid, plasma total homocysteine, serum ferritin, serum soluble transferrin receptor and plasma creatinine. Reference intervals were calculated using log(10)-transformed values (which showed normal distributions) as mean +/- 1.96 x SD.\nRESULTS: The lower reference value for Hb during pregnancy was 6.45 mmol/L (105 g/L) and 7.3 mmol/L (118 g/L) postpartum. The lower reference value for Hct was 0.31 in pregnancy and 0.35 postpartum. There was a gradual decline in the lower reference value for erythrocyte folate during pregnancy and postpartum from 0.46 to 0.29 micromol/L and in plasma folate from 6 to 4 nmol/L. Lower reference value for plasma cobalamin declined during pregnancy from 96 to 71 pmol/L, but increased postpartum to 148 pmol/L. Upper reference value for plasma homocysteine increased gradually during pregnancy and postpartum from 11.0 to 20.6 micromol/L. Geometric mean serum ferritin at 18 wk gestation was 32 microg/L. Plasma creatinine values were low during pregnancy and displayed a significant increase postpartum.\nCONCLUSION: The characteristic changes occurring in haematological indices during pregnancy and postpartum are described in this study. The results may be used as reference values in the assessment of health status of pregnant women with a similar socio-economic and racial background.","DOI":"10.1111/j.1600-0609.2007.00873.x","ISSN":"0902-4441","note":"PMID: 17598837","journalAbbreviation":"Eur. J. Haematol.","language":"eng","author":[{"family":"Milman","given":"Nils"},{"family":"Bergholt","given":"Thomas"},{"family":"Byg","given":"Keld-Erik"},{"family":"Eriksen","given":"Lisbeth"},{"family":"Hvas","given":"Anne-Mette"}],"issued":{"date-parts":[["2007",7]]}}},{"id":275,"uris":[""],"uri":[""],"itemData":{"id":275,"type":"article-journal","title":"Reference intervals for hemoglobin and hematocrit in a low-risk pregnancy cohort: implications of racial differences","container-title":"The Journal of Maternal-Fetal & Neonatal Medicine","page":"1-8","volume":"0","issue":"0","source":"Taylor and Francis+NEJM","abstract":"Objective: As anemia in pregnancy is associated with adverse perinatal outcomes, we sought to define the mean and the fifth percentile of Hb and Ht using a contemporary multiethnic large cohort of low-risk pregnancies, and assess potential racial differences.Methods: We conducted a retrospective cohort study on women who delivered between 1 January 2008 and 31 December 2013 in Reggio Emilia County, Italy. Linear mixed effects models were used to describe changes in mean Hb and Ht, while quantile regression with matrix-design bootstrap defined changes in the fifth percentile of Hb and Ht, controlling for race, maternal age, smoking, and pregnancy number.Results: We analyzed 23,657 hemograms from 7318 pregnancies and 6870 women. Multivariate analysis showed that when compared to Caucasians’, African women’s mean Hb and Ht were respectively 0.24 (95%CI 0.3–0.17) g/dl and 0.7 (95%CI 0.8–0.5) % lower, while Asian mothers’ were 0.11 (95%CI 0.19–0.03) g/dl and 0.3 (95%CI 0.5–0.1) % inferior. Similarly, both African and Asian women had lower fifth Ht percentiles (?1, 95%CI ?1.3 to ?0.6, and ?0.4, 95%CI ?0.7 to ?0.04) than Caucasians, while African mothers also had lower fifth Hb percentile (0.3, 95%CI 0.5–0.1). The fifth percentile for Hb and Ht were, respectively, 11.3 (95%CI 11–11.5) g/dl and 32.8 (95%CI 32.3–33.4) % in the first trimester, 10.4 (95%CI 10.1–10.6) g/dl and 30.2 (95%CI 29.6–30.8) % in the second trimester, 10.1 (95%CI 9.8–10.3) g/dl and 30.6 (95%CI 30–31.1) % in the third trimester.Conclusions: We provided contemporary references to define anemia in pregnancy, and we confirmed that even in pregnancy, African and Asian women have lower Hb and Ht than Caucasian. Racial and population-specific references may have significant clinical and public health implication for more accurate disease diagnosis and appropriate treatment.","DOI":"10.1080/14767058.2018.1452905","ISSN":"1476-7058","note":"PMID: 29534635","shortTitle":"Reference intervals for hemoglobin and hematocrit in a low-risk pregnancy cohort","author":[{"family":"Chiossi","given":"Giuseppe"},{"family":"Palomba","given":"Stefano"},{"family":"Costantine","given":"Maged M."},{"family":"Falbo","given":"Angela I."},{"family":"Harirah","given":"Hassan M."},{"family":"Saade","given":"George R."},{"family":"Sala","given":"Giovanni B. La"}],"issued":{"date-parts":[["2018",3,13]]}}},{"id":276,"uris":[""],"uri":[""],"itemData":{"id":276,"type":"book","title":"Handbook of diagnostic biochemistry and hematology in normal pregnancy","publisher":"CRC Press","publisher-place":"Boca Raton, Florida","number-of-pages":"235","event-place":"Boca Raton, Florida","URL":"","language":"English","author":[{"family":"Lockitch","given":"Gillian"}],"issued":{"date-parts":[["1993"]]}}}],"schema":""} 28–30: 1st trimester: hemoglobin < 110 g/L2nd trimester: hemoglobin < 105 g/L3rd trimester: hemoglobin < 105 g/LIf necessary, intravenous iron is considered to be safe for the second and third trimester (refer to Appendix B) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"NoLt5LLJ","properties":{"formattedCitation":"\\super 26\\nosupersub{}","plainCitation":"26","noteIndex":0},"citationItems":[{"id":131,"uris":[""],"uri":[""],"itemData":{"id":131,"type":"article-journal","title":"Prepartum anaemia: prevention and treatment","container-title":"Annals of Hematology","page":"949-959","volume":"87","issue":"12","source":"PubMed","abstract":"This review focuses on the occurrence, prevention and treatment of anaemia during pregnancy in Western societies. Iron deficiency anaemia (IDA) is the most prevalent deficiency disorder and the most frequent form of anaemia in pregnant women. Minor causes of anaemia are folate and vitamin B12 deficiency, haemoglobinopathy and haemolytic anaemia. Anaemia is defined as haemoglobin of <110 g/L in the first and third trimester and <105 g/L in the second trimester. The diagnosis relies on haemoglobin, a full blood count and plasma ferritin, which can be supported by plasma transferrin saturation and serum soluble transferrin receptor. Among fertile, non-pregnant women, approximately 40% have ferritin of <or=30 microg/L, i.e. small or absent iron reserves and therefore an unfavourable iron status with respect to upcoming pregnancy. The prevalence of prepartum anaemia in the third trimester ranges 14-52% in women taking placebo and 0-25% in women taking iron supplements, dependent on the doses of iron. In studies incorporating serum ferritin, the frequency of IDA in placebo-treated women ranges 12-17% and in iron-supplemented women 0-3%. Requirements for absorbed iron increase during pregnancy from 0.8 mg/day in the first trimester to 7.5 mg/day in the third trimester, on the average approximately 4.4 mg/day, and dietary measures are inadequate to reduce the frequency of prepartum IDA. However, IDA is efficiently prevented by oral iron supplements in doses of 30-40 mg ferrous iron taken between meals from early pregnancy to delivery. Treatment of IDA should aim at replenishing body iron deficits by oral and/or intravenous administration of iron. In women with slight to moderate IDA, i.e. haemoglobin of 90-105 g/L, treatment with oral ferrous iron of approximately 100 mg/day between meals is the therapeutic option in the first and second trimester; haemoglobin should be checked after 2 weeks and provided an increase of >or=10 g/L, oral iron therapy has proved effective and should continue. Treatment with intravenous iron is superior to oral iron with respect to the haematological response. Intravenous iron is considered safe in the second and third trimester, while there is little experience in the first trimester. Intravenous iron of 600-1,200 mg should be considered: (1) as second option if oral iron fails to increase haemoglobin within 2 weeks; (2) as first option at profound IDA, i.e. haemoglobin of <90 g/L in any trimester beyond 14 weeks gestation; and (3) as first option for IDA in third trimester. Profound IDA has serious consequences for both woman and foetus and requires prompt intervention with intravenous iron. This is especially important for the safety of women who for various reasons oppose blood transfusions.","DOI":"10.1007/s00277-008-0518-4","ISSN":"1432-0584","note":"PMID: 18641987","shortTitle":"Prepartum anaemia","journalAbbreviation":"Ann. Hematol.","language":"eng","author":[{"family":"Milman","given":"Nils"}],"issued":{"date-parts":[["2008",12]]}}}],"schema":""} 26.Iron Deficiency in the ElderlyAnemia in the elderly is a common clinical finding, often multifactorial, and has significant impact on quality of life, functional decline, and mortality. Treatment of iron deficiency and its underlying cause(s) may improve outcomes. Investigation of anemia in the elderly is recommended if the life expectancy is more than a year ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"8OwEJLj6","properties":{"formattedCitation":"\\super 31\\nosupersub{}","plainCitation":"31","noteIndex":0},"citationItems":[{"id":156,"uris":[""],"uri":[""],"itemData":{"id":156,"type":"article-journal","title":"Epidemiology of anemia in the elderly: information on diagnostic evaluation","container-title":"Journal of the American Geriatrics Society","page":"S2-9","volume":"51","issue":"3 Suppl","source":"PubMed","abstract":"A rise in the aging population has been predicted, and, as a result, it is expected that the incidence of age-related health conditions will also increase. Although common in the elderly, anemia is often mild and asymptomatic and rarely requires hospitalization. However, untreated anemia can be detrimental, because it is associated with increased mortality, poor health, fatigue, and functional dependence and can lead to cardiovascular and neurological complications. Several factors have been suggested to cause anemia in this population, for example, blood loss or chronic disease. In some cases, the cause is unknown. It has been suggested that this is a result of the presence of comorbid conditions that can mask the symptoms of anemia. Therefore, appropriate diagnosis and management strategies of anemia in the elderly need to be identified, particularly because anemia may indicate the presence of other serious diseases.","ISSN":"0002-8614","note":"PMID: 12588565","shortTitle":"Epidemiology of anemia in the elderly","journalAbbreviation":"J Am Geriatr Soc","language":"eng","author":[{"family":"Balducci","given":"Lodovico"}],"issued":{"date-parts":[["2003",3]]}}}],"schema":""} 31.Replacement options are similar to younger patients. If standard dosing is not tolerated, low dose iron therapy (15 mg elemental iron per day, or 30 mg every other day) is an effective treatment in octogenarians, with significantly reduced adverse effects (refer to Appendix B) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"QDDnS4TM","properties":{"formattedCitation":"\\super 32\\uc0\\u8211{}35\\nosupersub{}","plainCitation":"32–35","noteIndex":0},"citationItems":[{"id":137,"uris":[""],"uri":[""],"itemData":{"id":137,"type":"article-journal","title":"Iron Deficiency (ID) and Iron Deficiency Anaemia (IDA)","page":"2","source":"Zotero","language":"en","author":[{"family":"Mansvelt","given":"EPG"}]}},{"id":"wLwBSMsH/yBVenz1Y","uris":[""],"uri":[""],"itemData":{"id":142,"type":"book","title":"Therapeutic choices","publisher":"Canadian Pharmacists Association","publisher-place":"Ottawa, Ont.","source":"Open WorldCat","event-place":"Ottawa, Ont.","ISBN":"978-1-894402-40-8","note":"OCLC: 995560001","language":"English","author":[{"family":"Gray","given":"Jean"},{"literal":"Canadian Pharmacists Association"}],"issued":{"date-parts":[["2008"]]}}},{"id":149,"uris":[""],"uri":[""],"itemData":{"id":149,"type":"book","title":"Anemia Review Panel. Anemia Guidelines for Family Medicine","publisher":"MUMS Guideline Clearinghouse","publisher-place":"Toronto","edition":"2","event-place":"Toronto","issued":{"date-parts":[["2008"]]}}},{"id":158,"uris":[""],"uri":[""],"itemData":{"id":158,"type":"article-journal","title":"Are we giving too much iron? Low-dose iron therapy is effective in octogenarians","container-title":"The American Journal of Medicine","page":"1142-1147","volume":"118","issue":"10","source":"PubMed","abstract":"PURPOSE: Elderly patients are vulnerable to the dose-dependent adverse effects of iron replacement therapy. Our study examines whether low-dose iron therapy can efficiently resolve iron-deficiency anemia in patients over the age of 80 years and reduce adverse effects.\nSUBJECTS AND METHODS: Ninety hospitalized patients with iron-deficiency anemia were randomized to receive elemental iron in daily doses of 15 mg or 50 mg as liquid ferrous gluconate or 150 mg of ferrous calcium citrate tablets for 60 days. Thirty control patients without anemia were given 15 mg of iron for 60 days. A 2-hour iron absorption test was performed after the initial dose. Hemoglobin and ferritin levels were measured on day 1, 30, and 60 after initiating therapy. Each patient completed a weekly questionnaire regarding drug-induced adverse effects.\nRESULTS: Serum iron rose significantly in the anemic patients beginning 15 minutes after the first dose but not in nonanemic patients. Two months of iron treatment significantly increased hemoglobin and ferritin concentrations similarly in all 3 groups of iron-deficiency anemia patients (for example, hemoglobin levels rose from 10.0 g/dL to 11.3 g/dL with 15 mg/d of iron therapy and from 10.2 g/dL to 11.6 g/dL with 150 mg/d). Abdominal discomfort, nausea, vomiting, changes in bowel movements, and black stools were significantly more common at higher iron doses.\nCONCLUSIONS: Low-dose iron treatment is effective in elderly patients with iron-deficiency anemia. It can replace the commonly used higher doses and can significantly reduce adverse effects.","DOI":"10.1016/j.amjmed.2005.01.065","ISSN":"0002-9343","note":"PMID: 16194646","shortTitle":"Are we giving too much iron?","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Rimon","given":"Ephraim"},{"family":"Kagansky","given":"Nadya"},{"family":"Kagansky","given":"Michael"},{"family":"Mechnick","given":"Lora"},{"family":"Mashiah","given":"Tony"},{"family":"Namir","given":"Michael"},{"family":"Levy","given":"Shmuel"}],"issued":{"date-parts":[["2005",10]]}}}],"schema":""} 32–35. Note: iron stores take longer to replete with lower iron doses.Vegetarian and Vegan Diets Well-balanced vegetarian and vegan diets can provide sufficient iron intake for children, adolescents ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"UBfvMW7M","properties":{"formattedCitation":"\\super 36\\nosupersub{}","plainCitation":"36","noteIndex":0},"citationItems":[{"id":210,"uris":[""],"uri":[""],"itemData":{"id":210,"type":"webpage","title":"Vegetarian diets in children and adolescents | Canadian Paediatric Society","abstract":"A well-balanced vegetarian diet can provide for the needs of children and adolescents. However, appropriate caloric intake should be ensured and growth monitored. Particular attention should be paid to adequate protein intake and sources of essential fatty acids, iron, zinc, calcium, and vitamins B12 and D. Supplementation may be required in cases of strict vegetarian diets with no intake of any animal products. Pregnant and nursing mothers should also be appropriately advised to ensure that the…","URL":"","language":"en","author":[{"family":"Society","given":"Canadian Paediatric"}],"accessed":{"date-parts":[["2018",7,9]]}}}],"schema":""} 36 and adults. Vegetarians require 1.8 times higher iron intake than non-vegetarians because non-heme iron is not absorbed as well as heme iron ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"PeenAEvv","properties":{"formattedCitation":"\\super 37\\nosupersub{}","plainCitation":"37","noteIndex":0},"citationItems":[{"id":263,"uris":[""],"uri":[""],"itemData":{"id":263,"type":"webpage","title":"Dietary Reference Intakes","container-title":"Government of Canada","genre":"datasets","abstract":"Reference Values for Elements - Dietary Reference Intakes Tables [Health Canada, 2005]","URL":"","language":"eng","author":[{"family":"Health Canada","given":""}],"issued":{"date-parts":[["2005",7,20]]},"accessed":{"date-parts":[["2018",8,13]]}}}],"schema":""} 37. If uncertain, consider referral to a registered dietician. For information on getting enough dietary iron and choosing iron-rich foods, refer to HeathLink BC: Plant-based Diet Guidelines. Patients in BC can also phone a dietician at 8-1-1. Indications for specialist referral Failure of oral supplementation trialSuspected anemia of chronic diseaseSuspected GI bleedingAnemia with unknown causeResourcesPractitioner Resources RACE: Rapid Access to Consultative Expertise Program – raceconnect.ca A telephone consultation line for select specialty services for physicians, nurse practitioners and medical residents. If the relevant specialty area is available through your local RACE line, please contact them first. Contact your local RACE line for the list of available specialty areas. If your local RACE line does not cover the relevant specialty service or there is no local RACE line in your area, or to access Provincial Services, please contact the Vancouver Coastal Health Region/Providence Health Care RACE line. Vancouver Coastal Health Region/Providence Health Care: raceconnect.caAvailable Monday to Friday, 8 am to 5 pm 604-696-2131 (Vancouver area) or 1-877-696-2131 (toll free)Northern RACE: 1-877-605-7223 (toll free)Kootenay Boundary RACE: divisionsbc.ca/kb/race 1-844-365-7223 (toll free) For Fraser Valley RACE: raceapp.ca (download at Apple and Android stores) South Island RACE: raceapp.ca (download at Apple and Android stores) or see divisionsbc.ca/south-island/RACE Pathways – PathwaysBC.ca An online resource that allows GPs and nurse practitioners and their office staff to quickly access current and accurate referral information, including specialist wait times. Pathways also makes available hundreds of patient and physician resources that are categorized and searchable.Patient and Caregiver Resources Caring for Kids (Canadian Pediatric Society): Feeding Your Baby in the First Year: HealthLink BC Handouts (available in English, Chinese, Farsi, French, Korean, Punjabi and Vietnamese):“Iron and Your Health”: “Iron in Foods” – HealthLink BC: Translated patient handouts available from Refugee Health Vancouver: “Anemia” (Arabic, French, Somali, Spanish) “Iron-rich foods” (Farsi, Swahili)First Nations Traditional Foods Fact Sheets, including traditional foods high in iron: of Abbreviations ACDanemia of chronic diseaseADHD attention-deficit/hyperactivity disorderCBC complete blood countIDiron deficiencyIDAiron deficiency anemiaIMintramuscularIVintravenousReferences ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY Screening for Iron Deficiency Anemia, Including Iron Supplementations for Children and Pregnant Women: Recommendation Statement. Am Fam Physician. 2006 Aug 1;74(3):461. Nelson M, Bakaliou F, Trivedi A. Iron-deficiency anaemia and physical performance in adolescent girls from different ethnic backgrounds. Br J Nutr. 1994 Sep;72(3):427–33. Donovan UM, Gibson RS. Iron and zinc status of young women aged 14 to 19 years consuming vegetarian and omnivorous diets. J Am Coll Nutr. 1995 Oct;14(5):463–72. Cooper M, Greene-Finestone L, Lowell H, Levesque J, Robinson S. Iron sufficiency of Canadians. Health Rep. 2012 Dec;23(4):41–8. Pottie K, Greenaway C, Feightner J, Welch V, Swinkels H, Rashid M, et al. Evidence-based clinical guidelines for immigrants and refugees. Appendix 15: Iron-deficiency anemia: evidence review for newly arriving immigrants and refugees. Can Med Assoc J. 2011 Sep 6;183(12):E824–925. World Health Organization. The global prevalence of anaemia in 2011 [Internet]. World Health Organization; 2015 [cited 2018 Jul 19]. Available from: JD. Diagnosis and management of iron-deficiency anaemia. Best Pract Res Clin Haematol. 2005 Jun;18(2):319–32. Goddard AF, James MW, McIntyre AS, Scott BB, on behalf of the British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut. 2011 Oct 1;60(10):1309–16. Rockey DC, Cello JP. Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia. N Engl J Med. 1993 Dec 2;329(23):1691–5. Goddard AF, McIntyre AS, Scott BB. Guidelines for the management of iron deficiency anaemia. British Society of Gastroenterology. Gut. 2000 Jun;46 Suppl 3-4:IV1–5. Clark SF. Iron deficiency anemia. Nutr Clin Pract Off Publ Am Soc Parenter Enter Nutr. 2008 May;23(2):128–41. Patterson C, Guyatt GH, Singer J, Ali M, Turpie I. Iron deficiency anemia in the elderly: the diagnostic process. CMAJ Can Med Assoc J J Assoc Medicale Can. 1991 Feb 15;144(4):435–40. Guyatt GH, Patterson C, Ali M, Singer J, Levine M, Turpie I, et al. Diagnosis of iron-deficiency anemia in the elderly. Am J Med. 1990 Mar;88(3):205–9. Ioannou GN, Spector J, Scott K, Rockey DC. Prospective evaluation of a clinical guideline for the diagnosis and management of iron deficiency anemia. Am J Med. 2002 Sep;113(4):281–7. Mast AE, Blinder MA, Gronowski AM, Chumley C, Scott MG. Clinical utility of the soluble transferrin receptor and comparison with serum ferritin in several populations. Clin Chem. 1998 Jan;44(1):45–51. Goddard A, James M, McIntyre A. Guidelines for the management of iron deficiency anaemia. 2005. Pharmacist’s Letter. Comparison of oral iron supplements [Internet]. Therapeutic Research Center; 2008 [cited 2018 May 10]. Available from: of Medicine (US) Panel on Micronutrients. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc [Internet]. Washington (DC): National Academies Press (US); 2001 [cited 2018 May 10]. Available from: B, Gafter-Gvili A, Paul M, Leibovici L, Shpilberg O, Gafter U. Intravenous versus oral iron supplementation for the treatment of anemia in CKD: systematic review and meta-analysis. Am J Kidney Dis Off J Natl Kidney Found. 2008 Nov;52(5):897–906. Silverstein SB, Gilreath JA, Rodgers GM. Intravenous Iron Therapy: A Summary of Treatment Options and Review of Guidelines. J Pharm Pract. 2008 Dec;21(6):431–43. Bhargava S, Meurer LN, Jamieson B, Hunter-Smith D. Clinical inquiries. What is appropriate management of iron deficiency for young children? J Fam Pract. 2006 Jul;55(7):629–30. Hartfield D. Iron deficiency is a public health problem in Canadian infants and children. Paediatr Child Health. 2010 Jul;15(6):347–50. Society CP. Nutrition for healthy term infants, six to 24 months: An overview | Canadian Paediatric Society [Internet]. [cited 2018 Oct 5]. Available from: TH. Iron requirements in pregnancy and strategies to meet them. Am J Clin Nutr. 2000 Jul;72(1 Suppl):257S-264S. Reveiz L, Gyte GML, Cuervo LG. Treatments for iron-deficiency anaemia in pregnancy. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD003094. Milman N. Prepartum anaemia: prevention and treatment. Ann Hematol. 2008 Dec;87(12):949–59. Canada, Health Canada. Prenatal nutrition guidelines for health professionals: iron [Internet]. Ottawa: Health Canada; 2009 [cited 2018 Jul 9]. Available from: N, Bergholt T, Byg K-E, Eriksen L, Hvas A-M. Reference intervals for haematological variables during normal pregnancy and postpartum in 434 healthy Danish women. Eur J Haematol. 2007 Jul;79(1):39–46. Chiossi G, Palomba S, Costantine MM, Falbo AI, Harirah HM, Saade GR, et al. Reference intervals for hemoglobin and hematocrit in a low-risk pregnancy cohort: implications of racial differences. J Matern Fetal Neonatal Med. 2018 Mar 13;0(0):1–8. Lockitch G. Handbook of diagnostic biochemistry and hematology in normal pregnancy [Internet]. Boca Raton, Florida: CRC Press; 1993. 235 p. Available from: L. Epidemiology of anemia in the elderly: information on diagnostic evaluation. J Am Geriatr Soc. 2003 Mar;51(3 Suppl):S2-9. Mansvelt E. Iron Deficiency (ID) and Iron Deficiency Anaemia (IDA). :2. Gray J, Canadian Pharmacists Association. Therapeutic choices. Ottawa, Ont.: Canadian Pharmacists Association; 2008. Anemia Review Panel. Anemia Guidelines for Family Medicine. 2nd ed. Toronto: MUMS Guideline Clearinghouse; 2008. Rimon E, Kagansky N, Kagansky M, Mechnick L, Mashiah T, Namir M, et al. Are we giving too much iron? Low-dose iron therapy is effective in octogenarians. Am J Med. 2005 Oct;118(10):1142–7. Society CP. Vegetarian diets in children and adolescents | Canadian Paediatric Society [Internet]. [cited 2018 Jul 9]. Available from: Canada. Dietary Reference Intakes [Internet]. Government of Canada. 2005 [cited 2018 Aug 13]. Available from: draft guideline is based on scientific evidence current as of September 2018.The draft guideline was developed by the Guidelines and Protocols Advisory Committee.THE GUIDELINES AND PROTOCOLS ADVISORY COMMITTEEThe principles of the Guidelines and Protocols Advisory Committee are to:encourage appropriate responses to common medical situations recommend actions that are sufficient and efficient, neither excessive nor deficient permit exceptions when justified by clinical circumstances Contact Information:Guidelines and Protocols Advisory CommitteePO Box 9642 STN PROV GOVTVictoria, BC V8W 9P1Email: hlth.guidelines@gov.bc.ca Website: BCGuidelines.caDisclaimerThe Clinical Practice Guidelines (the guidelines) have been developed by the guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problem. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.Appendix A: Dietary Aspects of Iron Foods contain iron in two forms: “Heme” iron is present in red meat, fish and poultry, while the non-heme iron is present in fruits, vegetables, cereals and dairy products etc. “Heme” iron is absorbed very well (15-35% vs. 2-5% non-heme iron), and its absorption is independent of other factors present in food, while absorption of non-heme iron is markedly affected by other factors: Factors that inhibit iron absorption include decreased gastric acidity, Helicobacter pylori infection, tannins (tea), polyphenols (coffee, herbal teas and cocoa containing beverages – taken within one hour of the meal), phytates (legumes, grains, rice) and calcium and phosphate (antacids and calcium tablets). Factors that enhance absorption of non-heme iron are: meat, citrus juices, vitamin C (e.g. from broccoli, strawberries, tomato, spinach, citrus fruit), and EDTA fortification of foods. Recommended Dietary Allowance for IronMenAdult8 mgWomenAdult (age 50 on)8 mgAdult (ages 19 to 50)18 mgPregnant27 mgLactating9 mg to 10 mgAdolescents (ages 9 to 18)Girls8 mg to 15 mgBoys8 mg to 11 mgChildren (birth to age 8)Ages 4 to 810 mgAges 1 to 37 mgInfants (7 months to 1 year)11 mgInfants (birth to 6 months)0.27 mgTable cited from: Panel on Micronutrients, Food and Nutrition Board, Institute of Medicine–National Academy of Sciences (2001). Dietary reference intakes: Recommended intakes for individuals, vitamins. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc, pp. 772–773. Washington, DC: National Academy Press. Appendix B: Iron Preparations One preparation is not preferred over another; patient tolerance should be the guide. The usual adult dose is 180 mg of elemental iron/day in divided doses ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"hGJXfDtu","properties":{"formattedCitation":"\\super 32\\nosupersub{}","plainCitation":"32","noteIndex":0},"citationItems":[{"id":137,"uris":[""],"uri":[""],"itemData":{"id":137,"type":"article-journal","title":"Iron Deficiency (ID) and Iron Deficiency Anaemia (IDA)","page":"2","source":"Zotero","language":"en","author":[{"family":"Mansvelt","given":"EPG"}]}}],"schema":""} 32. Therapeutic doses can range from 100 to 200 mg of elemental iron/day, depending on severity of symptoms, ferritin levels, age of the patient, and gastrointestinal side effects.Iron saltFormulation (elemental iron)Usual Adult Daily DoseIncidence of Adverse ReactionsTherapeutic Considerations1Cost per 30 DaysOral FormulationsAdverse GI reactions may include: nausea, vomiting, dyspepsia, constipation, diarrhea, dark stools, bloatingferrous sulfate(Generics, Fer-in-Sol?, Ferodan?, Pediafer?)Tablets 300 mg (60 mg Fe)300 mg (60 mg Fe) PO TID+++Needs acid in the stomach to get absorbed. Take on an empty stomach — at least 1 hour before or 2 hours after eating, with orange juice or vitamin C. Absorption may be decreased if taking antacids or medications that reduce stomach acid. $2-5(Regular coverage for generics)Drops 75mg/mL (15mg Fe/mL)300 mg (60 mg Fe) PO TID++$74-144(Regular coverage for generics)Suspension 30mg/mL (6 mg Fe/mL)++$ 35-39(Regular coverage for generics)ferrous gluconate(Generics)Tablet 300 mg (35 mg Fe)600 mg (70 mg Fe) TID++$9-10(Regular coverage for generics)ferrous fumarate(Generics, Palafer?, Eurofer?)Tablet 300 mg (100 mg Fe)300 mg (100 mg Fe) PO BID++$10-11(Regular coverage for generics)Suspension 300 mg/5mL (20 mg Fe/mL)+$ 35(Regular coverage for generics)polysaccharide iron(Generics, Feramax?)Polysaccharide iron capsules 150mg (150 mg Fe)150 mg Fe PO DAILY+Taken with or without food. Does not need acid in the stomach to get absorbed. Good choice if taking medications that reduce stomach acid.Capsule can be opened and contents mixed into water or sprinkled over soft food. Virtually tasteless.$16-24(No coverage)Powder 60 mg/teaspoon (60 mg Fe)60 mg Fe PO TID+$161(No coverage)heme iron polypeptide(Generics, Proferrin?)11 mg heme Fe11 mg Fe PO DAILY to TID+Very easily absorbed. Taken with or without food. Does not need acid in the stomach to get absorbed. Good choice if taking medicines that reduce stomach acid.Do not take if allergic to cow products.$51-100(No coverage)i Treatment with oral iron may take as long as six to eight weeks in order to fully ameliorate the anemia, and as long as six months to replenish iron stores.ii Prices are estimates as of August 2018 based on the maximum adult dose; prices of all oral formulations include an estimated retail markup. Parenteral formulations are expected to be administered in an institution setting (e.g. hospitals) where PharmaCare coverage is irrelevant. All prices are subject to change.iii Iron absorption may be decreased by antacids or supplements containing aluminum, magnesium, calcium, zinc, proton pump inhibitors, and histamine2 receptor antagonists.Iron ProductFormulation (elemental iron)Usual Adult Daily DoseAdverse ReactionsIncidence of Adverse ReactionsTherapeutic Considerations1Cost per 30 DaysParenteral Formulationsiron sucrose(Venofer?)Injection (IV): 20 mg/mL Fe100 to 300 mg IV intermittent per session, given as a total cumulative dose of 1000 mg over 14 days CNS: headache, fever CVS: hypotension GI: metallic taste, nausea, vomiting MSK: muscular pain, cramps+Hypotension may occur from rapid IV administration; doses greater than 300 mg associated with significant hypotension.$405/1000mgiron dextran complex(Dexiron?)Injection (IV or IM): 50 mg/mL FeBased on body weight and hemoglobin; IV intermittent (maximum 1000 mg/day); or IM up to 100 mg Fe per site (maximum 250 mg/day)CNS: feverMSK: arthralgia, myalgia+++A test dose of 25mg elemental iron (0.5 mL) must be given before administering the first therapeutic dose.2Total dose depends on patient’s weight and hemoglobin level.2$297/1000 mgferric gluconate complex(Ferrlecit?)Injection (IV): 12.5 mg/mL Fe125 mg IV per dose; up to 1000 mg over 8 sessionsCNS: generalized seizuresCVS: hypotension, hypertension, vasodilationGI: diarrhea, nausea+++Indicated for treatment of iron-deficiency anemia in patients 6 years and older with chronic kidney disease undergoing hemodialysis in conjunction with supplemental erythropoietin therapy.$285/1000 mgAbbreviations: BID twice daily; CNS central nervous system; CVS cardiovascular system; Fe elemental iron; GI gastrointestinal; IV intravenous; IM intramuscular; max maximum; mg milligrams; mL milliliters; MSK muscular skeletal; PO orally; Tabs tablets; TID three times daily.ReferencesOntario Transfusion Coordinators Program. Choosing an Iron Pill. Hamilton Heath Sciences. Jan 2016Vancouver Coastal Health Pharmaceutical Sciences Clinical Services Unit. Iron Dextran and Iron Sucrose. Vancouver Coastal Health Parenteral Drug Manual. Vancouver British Columbia. Vancouver Coastal Health – 2008. Iron Dextran dose: total dose (mg) required to restore hemoglobin (Hgb in g/L) to normal: 50 x (0.00442 [desired Hgb – observed Hgb] x LBW + [0.26 x LBW])LBW in kg (male) = 50 kg + (2.3 x inches over 5 feet)LBW in kg (female) = 45.5 kg + (2.3 x inches over 5 feet)Appendix C: Algorithm for investigation of iron deficiency in adultsPlease note that Appendix C is undergoing review for applicability to pediatric patients and may be updated.Reference:Government of Canada SC. Canadian Health Measures Survey: Cycle 2 Data Tables: Table 51 — Distribution of ferritin measured in serum for the household population, by age and sex, Canada, 2009 to 2011 [Internet]. Available from: D: Algorithm for investigation of iron deficiency anemia in adultsPlease note that Appendix D is undergoing review for applicability to pediatric patients and may be updated.Reference:Government of Canada SC. Canadian Health Measures Survey: Cycle 2 Data Tables: Table 51 — Distribution of ferritin measured in serum for the household population, by age and sex, Canada, 2009 to 2011 [Internet]. Available from: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download