Iron, anaemia, and inflammatory bowel diseases

Nutritional management of adults with inflammatory bowel disease: practical lessons from the available evidence

Inflammatory bowel disease (IBD) is associated with impairment of nutritional status both anthropometrically and biochemically, which results from both qualitative and quantitative changes in dietary intake alongside disease activity. Dietary intervention to replace deficiency is essential and may also be used to treat active disease and to reduce symptoms. The evidence for dietary interventions in this area is reviewed and the following recommendations made: ■Assessment of nutritional status is an essential part of the investigation of all patients with IBD and deficiency should be actively sought.■Any patient with macro- or micronutrient deficiency should be referred for dietetic assessment.■Micronutrient deficiency (most frequently iron, vitamin B12, folate and magnesium) should be replaced aggressively, parenterally if necessary.■Significant improvement in gastrointestinal symptoms can be achieved by low-residue diets (for stricturing disease) and (always under dietetic supervision) management of lactose and other intolerances.■Irritable bowel syndrome symptoms in patients with IBD can respond to low fermentable oligo-, di-, monosaccharide and polyol (FODMAP) diets, again this must be done under dietetic supervision.■Active Crohn's disease can be treated by exclusive enteral nutrition (elemental/polymeric/altered fat formulations all have equivalent efficacy).■Enteral nutrition can maintain remission in Crohn's disease and in this context can be given alongside normal oral intake.■Nutritional support does not have an established role in the treatment of active ulcerative colitis, other than in the management of malnutrition.■Total parenteral nutrition should not be used unless intestinal failure occurs.■There is insufficient evidence to support the routine use of Ω3 fish oil, prebiotics and glutamine in the treatment of active IBD.

Effect of adalimumab on clinical laboratory parameters in patients with Crohn's disease: results from the CHARM trial

BACKGROUND

Nutritional deficiencies and anemia are common in Crohn's disease (CD).

METHODS

We evaluated the effect of adalimumab on changes in laboratory values using data from CHARM, in which patients were randomized to adalimumab 40 mg every other week (eow), adalimumab 40 mg weekly, or placebo for 56 weeks. Mean changes in laboratory values from baseline to Weeks 26 and 56 were compared between adalimumab and placebo using analysis of covariance models. Percentages of patients with suboptimal laboratory values at Weeks 26 and 56 were compared between treatment groups using Cochran-Mantel-Haenszel (CMH) tests. Pearson correlation coefficients for associations between changes in Crohn's Disease Activity Index (CDAI) score and changes in laboratory values were estimated at Weeks 4, 26, and 56.

RESULTS

The intention-to-treat analysis included 778 patients randomized to adalimumab eow (N = 260), adalimumab weekly (N = 257), or placebo (N = 261). Baseline abnormalities in laboratory values were common across treatment groups. CMH tests revealed significantly lesser rates of suboptimal laboratory values with adalimumab vs. placebo at Week 26, including hypoalbuminemia, calcium deficiency, low hemoglobin, low hematocrit, low red blood cell count, elevated platelet count, and elevated C-reactive protein concentration (all P < 0.05). These improvements persisted at Week 56. Improvements in CDAI from baseline to Weeks 4, 26, and 56 were significantly correlated with changes from baseline for albumin, hemoglobin, and C-reactive protein (all P < 0.001).

CONCLUSIONS

Adalimumab therapy for moderately to severely active CD was associated with significant improvements in nutritional, hematologic, and inflammatory markers.

Neutrophil gelatinase-associated lipocalin (NGAL) in inflammatory bowel disease: association with pathophysiology of inflammation, established markers, and disease activity

BACKGROUND

Neutrophil gelatinase-associated lipocalin (NGAL) is a multi-potent 25-kDa protein mainly secreted by neutrophils. In inflammatory bowel disease (IBD), overexpression of NGAL in colon epithelium has been previously shown. This is the first study analyzing serum and urinary NGAL levels in IBD patients, with regard to specific characteristics of patients and disease.

METHODS

Serum and urinary NGAL levels were determined in 181 patients with IBD, 93 with ulcerative colitis (UC), and 88 with Crohn's disease (CD), 82 healthy controls (HC), and 41 patients with irritable bowel syndrome (IBS).

RESULTS

Serum NGAL levels were elevated in IBD patients (88.19 ± 40.75 ng/mL) compared with either HC (60.06 ± 24.18 ng/mL) or IBS patients (60.80 ± 20.30 ng/mL), P < 0.0001. No significant difference was shown between UC (86.62 ± 35.40 ng/mL) and CD (89.92 ± 46.05 ng/mL). Significantly higher levels of serum NGAL were observed in patients with active (120.1 ± 38.46) versus inactive IBD (61.58 ± 15.98), P < 0.0001. Serum NGAL displayed a strong ability to distinguish active IBD from inactive disease, healthy controls, or IBS patients with a sensitivity of 100, 95, and 95% and a specificity of 68, 83, and 79%, respectively, performing better than erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the assessment of disease activity in both UC and CD. Urinary NGAL levels showed neither significant difference among patients and controls nor correlation with disease activity.

CONCLUSIONS

Serum NGAL is elevated particularly in active IBD and correlates with established markers of inflammation and disease activity, implicating its role in the pathophysiology of IBD.

Effect of iron therapy on platelet counts in patients with inflammatory bowel disease-associated anemia

Background and Aims

Secondary thrombocytosis is a clinical feature of unknown significance. In inflammatory bowel disease (IBD), thrombocytosis is considered a marker of active disease; however, iron deficiency itself may trigger platelet generation. In this study we tested the effect of iron therapy on platelet counts in patients with IBD-associated anemia.

Methods

Platelet counts were analyzed before and after iron therapy from four prospective clinical trials. Further, changes in hemoglobin, transferrin saturation, ferritin, C-reactive protein, and leukocyte counts, before and after iron therapy were compared. In a subgroup the effect of erythropoietin treatment was tested. The results were confirmed in a large independent cohort (FERGIcor).

Results

A total of 308 patient records were available for the initial analysis. A dose-depended drop in platelet counts (mean 425 G/L to 320 G/L; p<0.001) was found regardless of the type of iron preparation (iron sulphate, iron sucrose, or ferric carboxymaltose). Concomitant erythropoietin therapy as well as parameters of inflammation (leukocyte counts, C-reactive protein) had no effect on the change in platelet counts. This effect of iron therapy on platelets was confirmed in the FERGIcor study cohort (n=448, mean platelet counts before iron therapy: 383 G/L, after: 310 G/L, p<0.001).

Conclusion

Iron therapy normalizes elevated platelet counts in patients with IBD-associated anemia. Thus, iron deficiency is an important pathogenetic mechanism of secondary thrombocytosis in IBD.

Iron replacement therapy in inflammatory bowel disease patients with iron deficiency anemia: a systematic review and meta-analysis

BACKGROUND AND AIMS

Iron deficiency anemia (IDA) is a common problem in patients with Inflammatory Bowel Disease (IBD) and has a significant negative impact on quality of life. The aim was to compare the clinical efficacy of intravenous (IV) versus oral (PO) iron replacement in adult IBD with iron deficiency anemia (IDA).

METHODS

A systematic search for randomized controlled trials comparing the efficacy of IV versus PO iron therapy in the treatment of IDA in adult IBD patients. The primary outcome was the mean change in the hemoglobin at the end of study and secondary outcomes include mean change in ferritin, clinical disease activity index, quality of life score and the adverse reaction rate.

RESULTS

The search strategy identified 757 articles while only three industry-funded articles met the inclusion criteria for systematic review and meta-analysis. The total sample size was 333 patients with 203 patients receiving IV therapy. IV route was associated with a 6.8 g/L higher mean hemoglobin increment and 110 μg/L higher mean ferritin increment. The IBD activity index and Quality of Life scores were comparable between the two treatment groups. More adverse events were reported in the oral treatment group with the odds for discontinuation being 6.2 (CI 2.2, 17.1).

CONCLUSIONS

Intravenous iron treatment is better tolerated and more effective than oral iron treatment in improving ferritin. The higher hemoglobin gain with the IV route was small and of uncertain clinical significance. The combined sample size of the included studies was small and further clinical trials are required.

Recombinant human erythropoietin in patients with inflammatory bowel disease and refractory anemia: a 15-year single center experience

AIM OF THE STUDY

To describe our 15-year experience on the patients' response and safety to the use of EPO in IBD patients with refractory anemia.

PATIENTS-METHODS

Single center retrospective chart analysis of all IBD patients receiving EPO for the period 1994-2009. Patients with resistant anemia not responding to I.V. iron therapy were enrolled. Concommitant medication, medical and laboratory data on short and long-term patients' responses and safety were recorded.

RESULTS

In total 820 IBD files were reviewed and among 78 patients treated with I.V. iron we identified 26 patients who received EPO in concordance to our inclusion criteria. Azathioprine or methotrexate was administered in 17 patients and 7 patients received concomitant Infliximab. After EPO, 22/26 patients (84.6%) responded and peripheral blood parameters were significantly improved and blood transfusions were significantly decreased (p<0.001). Erythropoietin dose was increased in three non-responders while two patients required emergency transfusions. No adverse events were recorded.

CONCLUSIONS

In anemic IBD patients who are refractory to I.V. iron monotherapy, administration of EPO significantly improved peripheral blood parameters with safety. Prospective controlled trials are needed to confirm positive patients' response to EPO and identify those patients who are more likely to benefit.

Iron requirements based upon iron absorption tests are poorly predicted by haematological indices in patients with inactive inflammatory bowel disease

Fe deficiency and Fe-deficiency anaemia are common in patients with inflammatory bowel disease (IBD). Traditional clinical markers of Fe status can be skewed in the presence of inflammation, meaning that a patient's Fe status can be misinterpreted. Additionally, Fe absorption is known to be down-regulated in patients with active IBD. However, whether this is the case for quiescent or mildly active disease has not been formally assessed. The present study aimed to investigate the relationship between Fe absorption, Fe requirements and standard haematological indices in IBD patients without active disease. A group of twenty-nine patients with quiescent or mildly active IBD and twenty-eight control subjects undertook an Fe absorption test that measured sequential rises in serum Fe over 4 h following ingestion of 200 mg ferrous sulphate. At baseline, serum Fe, transferrin saturation, non-transferrin-bound Fe (NTBI), ferritin and soluble transferrin receptor were all measured. Thereafter (30-240 min), only serum Fe and NTBI were measured. Fe absorption did not differ between the two groups (P = 0·9; repeated-measures ANOVA). In control subjects, baseline haematological parameters predicted Fe absorption (i.e. Fe requirements), but this was not the case for patients with IBD. Fe absorption is normal in quiescent or mildly active IBD patients but standard haematological parameters do not accurately predict Fe requirements.

Validation of the functional assessment of chronic illness therapy-fatigue (FACIT-F) in patients with inflammatory bowel disease

BACKGROUND  Many patients with ulcerative colitis (UC) and Crohn's disease (CD) complain of significant fatigue. To date, no instrument to measure fatigue has been validated in a US inflammatory bowel disease (IBD) population. AIM  To determine the reliability and validity of the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) scale in IBD. METHODS  A total of 209 patients with IBD completed the 13 items of the FACIT-F, alongside laboratory testing and disease activity assessment. Internal consistency was measured by Cronbach's alpha; test-retest reliability by the intraclass correlation coefficient (ICC); validity by the correlation of the FACIT-F score with C-reactive protein (CRP) erythrocyte sedimentation rate (ESR), haematocrit (HCT) and disease activity as measured by the Harvey-Bradshaw Index (HBI; CD) and Simple Clinical Colitis Activity Index (SCCAI; UC). RESULTS  The mean ± SD FACIT-F score was 38.9 ± 11.0 overall (CD 38.6 ± 11.3; UC 39.4 ± 10.6). Cronbach's alpha was 0.94. The ICC for first and repeat FACIT-F scores assessed within 180 days without change in disease state was 0.81 (CD 0.78; UC 0.87). FACIT-F scores were lower in patients with active symptoms (CD 4.6 points, 95% CI 2.4-6.9, P < 0.001; UC 8.5 points, 95% CI 5.5-11.4, P < 0.001). In UC, FACIT-F scores were correlated with ESR (-0.76, 95% CI -0.89 to -0.50), CRP (-0.72, 95% CI -0.88 to -0.43) and HCT (0.53, 95% CI 0.22-0.74). CONCLUSION  The FACIT-F scale is a reliable and valid instrument for measuring fatigue in IBD.

Diagnostic yield of upper gastrointestinal endoscopy in the evaluation of iron deficiency anemia in older children and adolescents

Iron deficiency anemia (IDA) is frequent in childhood. Inadequate nutrition and gastrointestinal malabsorption are the frequent causes of IDA in children. But reduced iron absorption and insidious blood loss from the gastrointestinal tract has been identified as the most frequent causes of IDA in older children and adolescents. Therefore the authors evaluated the frequency and etiologies of the upper gastrointestinal system pathologies causing IDA in older pediatric population. Patients with known hematological or chronic diseases, heavy menstrual flow, and obvious blood loss were excluded from the study. Forty-four children between the ages of 9.5 and 17.5 years and diagnosed with IDA were enrolled. They underwent upper gastrointestinal endoscopy and biopsy from esophagus, stomach, and duodenum. Mean age and hemoglobin (Hb) levels of study group (32 boys, and 12 girls) were 14.6 ± 2.0 years and 7.9 ± 1.8 g/dL, respectively. Only 1 patient had a positive serology testing with anti-tissue transglutaminase and small bowel biopsy correlating with celiac disease. Endoscopy revealed abnormal findings in 25 (56.8%) patients (21 endoscopic antral gastritis, 2 active duodenal ulcers, and 2 duodenal polyps). Helicobacter pylori (HP) infection was identified by using antral histopathological evaluation in 19 of 44 children (43.2%). In 2 of duodenal samples, one patient had celiac disease, and the other one was diagnosed as giardiasis. In conclusion, there are different etiologies resulting in IDA in older children and adolescents. When older children and adolescents are found to have iron deficiency, HP infection and other gastrointestinal pathologies should be ruled out before iron deficiency treatment.

Diagnosing anemia in inflammatory bowel disease: beyond the established markers

The main types of anemia in inflammatory bowel disease (IBD) are iron deficiency anemia (IDA) and anemia of inflammatory etiology, or anemia of chronic disease (ACD). In the management of IBD patients with anemia it is essential for the physician to diagnose the type of anemia in order to decide in an evidence-based manner for the appropriate treatment. However, the assessment of iron status in IBD in many cases is rather difficult due to coexistent inflammation. For this assessment several indices and markers have been suggested. Ferritin, seems to play a central role in the definition and diagnosis of anemia in IBD and transferrin, transferrin saturation (Tsat), and soluble transferrin receptors are also valuable markers. All these biochemical markers have several limitations because they are not consistently reliable indices, since they are influenced by factors other than changes in iron balance. In this review, in addition to them, we discuss the newer alternative markers for iron status that may be useful when serum ferritin and Tsat are not sufficient. The iron metabolism regulators, hepcidin and prohepcidin, are still under investigation in IBD. Erythrocytes parameters like the red cell distribution width (RDW) and the percentage of hypochromic red cells as well as reticulocyte parameters such as hemoglobin concentration of reticulocytes, red blood cell size factor and reticulocyte distribution width could be useful markers for the evaluation of anemia in IBD.

Evaluation of status of zinc, copper, and iron levels in biological samples of normal children and children with night blindness with age groups of 3-7 and 8-12 years

The causes of night blindness in children are multifactorial, and particular consideration has been given to childhood nutritional deficiency, which is the most common problem found in underdeveloped countries. Such deficiency can result in physiological and pathological processes that in turn influence hair composition. This study was designed to compare the levels of zinc (Zn), copper (Cu), and iron (Fe) in scalp hair, blood, and urine of both genders of children with night blindness with age range of 3-7 and 8-12 years, comparing them to sex- and age-matched controls. A microwave-assisted wet acid digestion procedure was developed as a sample pretreatment, for the determination of zinc, copper, and iron in biological samples of children with night blindness. The proposed method was validated by using conventional wet digestion and certified reference samples of hair, blood, and urine. The digests of all biological samples were analyzed for Cu, Fe, and Zn by flame atomic absorption spectrometry using an air/acetylene flame. The results indicated significantly lower levels of Fe, Cu, and Zn in the biological samples (blood and scalp hair) of male and female children with night blindness, compared with control subjects of both genders. These data present guidance to clinicians and other professionals investigating the deficiency of essential trace metals in biological samples (scalp hair and blood) of children with night blindness.

A population-based study of fatigue and sleep difficulties in inflammatory bowel disease

BACKGROUND

There has been little investigation of fatigue, a common symptom in inflammatory bowel disease (IBD). The aim of this study was to evaluate fatigue more comprehensively, considering relationships with psychological and biological factors simultaneously in a population-based IBD community sample.

METHODS

Manitoba IBD Cohort Study participants (n = 318; 51% Crohn's disease [CD]) were assessed by survey, interview, and blood sample. Fatigue, sleep quality, daytime drowsiness, stress, psychological distress, and quality of life were measured with validated scales. Hemoglobin (Hg) and C-reactive protein (CRP) levels were also obtained. Differences were tested across disease activity and disease subtype.

RESULTS

Elevated CRP was found for 23% of the sample and 12% were anemic; 46% had active disease. Overall, 72% of those with active and 30% with inactive disease reached clinical thresholds for fatigue (Multidimensional Fatigue Inventory; P < 0.001); 77% and 49% of those with active or inactive disease, respectively, experienced poor sleep (P < 0.001). There were few differences between those with CD and ulcerative colitis (UC) on the factors assessed, except for higher CRP levels in CD (mean 8.8 versus 5.3, P < 0.02). Multiple logistic regression analyses found that elevated fatigue was associated with active disease (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.2-7.8), poor sleep quality (OR 4.0, 95% CI 1.9-8.6), and perceived stress (OR 4.2, 95% CI 2.2-8.1), but not with hours of sleep, Hg, or CRP.

CONCLUSIONS

Fatigue and poor sleep are not only highly prevalent in active disease, but both are still significant concerns for many with inactive disease. Psychological factors are associated with fatigue in IBD in addition to disease and sleep considerations.

FERGIcor, a randomized controlled trial on ferric carboxymaltose for iron deficiency anemia in inflammatory bowel disease

BACKGROUND & AIMS

Iron deficiency anemia (IDA) is common in chronic diseases and intravenous iron is an effective and recommended treatment. However, dose calculations and inconvenient administration may affect compliance and efficacy. We compared the efficacy and safety of a novel fixed-dose ferric carboxymaltose regimen (FCM) with individually calculated iron sucrose (IS) doses in patients with inflammatory bowel disease (IBD) and IDA.

METHODS

This randomized, controlled, open-label, multicenter study included 485 patients with IDA (ferritin <100 μg/L, hemoglobin [Hb] 7-12 g/dL [female] or 7-13 g/dL [male]) and mild-to-moderate or quiescent IBD at 88 hospitals and clinics in 14 countries. Patients received either FCM in a maximum of 3 infusions of 1000 or 500 mg iron, or Ganzoni-calculated IS dosages in up to 11 infusions of 200 mg iron. Primary end point was Hb response (Hb increase ≥ 2 g/dL); secondary end points included anemia resolution and iron status normalization by week 12.

RESULTS

The results of 240 FCM-treated and 235 IS-treated patients were analyzed. More patients with FCM than IS achieved Hb response (150 [65.8%] vs 118 [53.6%]; 12.2% difference, P = .004) or Hb normalization (166 [72.8%] vs 136 [61.8%]; 11.0% difference, P = .015). Both treatments improved quality of life scores by week 12. Study drugs were well tolerated and drug-related adverse events were in line with drug-specific clinical experience. Deviations from scheduled total iron dosages were more frequent in the IS group.

CONCLUSIONS

The simpler FCM-based dosing regimen showed better efficacy and compliance, as well as a good safety profile, compared with the Ganzoni-calculated IS dose regimen.

Measurement of reticulocyte and red blood cell indices in the evaluation of anemia in inflammatory bowel disease

BACKGROUND

The commonest types of anemia in inflammatory bowel disease (IBD) are iron deficiency (IDA) and anemia of chronic disease. The differentiation between these two conditions is important for the management of the patient. The aim of this study was to investigate the usefulness of reticulocyte and red blood cell indices in the evaluation of anemia in IBD.

METHODS

One hundred IBD patients [49 ulcerative colitis (UC), 51 Crohn's disease (CD)] and 102 healthy controls were enrolled. Measurement of reticulocyte and red blood cell indices was performed using the Coulter LH780 Hematology Analyzer (Beckman Coulter). Additionally, serum levels of ferritin, transferrin saturation (Tsat) and soluble transferrin receptor (sTfR) were analyzed in all patients and controls.

RESULTS

The prevalence of anemia was 41.2% for UC and 42.9% for CD, whereas 30 IBD patients (30%) had IDA. Red cell Distribution Width (RDW), Red blood cell Size Factor (RSF), and Reticulocyte Distribution Width-Coefficient of Variation (RDWR-CV) were found significantly correlated with both Tsat and sTfR but not with ferritin levels. Patients with IDA had significantly higher RDW and RDWR-CV and significantly lower RSF levels compared with those without IDA. High values of RDW (sensitivity 93%, specificity 81%) and low values of RSF (sensitivity 83%, specificity 82%) were the best markers for the diagnosis of IDA. Both RDWR-CV and RDWR-SD were significantly correlated with disease activity and CRP levels.

CONCLUSION

RDW, RSF and RDWR, could be useful markers for the evaluation of anemia and disease activity in IBD.

Chronic fatigue is more prevalent in patients with inflammatory bowel disease than in healthy controls

BACKGROUND

Fatigue is a common symptom in chronic disease. Few studies, however, have focused on fatigue related to inflammatory bowel disease (IBD). The aim was to determine the prevalence of fatigue in IBD and to identify demographic and clinical factors that influence fatigue.

METHODS

Patients in remission and with mild and moderate IBD completed the Fatigue Questionnaire (FQ). Higher FQ scores indicate greater levels of fatigue. In addition, demographic and clinical variables were obtained. Corresponding FQ data from healthy controls (HC) are based on 2287 Norwegian citizens.

RESULTS

In total, 140 patients were included, mean age 43.9 years (SD 16.4), male/female = 61/79, ulcerative colitis (UC) / Crohn's disease (CD) = 92/48. Total fatigue (TF) was 14.4, 14.7, and 12.2 for UC, CD, and HC, respectively. Chronic fatigue (CF), defined as substantial fatigue with duration more than 6 months, was reported in 29% (14/48) of CD and 22% (20/92) of UC compared to 11% (260/2287) of HC (P < 0.001 for both diagnoses). Linear regression analysis confirmed hemoglobin values, present gastrointestinal symptoms, and altered sleep to be the most important predictors of CF.

CONCLUSIONS

Chronic fatigue is more common in patients with UC and CD compared with healthy controls. IBD symptoms, hemoglobin values, and altered sleep patterns are significant predictors of CF.

Beyond efficacy and safety-the need for convenient and cost-effective iron therapy in health care

The National Service Framework advocates correction of anaemia in patients with chronic kidney disease (CKD). Oral iron is insufficient, while intravenous (IV) supplementation replenishes and maintains iron stores. Previously, effective delivery of iron therapy using available parenteral preparations has been hampered by dosing schedules and the need in some cases of a test dose. The introduction in Europe of newer iron preparations, including iron isomaltoside 1000 (Monofer) and iron carboxymaltose (Ferinject), now offers a potentially safe, effective and time-efficient method of outpatient iron repletion. This may potentially lead to better cost-effectiveness in a resource-limited service.

Serum prohepcidin levels in children with solid tumors, inflammatory bowel disease and iron deficiency anemia

BACKGROUND

Prohepcidin is one of the regulators of iron metabolism. Few studies examined its relation with solid tumors (ST), inflammatory bowel disease (IBD) and iron deficiency anemia (IDA) in children.

METHODS

We measured serum prohepcidin (SP), soluble transferrin receptor (sTfR), serum ferritin (SF), serum iron (SI), transferrin saturation (TS), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels in ST (n = 16), IBD (n = 15), IDA (n = 14) and controls (n = 18).

RESULTS

The mean SP was significantly higher in ST and IBD than in IDA and controls. SP was significantly correlated with SF in ST, IBD and ESR for IBD and CRP for ST and hemoglobin for ST.

CONCLUSION

Elevated SP may be a clinically important predictor of inflammation and leads to anemia by impairing iron utilization in IBD and ST. SP decreases in IDA and is correlated with TS but not with SF or sTfR.

Dietary and nutritional considerations for inflammatory bowel disease

Nutritional assessment and dietary advice are fundamental to inflammatory bowel disease (IBD) patient management and all patients should have access to a dietitian. Newly diagnosed patients often think that their pre-illness diet has contributed to the development of their IBD. However, epidemiological evidence to support diet as a risk factor is lacking. How the diet contributes to the gastrointestinal microbiota is interesting, although the role is not yet clearly defined. Nutritional problems in IBD are common. Malnutrition occurs in up to 85% of patients and weight loss affects up to 80% of patients with Crohn's disease and 18-62% of patients with ulcerative colitis. Nutritional deficiencies are prevalent, particularly in relation to anaemia and osteoporosis. Intestinal strictures can be problematic in Crohn's disease and limiting fibrous foods that may cause a mechanical obstruction in the gastrointestinal tract is helpful. Patients often explore dietary exclusion to alleviate symptoms but such changes may be self-directed or inappropriately advised and can lead to further nutritional deficiencies. Some patients experience concurrent functional symptoms (e.g. abdominal bloating, abdominal pain, flatulence and diarrhoea) that can significantly affect quality of life. Recently, a group of poorly absorbed carbohydrates that occur naturally in the diet called fermentable oligo-, di-, mono-saccharides and polyols have been associated with functional symptoms by intestinal bacterial fermentation leading to rapid gas production, and an osmotic effect increasing fluid delivery to the colon. Emerging evidence indicates that a diet low in fermentable oligo-, di-, mono-saccharides and polyols can alleviate functional symptoms in IBD.

The prevalence of anemia and iron deficiency in IBD outpatients in Scandinavia

OBJECTIVE

To evaluate the prevalence of anemia and iron deficiency (ID) among patients with inflammatory bowel disease (IBD) in the Scandinavian countries.

MATERIAL AND METHODS

A cross-sectional study including 429 IBD patients from six centers in Denmark, Norway and Sweden. Patients were screened for anemia and ID. Each center included ~5% of their IBD cohort. Patients were consecutively seen in the outpatient clinic, regardless of disease activity and whether the visits were scheduled or not.

RESULTS

The overall prevalence of anemia was 19% (95% CI: 16-23%). The prevalence was higher among patients with Crohn's disease than among patients with ulcerative colitis (p = 0.01). The etiology of anemia was as follows: iron deficiency anemia (20%), anemia of chronic disease (12%), and both conditions (68%). Less than 5% had folate acid or vitamin B12 deficiency. ID was found in 35% (CI: 31-40%) of the patients.

CONCLUSIONS

Anemia was present in every fifth IBD patient and ID in every third IBD patient.

When is high-dose intravenous iron repletion needed? Assessing new treatment options

High doses of intravenous iron have a role in the treatment of a number of clinical situations associated with iron deficiency, iron deficiency anemia, and blood loss. In the presence of functioning erythropoiesis, iron supplementation alone may be adequate to replenish iron stores and restore blood loss. Where hormone replacement with an erythropoiesis-stimulating agent is required, iron adequacy will optimize treatment. Intravenous iron offers a rapid means of iron repletion and is superior to oral iron in many circumstances, especially in the presence of anemia of chronic disease, where it appears to overcome the block to absorption of iron from the gastrointestinal tract and immobilization of stored iron. The clinical situations where high doses of iron are commonly required are reviewed. These include nondialysis-dependent chronic kidney disease, inflammatory bowel disease, obstetrics, menorrhagia, and anemia associated with cancer and its treatment. The literature indicates that high doses of iron are required, with levels of 1500 mg in nondialysis-dependent chronic kidney disease and up to 3600 mg in inflammatory bowel disease. New formulations of intravenous iron have recently been introduced that allow clinicians to administer high doses of iron in a single administration. Ferumoxytol is available in the US, has a maximum dose of 510 mg iron in a single administration, but is limited to use in chronic kidney disease. Ferric carboxymaltose can be rapidly administered in doses of 15 mg/kg body weight, up to a ceiling dose of 1000 mg. A test dose is not required, and it can be used more widely across a spectrum of iron deficiency and iron deficiency anemia indications. The latest introduction is iron isomaltoside 1000. Again, a test dose is not required, and it can be delivered rapidly as an infusion (in an hour), allowing even higher doses of iron to be administered in a single infusion, ie, 20 mg/kg body weight with no ceiling. This will allow clinicians to achieve high-dose repletion more frequently as a single administration. Treatment options for iron repletion have taken a major leap forward in the past two years, especially to meet the demand for high doses given as a single administration.

The pharmacokinetics and pharmacodynamics of iron preparations

Standard approaches are not appropriate when assessing pharmacokinetics of iron supplements due to the ubiquity of endogenous iron, its compartmentalized sites of action, and the complexity of the iron metabolism. The primary site of action of iron is the erythrocyte, and, in contrast to conventional drugs, no drug-receptor interaction takes place. Notably, the process of erythropoiesis, i.e., formation of new erythrocytes, takes 3–4 weeks. Accordingly, serum iron concentration and area under the curve (AUC) are clinically irrelevant for assessing iron utilization. Iron can be administered intravenously in the form of polynuclear iron(III)-hydroxide complexes with carbohydrate ligands or orally as iron(II) (ferrous) salts or iron(III) (ferric) complexes. Several approaches have been employed to study the pharmacodynamics of iron after oral administration. Quantification of iron uptake from radiolabeled preparations by the whole body or the erythrocytes is optimal, but alternatively total iron transfer can be calculated based on known elimination rates and the intrinsic reactivity of individual preparations. Degradation kinetics, and thus the safety, of parenteral iron preparations are directly related to the molecular weight and the stability of the complex. High oral iron doses or rapid release of iron from intravenous iron preparations can saturate the iron transport system, resulting in oxidative stress with adverse clinical and subclinical consequences. Appropriate pharmacokinetics and pharmacodynamics analyses will greatly assist our understanding of the likely contribution of novel preparations to the management of anemia.

Chronic fatigue is associated with impaired health-related quality of life in inflammatory bowel disease

BACKGROUND

Fatigue is reported to reduce health-related quality of life (HRQOL) in chronic diseases. Studies on the importance of fatigue and its implications for the patient's HRQOL in inflammatory bowel disease (IBD) remain scarce and need to be explored.

AIM

To investigate the influence of chronic fatigue on both generic and disease-specific HRQOL in IBD.

METHODS

Patients in remission, with mild and moderate IBD completed the Fatigue Questionnaire, the Short-Form 36 (SF-36) and the Norwegian version of the Inflammatory Bowel Disease Questionnaire (N-IBDQ). In addition, demographic and clinical variables were obtained.

RESULTS

In total, 140 patients were included; the mean age of patients with chronic fatigue was 44.2 years (s.d. = 15.8), that of nonfatigued was 44.7 years (s.d. = 16.0). Ulcerative colitis (UC)/Crohn's disease (CD) = 92/48. Chronic fatigue was associated, after controlling for covariates, with a reduction of HRQOL scores in 6/8 SF-36 dimensions in UC and 5/8 dimensions in CD. In N-IBDQ, chronic fatigue was associated with a reduction of HRQOL in four subdimensions and total score in CD and all dimensions in UC.

CONCLUSIONS

Fatigue is associated with reduction of HRQOL scores in IBD. The physical HRQOL domains are particularly affected. The impact of fatigue on disability, sick leave, school and work attendance has to be studied further.

Soluble transferrin receptor-ferritin index in the evaluation of anemia in inflammatory bowel disease: a case-control study

BACKGROUND

No reliable biochemical markers exist for the differentiation between iron deficiency anemia (IDA) and anemia of chronic disease (ACD) in the setting of inflammatory bowel disease (IBD). The aim of this study was to investigate the use of soluble transferrin receptor (sTfR) and sTfR-ferritin (sTfR-F) index in the evaluation of anemia in patients with IBD.

METHODS

One hundred IBD patients [49 ulcerative colitis (UC), 51 Crohn's disease (CD)] and 102 healthy controls were enrolled. Serum levels of ferritin, transferrin saturation and sTfR were analyzed in all patients and controls. sTfR-F index was calculated based on the ratio: sTfR/ log ferritin. The value of sTfR and sTfR-F for diagnosis of IDA was assessed.

RESULTS

Forty two IBD patients (41% of UC and 42.9 % of CD) fulfilled the WHO criteria for the diagnosis of anemia. Among them thirty (30 %) had IDA, four (4%) had ACD and eight (8%) had mixed IDA/ACD. Patients with IDA had significantly higher sTfR and sTfR-F index levels compared with those without IDA (P<0.0001). Both sTfR and sTfR-F index were not correlated with CRP levels or disease activity. High sTfR levels (>1.8 mg/L) had sensitivity 81% and specificity 80%, whereas high sTfR-F index (>1.4) had sensitivity 91% and specificity 92% for the diagnosis of IDA.

CONCLUSION

These results suggest that the sTfR-F index seems to be very efficient in the detection and diagnosis of IDA, among patients with IBD.

[Role of Helicobacter pylori infection in iron deficiency anemia]

Anemia induced by digestive diseases refers to anemia due to iron deficiency. Conventional gastrointestinal diagnostic workup fails to establish the cause of iron deficiency in about one third of patients. Abnormal iron absorption is increasingly recognized as an important cause of unexplained iron deficiency. The importance of coeliac disease as a possible cause of iron deficiency anemia refractory to oral iron treatment, without other manifestations of malabsorption syndrome, is increasingly being recognized. In addition, Helicobacter pylori (HP) has been implicated in several recent studies as a cause of iron deficiency anemia (IDA) refractory to oral iron treatment. Cure of previously refractory IDA by HP eradication provides strong evidence supporting a cause-and-effect relationship. In order to establish a cause-and-effect relationship between HP gastritis and IDA, prospective randomized studies comparing the effects of iron administration with or without H. pylorieradication are highly recommended.

Identification of clinical and simple laboratory variables predicting responsible gastrointestinal lesions in patients with iron deficiency anemia

Iron deficiency anemia (IDA) is a frequent disorder. Also, it may be a sign of underlying serious diseases. Iron deficiency points to an occult or frank bleeding lesion when occurred in men or postmenopausal women. In this study, we aimed to evaluate the diagnostic yield of endoscopy in patients with IDA and to define predictive factors of gastrointestinal (GI) lesions causing IDA. Ninety-one patients (77 women, 14 men; mean age: 43 years) who were decided to have esophago-duodenoscopy and/or colonoscopy for iron deficiency anemia were interviewed and responded to a questionnaire that included clinical and biochemical variables. The endoscopic findings were recorded as GI lesions causing IDA or not causing IDA. Endoscopy revealed a source of IDA in 18.6 % of cases. The risk factors for finding GI lesions causing IDA were as follows: male gender (p= 0.004), advanced age (> 50 years) (p= 0.010), weight loss (over 20% of total body weight lost in last 6 month) (p= 0.020), chronic diarrhea (p= 0.006), change of bowel habits (p= 0.043), epigastric tenderness (p= 0.037), raised carcinoembryonic antigen (CEA) level (normal range: 0-7 ng/mL) (p= 0.039), < 10 gr/dl hemoglobin (Hb) level (p=0.054). None of these risk factors had been present in 21 (23%) women younger than 51 years. In this group, no patient had any GI lesion likely to cause IDA (negative predictive value= 100%). In multivariate analysis, advanced age (p=0.017), male gender (p< 0.01) and weight lost (p=0.012) found that associated with GI lesions in all patients. It may be an appropriate clinical approach to consider these risk factors when deciding for gastrointestinal endoscopic evaluation in iron deficiency anemia.

Fatigue and health-related quality of life in inflammatory bowel disease: results from a population-based study in the Netherlands: the IBD-South Limburg cohort

BACKGROUND

The importance of fatigue in chronic disease has been increasingly recognized; however, little is known about fatigue in inflammatory bowel disease (IBD). The aim of the present study was to investigate the prevalence and severity of fatigue and the impact on health-related quality of life (HRQoL) in patients included in a population-based IBD cohort in the Netherlands.

METHODS

IBD patients, diagnosed between January 1st, 1991, and January 1st, 2003, were followed up for a median of 7.1 years. They completed a questionnaire, which included a disease activity score, the Multidimensional Fatigue Inventory (MFI-20), the Inflammatory Bowel Disease Questionnaire (IBDQ), and the Short Form health survey (SF-36). Hemoglobin levels were recorded.

RESULTS

Data were available in 304 Crohn's disease (CD), 368 ulcerative colitis (UC), and 35 indeterminate colitis (IC) patients. During quiescent disease, the prevalence of fatigue was nearly 40%. MFI-20 and HRQoL scores were significantly worse in IBD patients having active disease. In a multivariate analysis, disease activity was positively related with the level of fatigue in both CD and UC. In UC, anemia influenced the general fatigue score independently of disease activity. Disease activity as well as fatigue were independently associated with an impaired IBDQ.

CONCLUSIONS

In IBD, even in remission, fatigue is an important feature. Both in CD and in UC, fatigue determined HRQoL independently of disease activity or anemia. This implies that in IBD patients physicians need to be aware of fatigue in order to better understand its impact and to improve the HRQoL.

Slow hematological recovery in children with IBD-associated anemia in cases of "expectant management"

BACKGROUND AND OBJECTIVE

Allowing children with inflammatory bowel disease (IBD) to live with subnormal hemoglobin (Hb) levels affects their quality of life. The therapeutic approach to normalize Hb varies according to the cause of IBD-associated anemia. In exclusive iron-deficiency anemia (IDA) repletion of iron stores is obligatory, whereas controlling inflammation is the treatment of choice for anemia of chronic disease (ACD). In daily practice the focus is on control of intestinal inflammation, and spontaneous hematological recovery is awaited. The aim of the present study was to evaluate the hematological effect of "expectant management" on newly diagnosed pediatric patients with IBD with anemia.

PATIENTS AND METHODS

Medical records of children with IBD were reviewed. Study endpoints were the difference in Hb from the moment of IBD diagnosis (T0) to the end of the induction phase (T1), and time until normalization of Hb, stratified for the type of anemia at T0.

RESULTS

A total of 103 children were included in the study, of whom 80 (78%) had anemia at T0. Exclusive IDA was found in 58% of them. Expectant management caused a modest increase in Hb between T0 and T1 for both types of anemia (IDA 0.4 mmol/L; ACD 0.5 mmol/L), but 65 of 80 children (81%) still had anemia at T1. The proportion of children with exclusive IDA had increased to 74%. One third of the cases initially classified as having ACD had progressed to exclusive IDA. There was no significant difference in time until normalization of Hb between children with exclusive IDA and ACD. Twelve months after IBD diagnosis 24% of the group initially diagnosed as having exclusive IDA and 50% of the ACD group were still anemic.

CONCLUSIONS

Hematological recovery in children with IBD-associated anemia is slow with expectant management, regardless of the type of anemia at T0. Present results underline the need for a more active approach to improve Hb.

Prevalence of anaemia in inflammatory bowel disease in Switzerland: a cross-sectional study in patients from private practices and university hospitals

BACKGROUND

Anaemia represents a common complication of inflammatory bowel disease (IBD). Most studies on anaemia in IBD patients have been performed in tertiary referral centres (RC) and data from gastroenterologic practices (GP) are lacking. We investigated the frequency and severity of anaemia in IBD patients from tertiary referral centres and gastroenterologic practices compared to the general population.

METHODS

Data were acquired from patients included in the Swiss IBD Cohort Study. IBD activity was evaluated by CDAI and modified Truelove and Witts severity index (MTWSI). Anaemia was defined as haemoglobin ≤120g/L in women and ≤130g/L in men.

RESULTS

125 patients from RC (66 with Crohn's disease (CD) and 59 with ulcerative colitis (UC)) and 116 patients from GP (71 CD and 45 UC) were included and compared to 6074 blood donors. Anaemia was found in 21.2% (51/241) of the IBD patients and more frequently in patients from RC as compared to GP and healthy controls (28.8% vs. 12.9% vs. 3.4%; P<0.01). IBD patients from RC suffered more frequently from active disease compared to IBD patients in GP (36% vs. 23%, P=0.032). Supplementation therapy (iron, vitamin B12, folic acid) was performed in 40% of anaemic IBD patients in GP as compared to 43% in RC.

CONCLUSIONS

Anaemia is a common complication in patients with IBD and significantly more prevalent in patients from referral centres as compared to patients from gastroenterologic practices. Physicians treating IBD patients should pay attention to the presence of anaemia and ensure sufficient supplementation therapy.

Diagnosis and management of iron deficiency anemia in patients with IBD

Anemia is the most prevalent extraintestinal complication of IBD. It can affect quality of life and ability to work, and can also increase the hospitalization rate in patients with IBD. Although the causes of anemia in IBD are multifactorial, iron deficiency anemia (IDA) is the most common. Assessment of the iron status of patients who have a condition associated with inflammation, such as IBD, by using common biochemical values is insufficient. However, new indices of iron metabolism (for instance ferritin:transferrin receptor ratio, reticulocyte hemoglobin content or percentage of hypochromic red blood cells) may help to improve the assessment of iron status in patients with IBD. The treatment of IDA traditionally involves oral iron supplementation. However, because of extensive gastrointestinal adverse effects, and data showing that the use of oral iron in IBD may be associated with disease exacerbation, current guidelines suggest that iron supplementation in IBD should be administered intravenously. This Review provides an overview of iron homeostasis in health before discussing diagnostic and therapeutic strategies for IDA in patients with IBD.

The health care cost of intravenous iron treatment in IBD patients depends on the economic evaluation perspective

BACKGROUND AND AIM

Anemia is common in IBD patients and intravenous iron treatment is preferred. The drug cost of intravenous iron carboxymaltose is approximately twice the cost of intravenous iron sucrose. The aim was to evaluate the health care costs of intravenous iron sucrose (Venofer®, Vifor) and intravenous iron carboxymaltose (Ferinject®, Vifor) treatment to IBD patients in an outpatient setting.

METHODS

Based on data from 111 IBD patients treated with intravenous iron in an outpatient setting health care costs were evaluated by means of Budget Impact Analysis, Cost Effective Analysis and Cost Benefit Analysis.

RESULTS

The Cost Effective Analysis showed that iron carboxymaltose was more cost-effective than iron sucrose, due to fewer outpatient setting visits. Even a sensitivity analysis using a reduced patient income (50%) in the Cost Effective Analysis showed iron carboxymaltose to be the most cost effective treatment. The Budget Impact Analysis from a hospital perspective showed that iron carboxymaltose was more expensive than iron sucrose regardless of the dose given. In contrast the Cost Benefit Analysis showed that the average patients' 'willingness to pay' for a total of iron dose of 1400 mg was €233 in order to reduce the number of infusions from 7 to 2 by using iron carboxymaltose rather than iron sucrose.

CONCLUSION

Both the Cost Effective Analysis and the Cost Benefit Analysis showed clearly that iron carboxymaltose is a more cost effective way of giving intravenous iron than iron sucrose in IBD patients. Only the Budget Impact Analysis showed that intravenous iron sucrose was the cheapest choice if only direct cost was included in the analysis.

Impaired erythrocyte antioxidant defense in active inflammatory bowel disease: impact of anemia and treatment

BACKGROUND

Oxidative stress contributes to the propagation and exacerbation of inflammatory bowel disease (IBD) but the status of erythrocyte antioxidant defense remains unknown.

METHODS

Erythrocyte activities of superoxide dismutase-1 (SOD1), catalase, and glutathione peroxidase-1 (GPx1) were determined in 174 IBD patients and 105 controls and referred to IBD activity, inflammation severity, nutritional status, systemic oxidative stress, anemia, and treatment.

RESULTS

Catalase and GPx1 activities were decreased in active IBD, whereas SOD1 became upregulated by IBD-related oxidative stress. In Crohn's disease (CD) corticosteroids decreased SOD1 activity. SOD1 correlated indirectly with CD activity and erythrocyte sedimentation rate (ESR) and directly with transferrin. In ulcerative colitis (UC) anemia downregulated SOD1. Decreases in GPx activity corresponded with IBD activity, anemia, inflammation, and malnutrition. Oxidative stress in UC and corticosteroids in CD also downregulated GPx. Catalase activity was decreased by CD-related anemia, correlating directly with hemoglobin, and indirectly with CD activity, inflammatory and protein oxidative stress markers. When co-analyzed, anemia but not CD activity significantly contributed to catalase downregulation. In UC, catalase activity corresponded indirectly with UC endoscopic activity and inflammation and directly with hemoglobin. UC activity, anemia, and treatment with azathioprine negatively affected catalase. As indicators of active IBD, GPx1 showed a diagnostic accuracy of 73%, whereas catalase showed 63% as compared to 74% of C-reactive protein and ESR.

CONCLUSIONS

Erythrocyte antioxidant defense is impaired in active IBD. SOD1, GPx1, and CAT activities are differently affected by the disease type, activity, anemia, inflammation, oxidative stress, and treatment. As an active IBD indicator, GPx1 was comparable to C-reactive protein and ESR.

Safety and efficacy of total-dose infusion of low molecular weight iron dextran for iron deficiency anemia in patients with inflammatory bowel disease

BACKGROUND

Intravenous iron has been suggested as a safe and effective treatment of anemia complicating inflammatory bowel disease (IBD). Low molecular weight (LMW) iron dextran has the ability to administer the patient's total iron requirement in a single infusion.

AIMS

The aim of this study was to assess the safety and efficacy of the total dose of LMW iron dextran infusion for the treatment of iron deficiency in IBD.

METHODS

Fifty IBD patients (27 female, 35 Crohn's disease, 15 ulcerative colitis) were included in the study. Mean +/- standard deviation (SD) hemoglobin and ferritin levels before the infusion were 9.88 +/- 1.42 g/dl and 13.9 +/- 10.9 ng/ml, respectively. A 25-mg test dose was followed by infusion of the total dose of LMW iron dextran based on the iron deficit. Several clinical and laboratory parameters were measured before and on week 4 after infusion.

RESULTS

Four patients (8%) developed adverse reactions during the test infusion and did not receive the total-dose infusion. Only one patient developed an allergic reaction during the total-dose infusion. In the remaining 45 patients, the mean +/- SD iron dose that was given was 1,075 +/- 269 mg. The mean +/- SD elevation of hematocrit and hemoglobin on week 4 was 4.9 +/- 1.9% and 1.7 +/- 0.8 g/dl, respectively. Hematopoietic response was observed in 23 of 45 patients (51.1%).

CONCLUSION

Total parenteral iron replacement with LMW iron dextran is an easy, safe, and effective alternative method for treating iron deficiency anemia in IBD. Harmless adverse reactions may develop in a minority of patients.

Evaluation of erythrocytes, platelets, and serum iron profile in dogs with chronic enteropathy

The aim of this study is to evaluate iron status, erythrocyte, and platelet modifications in dogs with chronic enteropathy (CE). Dogs were grouped as food-responsive diarrhea (FRD, n = 11), antibiotic-responsive diarrhea (ARD, n = 5), and steroid-responsive diarrhea (SRD, n = 6) relating to therapeutic-response. Clinical and haematological findings, evidence of gastrointestinal blood loss, and iron metabolism were evaluated before and after treatment. A mild normocytic or microcytic anemia and thrombocytosis were identified, respectively in 18.0% and 31.8% of CE dogs. No significant differences between pre- and posttreatment of hematocrit, haemoglobin, and mean corpuscular volume, platelet count and mean platelet volume were found. Statistical analysis pointed out significant differences between pre- and posttreatment in serum iron (P < .03) and unsaturated iron binding capacity (UIBC) (P < .01). No significant correlations were found between these parameters and canine Inflammatory Bowel Disease activity index and pattern of CE as well.

Oxidative stress and mitochondrial functions in the intestinal Caco-2/15 cell line

Background

Although mitochondrial dysfunction and oxidative stress are central mechanisms in various pathological conditions, they have not been extensively studied in the gastrointestinal tract, which is known to be constantly exposed to luminal oxidants from ingested foods. Key among these is the simultaneous consumption of iron salts and ascorbic acid, which can cause oxidative damage to biomolecules.

Methodology/Principal Findings

The objective of the present work was to evaluate how iron-ascorbate (FE/ASC)-mediated lipid peroxidation affects mitochondrion functioning in Caco-2/15 cells. Our results show that treatment of Caco-2/15 cells with FE/ASC (0.2 mM/2 mM) (1) increased malondialdehyde levels assessed by HPLC; (2) reduced ATP production noted by luminescence assay; (3) provoked dysregulation of mitochondrial calcium homeostasis as evidenced by confocal fluorescence microscopy; (4) upregulated the protein expression of cytochrome C and apoptotic inducing factor, indicating exaggerated apoptosis; (5) affected mitochondrial respiratory chain complexes I, II, III and IV; (6) elicited mtDNA lesions as illustrated by the raised levels of 8-OHdG; (7) lowered DNA glycosylase, one of the first lines of defense against 8-OHdG mutagenicity; and (8) altered the gene expression and protein mass of mitochondrial transcription factors (mtTFA, mtTFB1, mtTFB2) without any effects on RNA Polymerase. The presence of the powerful antioxidant BHT (50 µM) prevented the occurrence of oxidative stress and most of the mitochondrial abnormalities.

Conclusions/Significance

Collectively, our findings indicate that acute exposure of Caco-2/15 cells to FE/ASC-catalyzed peroxidation produces harmful effects on mitochondrial functions and DNA integrity, which are abrogated by the powerful exogenous BHT antioxidant. Functional derangements of mitochondria may have implications in oxidative stress-related disorders such as inflammatory bowel diseases.

Systematic review: fatigue in inflammatory bowel disease

BACKGROUND

Fatigue is common, disabling yet underappreciated, in patients with chronic diseases, including inflammatory bowel disease (IBD).

AIMS

To examine the literature and determine the prevalence and patterns of fatigue in IBD patients, to identify opportunities and directions for future research in this area.

METHODS

A systematic review using PubMed and Ovid Medline databases was conducted using search terms 'fatigue', 'Crohn', 'colitis' and 'inflammatory bowel disease'. A review of fatigue in other similar chronic diseases was also performed.

RESULTS

Ten studies were found to include data on fatigue in IBD patients; all were conducted between 1999 and 2009. However, only one study (in children) measured fatigue in IBD patients as a primary outcome. In patients in remission, the prevalence of fatigue in IBD patients ranges from 41 to 48%. Data are sparse and conflicting on whether fatigue severity is proportional to disease severity/activity.

CONCLUSIONS

Despite the clinical reality of fatigue, there are few published studies examining fatigue in IBD as a primary outcome. More data are needed on the prevalence, correlation between disease activity and fatigue severity, and putative pathogenic pathways involved in fatigue pathogenesis, before ultimately elucidating targeted therapies for fatigue in IBD patients.

Iron-dextran injection into the substantia nigra in rats decreases striatal dopamine content ipsilateral to the injury site and impairs motor function

Iron chloride injections into the rat SNc can cause chronic decreases in striatal dopamine (DA) levels. However, changes in striatal DA content after iron-dextran injection into rat SNc have not been completely elucidated. The aim of this work was to measure striatal DA concentrations after iron-dextran injection into the SNc. We divided 40 male Wistar rats into five groups, including control, saline injected then sacrificed 7 days or 30 days later, and iron-dextran injected then sacrificed 7 days or 30 days later. Striatal DA content was measured in control animals and in all animals sacrificed 7 days or 30 days after injection, and motor performance was assessed in iron-dextran and saline injected groups 30 days after injection. The striatal DA levels were determined using HPLC. There were significant (P < 0.05) decreases in DA concentrations in the striatum ipsilateral to the injection site in the iron-dextran treated rats compared to control and saline-injected rats. There were no significant differences in DA concentration between the sham-operated (i.e., saline-injected) and control rats. We also observed motor deficits in the iron-dextran injected rats. The striatal DA reduction observed after iron-dextran injection may be attributable to iron-induced oxidative injury in the SNc. Motor deficits, in turn, may be explained by subsequent disturbances in striatal and cortical dopaminergic neuromodulation.

Intravenous iron sucrose is superior to oral iron sulphate for correcting anaemia and restoring iron stores in IBD patients: A randomized, controlled, evaluator-blind, multicentre study

OBJECTIVE

Patients with inflammatory bowel disease (IBD) often have low iron stores or anaemia. There is controversy about whether iron should be supplemented orally or intravenously (i.v.). The purpose of this study was to investigate whether treatment with intravenous iron is superior to treatment with oral iron. The primary end-points were response and remaining anaemia at the end of treatment (EOT).

MATERIAL AND METHODS

Ninety-one patients with IBD and anaemia (B-Hb <115 g/L) were randomized to oral iron sulphate (n=46) or intravenous iron sucrose (n=45) treatment for 20 weeks.

RESULTS

Forty-three patients in the intravenous iron group completed the study compared to 35 patients in the oral iron group (p=0.0009). Only 22 patients (48%) tolerated the prescribed oral dose, and 52% reduced the dose or withdrew from treatment because of poor tolerance. At EOT, 47% patients in the oral iron group increased their B-Hb by > or =20 g/L, compared with 66% in the intravenous iron group (p=0.07). In the oral iron group, 41% still had anaemia versus 16% of the patients in the intravenous iron group (p=0.007), and 22% versus 42% reached their reference B-Hb level (p=0.04). Treatment with intravenous iron sucrose improved iron stores faster and more effectively than oral iron (p=0.002). Under treatment with intravenous iron, 74% of the patients had no anaemia and normal S-ferritin levels (>25 microg/L) at EOT compared with 48% of patients receiving oral iron (p=0.013).

CONCLUSIONS

Treatment with intravenous iron sucrose is effective, safe, well tolerated and superior to oral iron in correcting haemoglobin and iron stores in patients with IBD.

Does Helicobacter pylori infection play a role in iron deficiency anemia? A meta-analysis

AIM: To perform a meta-analysis of observational studies and randomized controlled trials (RCTs) on the association between Helicobacter pylori (H. pylori) and iron deficiency anemia (IDA).

METHODS: A defined search strategy was used to search Medline, Embase, the Cochrane Library, Clinical Trials, Cochrane Central Register of Controlled Trials, Premedline and Healthstar. Odds ratio (OR) was used to evaluate observational epidemiology studies, and weighted mean difference (WMD) was used to demonstrate the difference between control and intervention groups.

RESULTS: Fifteen observational studies and 5 RCTs were identified and used for calculation. The pooled OR for observational studies was 2.22 (95% CI: 1.52-3.24, P < 0.0001). The WMD for hemoglobin (HB) was 4.06 g/L (95% CI: -2.57-10.69, P = 0.01), and the WMD for serum ferritin (SF) was 9.47 μg/L (95% CI: -0.50-19.43, P < 0.0001). Results were heterogeneous for all comparisons.

CONCLUSION: This meta-analysis on observational studies suggests an association between H. pylori and IDA. In RCTs, eradication of H. pylori can improve HB and SF levels but not significantly.

Prevalence and pathogenesis of anemia in inflammatory bowel disease. Influence of anti-tumor necrosis factor-alpha treatment

BACKGROUND

Anemia is a common complication of inflammatory bowel disease, but its epidemiology may be changing due to earlier diagnosis and improved treatments. We investigated the prevalence and pathogenesis of anemia in patients with inflammatory bowel disease.

DESIGN AND METHODS

In a cross-sectional study 263 out-patients with inflammatory bowel disease (165 with Crohn's disease, 98 with ulcerative colitis) were investigated. The influence of time from diagnosis, disease activity, inflammation and the status of iron and hematinic vitamins on the level of hemoglobin and prevalence of anemia were evaluated. In a second group of 27 patients with Crohn's disease, undergoing anti-tumor necrosis factor-alpha treatment with infliximab because of refractory or fistulizing disease, we determined the effects of infliximab on disease activity, hemoglobin, serum erythropoietin levels, iron status and inflammation.

RESULTS

In all, 104 of the 263 patients with inflammatory bowel disease were anemic. Age, gender and azathioprine treatment had no influence on anemia. The prevalence of anemia was highest at diagnosis (65%), decreased during the first 4 years after disease onset, and was stable thereafter. Active disease was associated with higher rates of anemia. At diagnosis most anemic patients had anemia of chronic disease; during follow-up iron deficiency and multifactorial forms of anemia became more prevalent. Eighteen of 27 patients undergoing treatment with infliximab were anemic; most of them had anemia of chronic disease. Infliximab reduced disease activity and improved anemia in 12 patients. This was mediated by an increased production of erythropoietin for the degree of anemia. In vitro infliximab increased the growth of erythroid progenitors from the peripheral blood of patients with active disease. Conclusions Anemia is a common problem in out-patients with inflammatory bowel disease; the prevalence and severity of anemia are related to the activity of the bowel disorder. The pathogenesis of anemia changes during the course of the disease, with anemia of chronic disease having a major role at diagnosis and iron deficiency and multifactorial forms of anemia during follow-up. In patients requiring anti-tumor necrosis factor-alpha treatment, response to therapy improves erythropoiesis.

Evaluation and treatment of iron deficiency anemia: a gastroenterological perspective

A substantial volume of the consultations requested of gastroenterologists are directed towards the evaluation of anemia. Since iron deficiency anemia often arises from bleeding gastrointestinal lesions, many of which are malignant, establishment of a firm diagnosis usually obligates an endoscopic evaluation. Although the laboratory tests used to make the diagnosis have not changed in many decades, their interpretation has, and this is possibly due to the availability of extensive testing in key populations. We provide data supporting the use of the serum ferritin as the sole useful measure of iron stores, setting the lower limit at 100 microg/l for some populations in order to increase the sensitivity of the test. Trends of the commonly obtained red cell indices, mean corpuscular volume, and the red cell distribution width can provide valuable diagnostic information. Once the diagnosis is established, upper and lower gastrointestinal endoscopy is usually indicated. Nevertheless, in many cases a gastrointestinal source is not found after routine evaluation. Additional studies, including repeat upper and lower endoscopy and often investigation of the small intestine may thus be required. Although oral iron is inexpensive and usually effective, there are many gastrointestinal conditions that warrant treatment of iron deficiency with intravenous iron.

Iron absorption and distribution in TNF(DeltaARE/+) mice, a model of chronic inflammation

Hemizygous TNF(DeltaARE/+) mice are a murine model for chronic inflammation. We utilized these animals to study iron-kinetics and corresponding protein expression in an iron-deficient and iron-adequate setting. (59)Fe-absorption was determined in ligated duodenal loops in vivo. Whole body distribution of i.v. injected (59)Fe was analysed, and the organ specific expression of ferroportin, transferrin receptor-1, hepcidin and duodenal DMT-1 was quantified by real-time PCR and Western blotting. Duodenal (59)Fe-lumen-to-body transport was not affected by the genotype. Duodenal (59)Fe-retention was increased in TNF(DeltaARE/+) mice, suggesting higher (59)Fe-losses with defoliated enterocytes. Iron-deficiency increased duodenal (59)Fe-lumen-to-body transport, and higher duodenal (59)Fe-tissue retention went along with higher duodenal DMT-1, ferroportin, and liver hepcidin expression. TNF(DeltaARE/+) mice significantly increase their (59)Fe-content in inflamed joints and ilea, and correspondingly reduce splenic (59)Fe-content. Leukocyte infiltrations in the joints suggest a substantial shift of iron-loaded RES cells to inflamed tissues as the underlying mechanism. This finding was paralleled by increased non-haem iron content in joints and reduced haemoglobin and haematocrit concentrations in TNF(DeltaARE/+) mice. In conclusion, erythropoiesis in inflamed TNF(DeltaARE/+) mice could be iron-limited due to losses with exfoliated iron-loaded enterocytes and/or to increased iron-retention in RES cells that shift from the spleen to inflamed tissues.

Clinical use of intravenous iron: administration, efficacy, and safety

This section reviews the history, pharmacology, administration, efficacy, and toxicity of intravenous iron. Intravenous iron offers advantages over oral iron for the treatment of iron deficiency anemia across a wide range of disease states associated with absolute and functional iron deficiency. However, there remain concerns about the acute safety profiles of the available preparations and the potential for long-term toxicity with their repeated administration. Seven intravenous iron formulations are available. Confusion concerning the relative toxicities of the different formulations abounds. The similarities and differences are discussed. Iron repletion has been associated with adverse outcomes in infections. The relationship, if any, between intravenous iron administration and infections is reviewed. The potential advantages of total dose infusion (TDI), complete repletion in a single setting, are highlighted. A new paradigm for iron replacement therapy in iron deficiency anemia is presented.

Use of agents stimulating erythropoiesis in digestive diseases

Anemia is the most common complication of inflammatory bowel disease (IBD). Control and inadequate treatment leads to a worse quality of life and increased morbidity and hospitalization. Blood loss, and to a lesser extent, malabsorption of iron are the main causes of iron deficiency in IBD. There is also a variable component of anemia related to chronic inflammation. The anemia of chronic renal failure has been treated for many years with recombinant human erythropoietin (rHuEPO), which significantly improves quality of life and survival. Subsequently, rHuEPO has been used progressively in other conditions that occur with anemia of chronic processes such as cancer, rheumatoid arthritis or IBD, and anemia associated with the treatment of hepatitis C virus. Erythropoietic agents complete the range of available therapeutic options for treatment of anemia associated with IBD, which begins by treating the basis of the inflammatory disease, along with intravenous iron therapy as first choice. In cases of resistance to treatment with iron, combined therapy with erythropoietic agents aims to achieve near-normal levels of hemoglobin/hematocrit (11-12 g/dL). New formulations of intravenous iron (iron carboxymaltose) and the new generation of erythropoietic agents (darbepoetin and continuous erythropoietin receptor activator) will allow better dosing with the same efficacy and safety.

Anemia and inflammatory bowel diseases

Too often anemia is considered a rare or unimportant manifestation in inflammatory bowel disease (IBD). However, over the last 10 years a number of studies have been conducted and the most relevant conclusions obtained are: (1) anemia is quite common in IBD; (2) although in many cases anemia parallels the clinical activity of the disease, many patients in remission have anemia, and iron, vitamin B12 and/or folic acid deficiency; (3) anemia, and also iron deficiency without anemia, have important consequences in the clinical status and quality of life of the patient; (4) oral iron can lead to gastrointestinal intolerance and failure of treatment; (5) intravenous iron is an effective and safe way to treat iron deficiency; (6) erythropoietin is needed in a significant number of cases to achieve normal hemoglobin levels. Thus, the clinician caring for IBD patients should have a comprehensive knowledge of anemia, and apply recently published guidelines in clinical practice.