QuestionSBA
QuestionChoice
Given the patient's age he needs exclusion of malignancy before looking at a dietary cause for his iron-deficiency anaemia.
62195
c
Iron tablets
QuestionChoice
Whilst tiredness can be multi-factorial and social stressors or care needs may be a factor, the most important first step is ruling out malignancy
62197
e
Discussion of social circumstances and mood
QuestionChoice
Whilst a blood film can be helpful in determining the type of anaemia (eg hypochromic or microcytic), with the above results including the haematinics it is likely an iron deficiency anaemia. If there was a suspicion of a haematological malignancy or the blood results were suggestive of bone marrow failure, then a blood film would be helpful.
62196
d
Blood film
QuestionChoice
NICE guidance advises referral on the 2 week wait suspected cancer pathway for patients over the age of 60 with iron deficiency anaemia.
62193
a
Urgent 2 week wait referral for lower gastrointestinal tract cancers
QuestionChoice
Whilst the patient is pre-diabetic and may benefit from some lifestyle modifications, given his age and iron deficiency anaemia the most important step is 2 week wait referral for suspected lower gastrointestinal cancer.
62194
b
Diet and lifestyle modifcation
Concept
Chapter
# Summary

Iron deficiency anaemia (IDA) is a common haematological disorder characterized by a shortage of iron in the body, leading to diminished red blood cell production and subsequent oxygen transport. Typical symptoms include fatigue, paleness, shortness of breath, and cognitive impairment. In older adults, it is imperative to consider the possibility of colorectal malignancy, as IDA may result from gastrointestinal bleeding. Thorough investigations, including endoscopic procedures, are often necessary. Management involves iron supplementation, dietary adjustments, and addressing underlying causes. 

# Definition

Iron deficiency anaemia is a haematological disorder stemming from an insufficient supply of iron, which is vital for the synthesis of haemoglobin—a crucial component of red blood cells. Without adequate iron, the body struggles to produce a sufficient quantity of healthy red blood cells, leading to a reduction in oxygen-carrying capacity and subsequent symptoms of anaemia.

# Epidemiology

Iron deficiency anaemia is a global health concern, affecting individuals of all age groups. The prevalence is particularly high among young children, women of childbearing age, and elderly individuals. Geographical variations in prevalence exist, with a higher burden in regions with limited access to diverse diets and iron-rich foods.


# Aetiology 

The causes of iron deficiency anaemia are multifactorial and can be attributed to several factors:

- **Dietary Insufficiency:** Inadequate iron intake, especially in individuals with restrictive diets or limited access to iron-rich foods.
- **Chronic Blood Loss:** Gastrointestinal bleeding, heavy menstrual periods, and other sources of chronic blood loss (e.g. angiodysplasia) can deplete iron stores.
- **Malabsorption Disorders:** Conditions like coeliac disease, inflammatory bowel disease and atrophic gastritis can hinder iron absorption in the gut. Hookworms are a more prominent cause in tropical setting.
- **Increased Demand:** During pregnancy and rapid growth phases, the body's iron requirements can surpass the available supply. This can also occur if there is chronic haemolysis

# Signs and Symptoms

The symptoms of iron deficiency anaemia include: 

- Tiredness
- Lethargy
- Weakness
- Palpitations: An increased heart rate may be noticeable, especially when at rest.
- Cognitive Impairment: Some patients may exhibit difficulty concentrating or memory issues.
- Cold Intolerance
- Headaches and dizziness
- Brittle Nails: Changes in the nails, such as brittleness and spoon-shaped deformities **(koilonychia)**, can be observed.
- Angular stomatitis
- Atrophic glossitis
- Pica: Iron-deficiency anaemia may manifest as pica, with cravings for non-food substances like ice (pagophagia) or clay (geophagia). This is more common in children.


# Differential Diagnosis

Distinguishing IDA from other forms of anaemia (such as anaemia of chronic disease) and underlying conditions is crucial. 

- **Colorectal Malignancy:** In older adults, it is imperative to rule out colorectal malignancies, especially when IDA is detected. Gastrointestinal bleeding, often occult, can be a sign of an underlying tumour.
- **Thalassaemias:** Thalasasemias, a group of genetic disorders affecting haemoglobin production, may present with microcytic anaemia. Hemoglobin electrophoresis can help differentiate thalassaemias from IDA.
- **Chronic Inflammatory Conditions:** Chronic diseases like rheumatoid arthritis or inflammatory bowel disease can lead to anaemia of chronic disease, which must be considered in the evaluation.

# Investigations

Together with classical symptoms, full blood count (FBC) and blood film will show the presence of: 

- **Hypochromic, microcytic red cells** 
- Additional **pencil cells** 
- Occasional **target cells**

Reticulocyte counts will be low for the degree of anaemia; red cell count will also be low.

**Further tests** may be performed to confirm the diagnosis of iron deficiency anaemia including:

- **Total iron binding capacity** (TIBC) – Will typically be high as the body mobilises available iron stores owing to the iron deficiency

- **Ferritin** – will be low as available iron stores in the body are mobilised to counteract the iron deficiency

  - Note: Ferritin should be measured alongside B<sub>12</sub> and folate to assess possible coexisting haematinic deficiency

  - A low ferritin is diagnostic of iron deficiency; however, a normal or high ferritin does not exclude iron deficiency

    - Ferritin is an acute phase protein so levels can be masked/influenced by other conditions, particularly inflammation 
      – It is good to check a C-reactive protein (CRP) at the same time

Iron deficiency anaemia in patients >60y should prompt suspicion **colonic malignancy until proven otherwise** and prompt FIT testing and subsequent 2 week wait referral if indicated according to NICE guidelines. 

# Management

* **Iron Supplementation:** Oral or intravenous iron supplements are administered to correct iron deficiency. Intravenous iron is preferred in cases of severe deficiency or malabsorption.  Important considerations of oral iron supplementation (usually a 3 month course) include:
	* Side effects - diarrhoea, constipation, black stools, abdominal pain, nausea
	* If it is not tolerated due to SEs, reduce the dose to one tablet on alternate days, or consider alternative oral preparations.
	* Iron supplements should be taken on an empty stomach (preferably one hour before a meal) with a drink containing vitamin C, such as a glass of orange juice or another juice drink with added vitamin C. This aids absorption.
	* Oral iron decreases the absorption of oral Levothyroxine. Therefore if both are prescribed, advise patients to take at least 4 hours apart.
	* Monitoring - recheck FBC within 4 weeks of starting treatment (haemoglobin concentration should rise by about 20 g/L over 3–4 weeks). Then check the FBC again at 2–4 months to ensure that the haemoglobin level has returned to normal. Once Hb is normal can continue supplementation for 3 further months, and then monitor at 3/6/12-monthly intervals.
* **Dietary Modifications:** Encouraging a diet rich in iron sources, such as red meat, leafy greens, and fortified cereals, can help maintain iron levels.
* **Treatment of Contributing Conditions:** If the cause of IDA is chronic blood loss or malabsorption, addressing the underlying condition is essential.
* **Endoscopic Procedures:** In cases where gastrointestinal bleeding is suspected, endoscopy and colonoscopy may be necessary to locate and treat the bleeding source.


# NICE Guidelines

[NICE CKS - Iron-deficiency anaemia](https://cks.nice.org.uk/topics/anaemia-iron-deficiency/)
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A blood film showing iron deficiency anaemia.
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Iron deficiency anaemia
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Haematology
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Iron deficiency anaemia
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Myelofibrosis
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Quesmed Tutorial: General Practice
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A 70 year old man presented to his GP with several months of increasing tiredness. His examination was unremarkable. The GP carried out some blood tests which are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|87 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|10x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|140x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|78 fL|80 - 96|
|Serum Vitamin B12|532 ng/L|160 - 925|
|Serum Folate|3.0 μg/L|3 - 15|
|HbA1c (Glycated Haemoglobin)|47 mmol/mol or %|20 - 42 or 4-6%|


Which of the following is the best next step in the management of this patient?
a