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Cohen CT, Powers JM. Nutritional Strategies for Managing Iron Deficiency in Adolescents: Approaches to a Challenging but Common Problem. Adv Nutr 2024; 15:100215. [PMID: 38556251 PMCID: PMC11070695 DOI: 10.1016/j.advnut.2024.100215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024] Open
Abstract
Iron deficiency (ID) is a common and challenging problem in adolescence. In order to prevent, recognize, and treat ID in this age range, it is critical to understand the recommended daily intake of iron in relation to an adolescent's activity, dietary habits, and basal iron losses. Adolescents following vegetarian or vegan diets exclusively rely on plant-based, nonheme iron, which has decreased bioavailability compared with heme iron and requires increased total iron intake. Individuals with disordered eating habits, excessive menstrual blood loss, and certain chronic health conditions (including inflammatory bowel disease and heart failure) are at high risk of ID and the development of symptomatic iron deficiency anemia (IDA). Adolescent athletes and those with sleep and movement disorders may also be more sensitive to changes in iron status. Iron deficiency is typically treated with oral iron supplementation. To maximize iron absorption, oral iron should be administered no more than once daily, ideally in the morning, while avoiding foods and drinks that inhibit iron absorption. Oral iron therapy should be provided for ≥3 mo in the setting of ID to reach a ferritin of 20 ng/mL before discontinuation. Intravenous iron is being increasingly used in this population and has demonstrated efficacy and safety in adolescents. It should be considered in those with persistent ID despite a course of oral iron, severe and/or symptomatic IDA, and chronic inflammatory conditions characterized by decreased gastrointestinal iron absorption.
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Affiliation(s)
- Clay T Cohen
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Cancer and Hematology Center, Texas Children's Hospital, Houston, TX, United States
| | - Jacquelyn M Powers
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Cancer and Hematology Center, Texas Children's Hospital, Houston, TX, United States.
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Jin J, Ran Z, Noseda E, Roubert B, Marty M, Mezzacasa A, Göring UM. A randomized, controlled, open label non-inferiority trial of intravenous ferric carboxymaltose versus iron sucrose in patients with iron deficiency anemia in China. Front Med 2024; 18:98-108. [PMID: 37897561 DOI: 10.1007/s11684-023-1001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 04/01/2023] [Indexed: 10/30/2023]
Abstract
Iron deficiency (ID) and ID anemia (IDA) pose significant public health concerns in China. Although iron sucrose (IS) treatment is well-established in the country, ferric carboxymaltose (FCM) offers the advantage of higher doses and fewer infusions. This open label, randomized, controlled, non-inferiority trial was conducted at multiple sites in China to compare the outcomes of FCM (maximum of 2 doses, 500 or 1000 mg iron) and IS (up to 11 infusions, 200 mg iron) treatments in subjects with IDA. The primary endpoint was the achievement of hemoglobin (Hb) response (an increase of ⩾2 g/dL from baseline) within 8 weeks, whereas secondary endpoints included changes in Hb, transferrin saturation, and serum ferritin levels. Among the 371 randomized subjects, a similar percentage of subjects treated with FCM and IS achieved Hb-response (FCM 99.4%, IS 98.3%), thereby confirming the non-inferiority of FCM compared with IS (difference 1.12 (-2.15, 4.71; 95% confidence interval (CI))). Furthermore, a significantly higher proportion of FCM-treated subjects achieved early Hb-response at Week 2 (FCM 85.2%, IS 73.2%; difference 12.1 (3.31, 20.65; 95% CI)). Additionally, the increase in TSAT and serum ferritin levels from baseline was significantly greater at all time points for FCM-treated subjects. The safety profiles of FCM and IS were comparable, with the exception of transient hypophosphatemia and pyrexia, which are consistent with FCM's known safety profile. In conclusion, FCM proves to be an efficacious treatment for IDA, providing faster Hb-response and correction of ID with fewer administrations than IS.
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Affiliation(s)
- Jie Jin
- The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, 310058, China
| | - Zhihua Ran
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
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Gordon H, Burisch J, Ellul P, Karmiris K, Katsanos K, Allocca M, Bamias G, Barreiro-de Acosta M, Braithwaite T, Greuter T, Harwood C, Juillerat P, Lobaton T, Müller-Ladner U, Noor N, Pellino G, Savarino E, Schramm C, Soriano A, Michael Stein J, Uzzan M, van Rheenen PF, Vavricka SR, Vecchi M, Zuily S, Kucharzik T. ECCO Guidelines on Extraintestinal Manifestations in Inflammatory Bowel Disease. J Crohns Colitis 2024; 18:1-37. [PMID: 37351850 DOI: 10.1093/ecco-jcc/jjad108] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, London, Centre for Immunobiology, Blizard Institute, Faculty of Medicine, Barts & The London Medical School, Queen Mary University of London, UK
| | - Johan Burisch
- Gastrounit, medical division, Hvidovre Hospital, University of Copenhagen, Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Giorgos Bamias
- GI Unit, 3rd Academic Department of Internal Medicine, National and Kapodistrian University of Athens, Sotiria Hospital, Athens, Greece
| | - Manuel Barreiro-de Acosta
- University Hospital Santiago De Compostela CHUS, Department of Gastroenterology - IBD Unit, Santiago De Compostela, Spain
| | - Tasanee Braithwaite
- School of Immunology and Microbiology, King's College London, The Medical Eye Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, GZO - Zurich Regional Health Center, Wetzikon, Division of Gastroenterology and Hepatology, University Hospital Lausanne - CHUV, Lausanne, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Department of Dermatology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Pascal Juillerat
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland; Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
| | - Triana Lobaton
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent; Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus Liebig University Giessen, Bad Nauheim, Germany
| | - Nurulamin Noor
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gianluca Pellino
- Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Christoph Schramm
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandra Soriano
- Gastroenterology Division and IBD Center, Internal Medicine Department, Azienda Unità Sanitaria Locale - IRCCS, 42122 Reggio Emilia, Italy
| | - Jürgen Michael Stein
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/Main, Department of Gastroenterology and Clinical Nutrition, DGD Clinics Sachsenhausen, Frankfurt/Main, Germany
| | - Mathieu Uzzan
- Department of Gastroenterology, Hôpital Henri Mondor, APHP, Créteil, France
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital, Zurich, Switzerland
| | - Maurizio Vecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stephane Zuily
- Vascular Medicine Division and French Referral Center for Rare Auto-Immune Diseases, Université de Lorraine, INSERM, DCAC and CHRU-Nancy, Nancy, France
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Münster, Lüneburg, Germany
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Cohen CT, Powers JM. Intravenous iron therapy in pediatrics: who should get it and when is the right time? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:630-635. [PMID: 38066925 PMCID: PMC10727076 DOI: 10.1182/hematology.2023000496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Iron-deficiency anemia occurs most commonly in young children due to a low-iron diet and adolescent girls due to menstrual blood loss. However, children with gastrointestinal conditions such as intestinal failure, inflammatory bowel disease, celiac disease, and/or other chronic conditions, including chronic kidney disease and heart failure, also commonly have iron deficiency. Many patients with classic iron-deficiency anemia will improve with oral iron therapy. However, in children who have an incomplete response to oral iron, intravenous iron therapy is increasingly being used. Benefits of intravenous iron therapy include a rapid repletion of iron stores in addition to resolution of anemia, less gastrointestinal side effects, and relief for patients and families struggling with long-term iron supplementation. Indications for first-line therapy with intravenous iron in children with chronic conditions have also increased. Four intravenous iron formulations have approved indications in pediatrics, and many are increasingly used off-label in children as well. Here we discuss the indications and appropriate timing of intravenous iron therapy in children with a wide range of underlying etiologies.
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Affiliation(s)
- Clay T Cohen
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Cancer and Hematology Center, Houston, TX
| | - Jacquelyn M Powers
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Cancer and Hematology Center, Houston, TX
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Pai RD, Chong YS, Clemente-Chua LR, Irwinda R, Huynh TNK, Wibowo N, Gamilla MCZ, Mahdy ZA. Prevention and Management of Iron Deficiency/Iron-Deficiency Anemia in Women: An Asian Expert Consensus. Nutrients 2023; 15:3125. [PMID: 37513543 PMCID: PMC10383547 DOI: 10.3390/nu15143125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 06/27/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
The lack of standardized clinical practice impeding the optimal management of iron deficiency (ID) and iron deficiency anemia (IDA) in women is a global concern, particularly in the Asia-Pacific region. The aim of this study was to determine best practices through a Delphi consensus process. In Round 1, panelists were asked to rate their level of agreement with 99 statements across four domains: identification, diagnosis and assessment, prevention, and treatment of ID/IDA in women. In Round 2, panelists reappraised their ratings in view of the collective feedback and responses to Round 1. After two rounds, consensus (≥85% agreement) was reached for 84% of the Delphi statements. Experts agreed on the role of presenting symptoms and risk factors in prompting assessments of anemia and iron status in women. Experts repeatedly called for prevention, recommending preventive iron supplementation for pregnant women irrespective of anemia prevalence levels, and for non-pregnant adult women, adolescent girls, and perimenopausal women living in areas with a high prevalence of anemia. Experts unanimously agreed to prescribing oral ferrous iron as first-line therapy for uncomplicated ID/IDA. The recommendations and clinical pathway algorithms generated should be used to inform clinical practice and standardize the care of women at risk or presenting with ID/IDA in the Asia-Pacific region.
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Affiliation(s)
- Rishma Dhillon Pai
- Department of Obstetrics and Gynaecology, Lilavati Hospital, Mumbai 400050, India;
| | - Yap Seng Chong
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
| | | | - Rima Irwinda
- Fetomaternal Division, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Indonesia—Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (R.I.); (N.W.)
| | - Trang Nguyen Khanh Huynh
- Department of Obstetrics and Gynecology, Pham Ngoc Thach University of Medicine, Ho Chi Minh 700000, Vietnam;
| | - Noroyono Wibowo
- Fetomaternal Division, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Indonesia—Cipto Mangunkusumo Hospital, Jakarta 10430, Indonesia; (R.I.); (N.W.)
| | | | - Zaleha Abdullah Mahdy
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
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Diagnosis and Treatment of Iron Deficiency and Anemia in Youth With Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2023; 76:313-318. [PMID: 36730097 DOI: 10.1097/mpg.0000000000003673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Iron deficiency (ID) with and without anemia is prevalent in children and adults diagnosed with inflammatory bowel disease (IBD), but often goes unrecognized. We hypothesized, quality improvement (QI) methodology could increase the screening for and treatment of ID in children newly diagnosed with IBD. METHODS We developed and implemented an easy-to-follow algorithm to facilitate screening for and treatment of ID for patients diagnosed with IBD. Through a series of Plan-Do-Study-Act cycles, the approach was modified to increase screening and treatment of ID. Data between January 2019 and July 2021 were assessed using statistical process control. RESULTS Among patients newly diagnosed with IBD, 298 patients were included (67% Crohn disease, 29% ulcerative colitis, 4% indeterminate colitis, and 56% males). Rates of ID screening increased significantly from a baseline of 20% to >90%. Of the 232 patients screened for ID during the improvement period, 205 (88%) met criteria for either iron deficiency anemia (IDA) or ID at diagnosis, specifically, 151 (65%) met criteria for IDA and 54 (23%) met criteria for ID. CONCLUSIONS Use of QI methodology to standardize screening assessments for ID among children newly diagnosed with IBD improved screening rates from a baseline of 20% to >90%, with 88% of patients found to have IDA or ID.
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Letras P, Oliveira S, Varela J, Nunes M, Raymundo A. 3D printed gluten-free cereal snack with incorporation of Spirulina (Arthrospira platensis) and/or Chlorella vulgaris. ALGAL RES 2022. [DOI: 10.1016/j.algal.2022.102863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Abnormal uterine bleeding (AUB) is a common diagnosis in the adolescent female population. In recent years, changes have been made to standardize nomenclature, evaluation and management of AUB in adolescents. The terms "abnormal uterine bleeding" and "heavy menstrual bleeding" have replaced terms including "dysfunctional uterine bleeding," "menorrhagia," "metrorrhagia", and "menometrorrhagia." Due to a high prevalence of these diagnoses in this population and resulting effects on quality of life, clinicians should understand and practice current evidence-based care, yet variability continues to exist. Evaluation should be focused on common etiologies of AUB in adolescents, namely non-structural causes, rather than those etiologies more common in adult females. The aim of this article is to review the existing definition, etiologies, pathophysiology, evaluation and management of AUB in adolescent females, with an emphasis on current universally accepted nomenclature and guidelines for use in clinical care.
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Affiliation(s)
- Rashi Kabra
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, New York, USA.
| | - Martin Fisher
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, New York, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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Stoffers VL, Weyand AC, Quint EH, Rosen MW. Assessment of Iron Status in Adolescents Presenting to the Emergency Department With Heavy Menstrual Bleeding. Pediatr Emerg Care 2022; 38:e1266-e1270. [PMID: 35482504 DOI: 10.1097/pec.0000000000002591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Iron deficiency is extremely common in adolescents with heavy menstrual bleeding (HMB) presenting to the emergency department; however, patients are rarely screened for this. The objective of this study was to evaluate screening for iron deficiency in adolescents presenting to the emergency department for HMB. METHODS This is a secondary analysis of a single-center, cross-sectional observational study using retrospective chart review. The study subjects are adolescents ages 11 to 19 years with International Classification of Diseases, Ninth Revision, Clinical Modification/International Classification of Diseases, Tenth Revision, Clinical Modification, codes for HMB who presented to the emergency department at a national tertiary care hospital from 2006 to 2018. Pregnant adolescents with HMB were excluded. Chart abstraction for demographic data, symptoms, laboratory tests, treatments, and outcomes was performed. The main outcome measure was the number of adolescents who had an iron evaluation in the emergency department and were discharged on oral iron. RESULTS Of the 258 nonpregnant adolescents who sought care for HMB in the emergency department, 225 (87.2%) were evaluated with serum hemoglobin testing. Ninety-four (41.7%) of those tested were anemic. Only 23 of the 258 patients (8.9%) had iron studies (serum ferritin) performed; 18 of 23 (78.3%) had iron deficiency and 21 of 23 (92.3%) were anemic. Subjects presenting with fatigue, headache, or palpitations were more likely to have iron studies performed than those without these symptoms (all P < 0.01). Thirty-two of the 258 subjects (12.4%) were discharged on oral iron therapy, which included only 15 of the 18 subjects (83.3%) with iron deficiency determined by ferritin testing. CONCLUSIONS Adolescents presenting to the emergency department with HMB are at significant risk of iron deficiency but are not being screened or treated, which may have significant consequences.
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Affiliation(s)
| | | | | | - Monica W Rosen
- Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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Lobbes H, Durupt S, Mainbourg S, Pereira B, Nove-Josserand R, Durieu I, Reynaud Q. Iron Deficiency in Cystic Fibrosis: A Cross-Sectional Single-Centre Study in a Referral Adult Centre. Nutrients 2022; 14:nu14030673. [PMID: 35277032 PMCID: PMC8838796 DOI: 10.3390/nu14030673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 01/27/2023] Open
Abstract
Iron deficiency (ID) diagnosis in cystic fibrosis (CF) is challenging because of frequent systemic inflammation. We aimed to determine the prevalence and risk factors of ID in adult patients with CF. We conducted a single-centre prospective study in a referral centre. ID was defined by transferrin saturation ≤16% or ferritin ≤20 (women) or 30 (men) μg/L, or ≤100 μg/L in the case of systemic inflammation. Apparent exacerbation was an exclusion criterion. We included 165 patients (78 women), mean age—31.1 ± 8.9 years. ID prevalence was 44.2%. ID was significantly associated with female gender (58.9% vs. 38%), lower age (29.4 ± 8.5 vs. 32.5 ± 9.1), lower body mass index (20.5 ± 2.2 vs. 21.3 ± 2.5), and Pseudomonas aeruginosa colonization (70.8% vs. 55.1%). Diabetes mellitus, antiacid drug use and low pulmonary function were more frequent in patients with ID with no statistical significance. The use of CFTR correctors was not associated with ID. In the multivariate analysis, ID was associated with female gender (OR 2.64, CI95% 1.31−5.31), age < 30 years (OR 2.30, CI95% 1.16−4.56), and P. aeruginosa (OR 2.09, CI95% 1.04−4.19).
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Affiliation(s)
- Hervé Lobbes
- Service de Médecine Interne, Hôpital Estaing, CHU de Clermont-Ferrand, F-63000 Clermont-Ferrand, France
- SIGMA Clermont, Institut Pascal, CHU Clermont-Ferrand, Université Clermont Auvergne, CNRS, F-63000 Clermont-Ferrand, France
- Correspondence: ; Tel.: +33-4-73-750-085; Fax: +33-4-73-750-361
| | - Stéphane Durupt
- Département de Médecine Interne et Centre de Référence Mucoviscidose, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, F-69310 Pierre-Bénite, France; (S.D.); (S.M.); (R.N.-J.); (I.D.); (Q.R.)
| | - Sabine Mainbourg
- Département de Médecine Interne et Centre de Référence Mucoviscidose, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, F-69310 Pierre-Bénite, France; (S.D.); (S.M.); (R.N.-J.); (I.D.); (Q.R.)
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, F-69622 Villeurbanne, France
| | - Bruno Pereira
- Biostatistics Unit, Centre Hospitalier Universitaire de Clermont-Ferrand, F-63000 Clermont-Ferrand, France;
| | - Raphaele Nove-Josserand
- Département de Médecine Interne et Centre de Référence Mucoviscidose, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, F-69310 Pierre-Bénite, France; (S.D.); (S.M.); (R.N.-J.); (I.D.); (Q.R.)
| | - Isabelle Durieu
- Département de Médecine Interne et Centre de Référence Mucoviscidose, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, F-69310 Pierre-Bénite, France; (S.D.); (S.M.); (R.N.-J.); (I.D.); (Q.R.)
- Research on Healthcare Performance (REHSAPE), INSERM U1290, Université Claude Bernard Lyon 1, F-69373 Lyon, France
| | - Quitterie Reynaud
- Département de Médecine Interne et Centre de Référence Mucoviscidose, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, F-69310 Pierre-Bénite, France; (S.D.); (S.M.); (R.N.-J.); (I.D.); (Q.R.)
- Research on Healthcare Performance (REHSAPE), INSERM U1290, Université Claude Bernard Lyon 1, F-69373 Lyon, France
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Zia A, Stanek J, Christian‐Rancy M, Savelli S, O'Brien SH. Iron deficiency and fatigue among adolescents with bleeding disorders. Am J Hematol 2022; 97:60-67. [PMID: 34710246 DOI: 10.1002/ajh.26389] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 01/01/2023]
Abstract
Iron deficiency anemia is associated with heavy menstrual bleeding (HMB) and, by extension, a bleeding disorder (BD). It is unknown if iron deficiency without anemia is associated with a BD in adolescents. Moreover, the threshold of ferritin associated with fatigue in adolescents with HMB is unclear. In this multicenter study, we enrolled adolescents with HMB without BD. Participants underwent BD and anemia work-up in Young Women's Hematology Clinics and completed the Peds QL™ fatigue scale. BDs were defined as von Willebrand Disease, platelet function defect, clotting factor deficiencies, and hypermobility syndrome. Two hundred and fifty consecutive adolescents were enrolled, of whom 196 met eligibility criteria. Overall, 43% (95% confidence interval: 36%-50%) were diagnosed with BD. A total of 61% (n = 119) had serum ferritin levels < 15 ng/mL, 23.5% (n = 46) had iron deficiency only, and 37% (n = 73) had iron deficiency anemia. Low ferritin or ferritin dichotomized as < 15 or ≥ 15 ng/mL was not associated with BD on univariable analysis (p = .24) or when accounting for age, race, ethnicity, body mass index, and hemoglobin (p = .35). A total of 85% had total fatigue score below the population mean of 80.5, and 52% (n = 102) were > 2 SD (or < 54) below the mean, the cut-off associated with severe fatigue. A ferritin threshold of < 6 ng/mL had a specificity of 79.8% but a sensitivity of 36% for severe fatigue. In conclusion, iron deficiency without anemia is not a predictor of BD in adolescents with HMB in a specialty setting. Severe fatigue, especially sleep fatigue, is prevalent in adolescents with BD. Ferritin of < 6 ng/mL has ~80% specificity for severe fatigue in adolescents with HMB.
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Affiliation(s)
- Ayesha Zia
- Division of Pediatric Hematology/Oncology University of Texas Southwestern Medical Center Dallas Texas USA
- Department of Pediatrics University of Texas Southwestern Medical Center Dallas Texas USA
| | - Joseph Stanek
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital Columbus Ohio USA
| | - Myra Christian‐Rancy
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital Columbus Ohio USA
| | - Stephanie Savelli
- Department of Pediatrics, Akron Children's Hospital, The Ohio State University Columbus Ohio USA
- Northeastern Ohio Universities College of Medicine Columbus Ohio USA
| | - Sarah H. O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital Columbus Ohio USA
- Department of Pediatrics The Ohio State University, College of Medicine Columbus Ohio USA
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Beatrix J, Piales C, Berland P, Marchiset E, Gerbaud L, Ruivard M. Non-anemic iron deficiency: correlations between symptoms and iron status parameters. Eur J Clin Nutr 2021; 76:835-840. [PMID: 34811510 DOI: 10.1038/s41430-021-01047-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 08/02/2021] [Accepted: 11/01/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To register all symptoms reported by non-anemic menstruating women, and examine the links between these symptoms and iron status parameters available including serum ferritin (SF) in primary care. SUBJECTS AND METHODS In this cross-sectional study, we collected clinical and biological data from 780 French menstruating women aged 18-50 years. The data included an anonymous questionnaire (biometric information, physical and cognitive symptoms, reduction in physical performance, current quality of life with SF-36 questionnaire) and seven biological parameters available in primary care. We excluded women with anemia (hemoglobin < 12 g/dl) or chronic disease. Correlations were studied for 554 participants in bivariate analysis (BVA) and multivariate analysis (MVA), with adjusted odds ratio (OR). Receiver operating characteristic (ROC) curves were established for significant correlations in MVA (p < 0.05). RESULTS Among these 554 non-anemic women included, 304 (54.9%) had SF level below 50 µg/l, 103 (18.6%) had SF level below 20 µg/l, and 60 (10.8%) had SF level below 15 µg/l. Iron deficiency was significantly correlated with recent hair loss for SF ≤ 15 µg/l (OR = 2.19 with p = 0.02 in MVA) and SF ≤ 20 µg/l (OR = 2.26 with p < 0.01 in MVA). SF ≤ 20 µg/l was also correlated with limitations due to emotional problems according to SF-36 questionnaire (p = 0.01 in MVA). SF ≤ 50 µg/l was significantly correlated with restless legs syndrome (OR = 2.82 with p = 0.01 in MVA). Only one ROC curve for restless legs syndrome could suggest an optimal SF cut-off point at 39 µg/l (sensitivity 73%, specificity 61%). CONCLUSION We identified two symptoms significantly more reported by non-anemic iron-deficient menstruating women: recent hair loss for serum ferritin (SF) ≤ 20 µg/l and restless legs syndrome for SF ≤ 50 µg/l. Non-anemic iron deficiency may also impact their quality of life, but further investigation is needed. If one of these symptoms is reported in primary care, the possibility of a symptomatic iron deficiency cannot be ruled out, and iron supplementation should be considered.
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Affiliation(s)
- Julien Beatrix
- Service Médecine Interne, CHU Estaing, Clermont-Ferrand, France.
| | - Claire Piales
- Service Hématologie, Gen-Bio, Clermont-Ferrand, France
| | - Pauline Berland
- Service Santé Publique, CHU Gabriel Montpied, Clermont-Ferrand, France
| | | | - Laurent Gerbaud
- Service Santé Publique, CHU Gabriel Montpied, Clermont-Ferrand, France.,UMR 6602 UCA/CNRS/SIGMA - T.G.I., Université Clermont Auvergne, Clermont-Ferrand, France
| | - Marc Ruivard
- Service Médecine Interne, CHU Estaing, Clermont-Ferrand, France.,UMR 6602 UCA/CNRS/SIGMA - T.G.I., Université Clermont Auvergne, Clermont-Ferrand, France
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13
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Mansour D, Hofmann A, Gemzell-Danielsson K. A Review of Clinical Guidelines on the Management of Iron Deficiency and Iron-Deficiency Anemia in Women with Heavy Menstrual Bleeding. Adv Ther 2021; 38:201-225. [PMID: 33247314 PMCID: PMC7695235 DOI: 10.1007/s12325-020-01564-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/06/2020] [Indexed: 12/19/2022]
Abstract
Introduction Up to one-third of women of reproductive age experience heavy menstrual bleeding (HMB). HMB can give rise to iron deficiency (ID) and, in severe cases, iron-deficiency anemia (IDA). Aim To review current guidelines for the management of HMB, with regards to screening for anemia, measuring iron levels, and treating ID/IDA with iron replacement therapy and non-iron-based treatments. Methods The literature was searched for English-language guidelines relating to HMB published between 2010 and 2020, using the PubMed database, web searching, and retrieval of clinical guidelines from professional societies. Results Overall, 55 guidelines mostly originating from North America and Europe were identified and screened. Twenty-two were included in this review, with the majority (16/22) focusing on guidance to screen women with HMB for anemia. The guidance varied with respect to identifying symptoms, the criteria for testing, and diagnostic hemoglobin levels for ID/IDA. There was inconsistency concerning screening for ID, with 11/22 guidelines providing no recommendations for measurement of iron levels and four contrasting guidelines explicitly advising against initial assessment of iron levels. In terms of treatment, 8/22 guidelines provided guidance on iron therapy, with oral iron administration generally recommended as first-line treatment for ID and/or IDA. Four guidelines recommended intravenous iron administration for severe anemia, in non-responders, or before surgery. Three guidelines provided hemoglobin thresholds for choosing between oral or intravenous iron treatment. Four guidelines discussed the use of transfusion for severe IDA. Conclusion Many of the guidelines for managing HMB recognize the importance of treating anemia, but there is a lack of consensus in relation to screening for ID and use of iron therapy. Consequently, ID/IDA associated with HMB is likely to be underdiagnosed and undertreated. A consensus guidance, covering all aspects of screening and management of ID/IDA in women with HMB, is needed to optimize health outcomes in these patients. Women who bleed heavily during menstruation are at risk of iron deficiency and anemia. This can have a negative effect on the well-being of women and can cause serious complications after surgery. Iron is an important part of the hemoglobin in red blood cells that carries oxygen around the body. Bleeding causes iron to be lost from the body. If there is heavy blood loss, iron stores in the body can become low, leading to iron deficiency. If the iron deficiency is severe enough to impair red blood cell production, iron-deficiency anemia can develop. We reviewed the current guidelines for the care of women with heavy menstrual bleeding, focusing on the detection and treatment of iron deficiency and anemia. Most guidelines include routine testing for anemia. Fewer guidelines consider measuring iron levels. Not all the guidelines include advice on the best way to treat iron deficiency and anemia. For those that do, the recommendations vary and sometimes offer conflicting advice. There is little agreement on when to give iron therapy, and whether this should be given by mouth or by infusion. A lack of clear guidance on detecting and treating iron deficiency and anemia caused by heavy menstrual bleeding puts women at risk of being undiagnosed and untreated. To address these concerns, the authors recommend the development of consensus guidelines. These should contain comprehensive recommendations on all aspects of the diagnosis and management of iron deficiency and anemia in women with heavy menstrual bleeding.
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Prevalence of iron deficiency and related factors in Spanish adolescents. Eur J Pediatr 2020; 179:1587-1595. [PMID: 32342190 DOI: 10.1007/s00431-020-03651-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 04/12/2020] [Accepted: 04/15/2020] [Indexed: 12/21/2022]
Abstract
Iron deficiency anaemia continues to be the world's most important cause of years lived with disability in children and adolescents. Assessment of iron deficiency traditionally depended on laboratory parameters that may be modified by inflammation states, including obesity, which is nowadays a current condition in adolescent population of high-income countries. The present study ascertains the prevalence of iron deficiency and its related factors in adolescents, using the serum transferrin receptor and the reticulocyte haemoglobin content, in order to avoid this confusing effect of classical parameters. A cross-sectional study was conducted on a population-based representative sample for teenagers in Almería (Spain), of 405 subjects aged 12 to 16 years. Iron deficiency was present in 13.3% of adolescents, but iron deficiency anaemia only in 1.2%. Multivariate logistic regression analyses showed that being part of an immigrant family, a low iron bioavailability diet, meat consumption below four times a week and fish consumption below twice a week, were independent risk factors for iron deficiency.Conclusion: This study provides an estimate iron deficiency prevalence of 13.3% in Spanish healthy adolescents, avoiding potential confounding factors through the use of new iron status parameters, based on a wide representative sample of adolescents from the city of Almería. What is Known: • For children and adolescents, iron deficiency anaemia continues to be the world's most important cause of years lived with disability. • Assessment of iron deficiency has traditionally depended on laboratory parameters that may be modified by inflammatory states, including obesity. What is New: • Iron deficiency prevalence and their related factors were analysed in Spanish adolescents, avoiding potential confounding factors through the use of sTfR and CHr. • Being part of an immigrant family and consuming a low iron bioavailability diet are independent risk factors for iron deficiency.
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15
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Ozsahin H, Schaeppi M, Bernimoulin M, Allard M, Guidard C, van den Ouweland F. Intravenous ferric carboxymaltose for iron deficiency anemia or iron deficiency without anemia after poor response to oral iron treatment: Benefits and risks in a cohort of 144 children and adolescents. Pediatr Blood Cancer 2020; 67:e28614. [PMID: 32729200 DOI: 10.1002/pbc.28614] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/21/2020] [Accepted: 07/10/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of this single-center observational study was to determine the clinical and hematologic responses to intravenous ferric carboxymaltose (FCM) in a cohort of pediatric patients with poor response to oral iron therapy. The occurrence of adverse events was systematically recorded for up to 96 hours after infusion. STUDY DESIGN A retrospective cohort of 144 consecutive patients aged 18 months to < 18 years with iron deficiency anemia (IDA) or iron deficiency (ID) without anemia was investigated. All patients had failed oral iron therapy. The assessments before and after FCM treatment followed a predefined protocol. RESULTS One hundred of 117 (85 %) of patients with complete data achieved the target ferritin level ≥ 30 µg/L after a single FCM dose. Of 77 patients with IDA and complete data, 38 (49%) showed a complete hematological response within 6-12 weeks; a complete or partial response was achieved by 83%. Clinical symptoms improved in 85% of all patients. In 92% of patients (n = 133 /144), FCM infusion was uneventful. During the 96-hour follow-up, five patients reported potentially related symptoms. No serious adverse events occurred. CONCLUSION The study confirms the safety and efficacy of FCM in children (aged 18 months and older) and adolescents unresponsive to oral therapy, in real-world experience. Single-dose FCM treatment was followed by clinical improvement with advantages of safety, compliance, and lower cost compared with previous generation parenteral iron preparations that had to be administered in fractionated sessions.
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Affiliation(s)
- Hulya Ozsahin
- Centre de Pédiatrie, Clinique des Grangettes, Chêne-Bougeries, Switzerland
| | - Michela Schaeppi
- Centre de Pédiatrie, Clinique des Grangettes, Chêne-Bougeries, Switzerland
| | - Michael Bernimoulin
- Department of Oncology and Hematology, Hôpital de La Tour, Meyrin, Switzerland.,Dianalabs Medical Laboratory, Geneva, Switzerland
| | - Magali Allard
- Centre de Pédiatrie, Clinique des Grangettes, Chêne-Bougeries, Switzerland
| | - Clémence Guidard
- Centre de Pédiatrie, Clinique des Grangettes, Chêne-Bougeries, Switzerland
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16
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Anemia in Children With Inflammatory Bowel Disease: A Position Paper by the IBD Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2020; 71:563-582. [PMID: 32947565 DOI: 10.1097/mpg.0000000000002885] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Anemia is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). It can be asymptomatic or associated with nonspecific symptoms, such as irritability, headaches, fatigue, dizziness, and anorexia. In IBD patients, the etiology of anemia is often multifactorial. Various causes include iron deficiency, anemia of inflammation and chronic disease, vitamin deficiencies, hemolysis, or myelosuppressive effect of drugs. Anemia and iron deficiency in these patients may be underestimated because of their insidious onset, lack of standardized screening practices, and possibly underappreciation that treatment of anemia is also required when treating IBD. Practitioners may hesitate to use oral preparations because of their intolerance whereas intravenous preparations are underutilized because of fear of adverse events, availability, and cost. Several publications in recent years have documented the safety and comparative efficacy of various intravenous preparations. This article reviews management of anemia in children with IBD, including diagnosis, etiopathogenesis, evaluation of a patient, protocol to screen and monitor patients for early detection and response to therapy, treatment including parenteral iron therapy, and newer approaches in management of anemia of chronic disease. This report has been compiled by a group of pediatric gastroenterologists serving on the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) IBD committee, in collaboration with a pediatric hematologist, pharmacist, and a registered dietician who specializes in pediatric IBD (IBD Anemia Working Group), after an extensive review of the current literature. The purpose of this review is to raise awareness of under-diagnosis of anemia in children with IBD and make recommendations for screening, testing, and treatment in this population.
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17
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Spencer BR, Fox MP, Wise LA, Cable RG, Mast AE. Iron status and self-reported fatigue in blood donors. Transfusion 2020; 61:124-133. [PMID: 32974931 DOI: 10.1111/trf.16095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 12/21/2022]
Abstract
Fatigue is a reported symptom of iron depletion, but studies in blood donors show no conclusive link. We conducted an observational analysis of data from the STRIDE randomized trial to evaluate association of iron status with self-reported fatigue. STUDY DESIGN AND METHODS Three blood centers randomly assigned 692 frequent donors to education or iron supplementation treatments. Biomarkers for iron status were measured during 20 to 24 months of follow-up. A fatigue score was derived from an 11-item questionnaire at baseline and final visits, and associations between iron status and fatigue were assessed. RESULTS Final lab and questionnaire data were evaluable from 337 subjects. At baseline, female sex, older age, and anemia were associated with fatigue, but iron status was not. Mean (±SD) fatigue score change was 0.0 (±0.5). Mean (±SD) increase in iron stores was 1.0 (±3.5) mg/kg, but changes in body iron stores were not associated with fatigue score changes (0.01 per mg/kg; 95% CI, -0.01 to 0.02) or with fatigue (RR, 1.01; 95% CI, 0.99 to 1.04). The only factor associated with fatigue score changes was baseline fatigue (0.36; 95% CI, 0.25 to 0.48). CONCLUSION Among high-frequency donors, neither iron status at baseline nor changes in iron status predicted fatigue during follow-up, with improvements limited to those with higher levels of baseline fatigue. Assessment of the association between iron and fatigue in blood donors benefits from careful consideration of study design and the study population.
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Affiliation(s)
- Bryan R Spencer
- American Red Cross, Scientific Affairs, Dedham, Massachusetts, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Ritchard G Cable
- American Red Cross, Scientific Affairs, Dedham, Massachusetts, USA
| | - Alan E Mast
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA.,Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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18
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Microalgae biomass as an additional ingredient of gluten-free bread: Dough rheology, texture quality and nutritional properties. ALGAL RES 2020. [DOI: 10.1016/j.algal.2020.101998] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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19
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Jacobson-Kelly AE, Stanek JR, Powers JM, Dotson JL, O'Brien SH. Trends in Anemia, Iron, Therapy, and Transfusion in Hospitalized Pediatric Patients with Inflammatory Bowel Disease. J Pediatr 2020; 222:141-145.e1. [PMID: 32444225 DOI: 10.1016/j.jpeds.2020.02.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/27/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate trends in diagnosis and management of iron deficiency anemia using a large national children's hospital database in pediatric patients admitted with inflammatory bowel disease (IBD). STUDY DESIGN In this retrospective multicenter cohort study, we used the Pediatric Health Information System de-identified administrative database. Patients age <21 years with ≥2 admissions with International Classification of Disease, Ninth Revision and Tenth Revision codes for Crohn's disease or ulcerative colitis from 2012 to 2018 were included. We extracted data regarding diagnoses of anemia and/or iron deficiency, and receipt of oral iron, intravenous (IV) iron, and/or blood transfusion. Data were analyzed descriptively. RESULTS We identified 8007 unique patients meeting study criteria for a total of 28 260 admissions. The median age at admission was 15.4 years. A diagnosis of anemia was documented in 29.8% of admissions and iron studies were performed in 12.6%. IV iron was given in 6.3% of admissions and blood transfusions in 7.4%. The prevalence of the diagnosis of anemia among IBD admissions increased from 24.6% in 2012 to 32.4% in 2018 (P < .0001). There was a steady increase in the proportion of IBD admissions that used IV iron, from 3.5% in 2012 to 10.4% in 2018 (P < .0001), and the proportion of admissions with red cell transfusions decreased over time from 9.4% to 4.4% (P < .0001). CONCLUSIONS Iron deficiency anemia is prevalent among pediatric patients with IBD admitted to US children's hospitals. From 2012 to 2018, there was an increase in the use of inpatient IV iron for the treatment of iron deficiency anemia and a decrease in transfusions.
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Affiliation(s)
- Amanda E Jacobson-Kelly
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH
| | - Joseph R Stanek
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH
| | - Jacquelyn M Powers
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine; Texas Children's Hospital, Houston, TX
| | - Jennifer L Dotson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital/The Ohio State University; Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH; Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.
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20
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Philip KEJ, Sadaka AS, Polkey MI, Hopkinson NS, Steptoe A, Fancourt D. The prevalence and associated mortality of non-anaemic iron deficiency in older adults: a 14 years observational cohort study. Br J Haematol 2020; 189:566-572. [PMID: 32072619 PMCID: PMC7613129 DOI: 10.1111/bjh.16409] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/21/2019] [Indexed: 08/08/2023]
Abstract
Iron is central to multiple biological pathways, and treatment of non-anaemic absolute iron deficiency (NAID) is beneficial in certain conditions. However, it is unknown if NAID is associated with increased mortality in older adults. A nationally representative sample of 4451 older adults from the English Longitudinal Study of Ageing was used. NAID was defined as serum ferritin < 30 μg/l and haemoglobin ≥ 120 g/l (women) or ≥ 130 g/l (men). Cumulative mortality was estimated by Kaplan-Meier method. Unadjusted and adjusted hazard ratios (HRs) of mortality were calculated using Cox proportional hazards regression models. Baseline NAID prevalence was 8·8% (95% confidence interval [CI] 8·0-9·7%); 10·9% (95% CI 9·7-12·3%) for women and 6·35% for men (95% CI 5·3-7·5%). The HR for mortality for individuals with NAID compared with non-anaemic individuals without iron deficiency over the 14-year follow-up was 1·58 (95% CI 1·29-1·93). This association was independent of all identified demographic, health-related and biological covariates, and robust in multiple sensitivity analyses. In older adults in England, NAID is common and associated with an increased mortality rate compared to non-anaemic individuals with normal serum ferritin. The association is principally driven by an excess mortality in women.
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Affiliation(s)
- Keir EJ Philip
- National Heart and Lung Institute, Imperial College London, Fulham Rd, London, SW3 6NP, United Kingdom
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust
| | - Ahmed S Sadaka
- Alexandria University Faculty of Medicine, Chest Department, Alexandria, Egypt
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust
| | - Michael I Polkey
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust
| | - Nicholas S Hopkinson
- National Heart and Lung Institute, Imperial College London, Fulham Rd, London, SW3 6NP, United Kingdom
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust
| | - Andrew Steptoe
- Department of Behavioural Science and Health, University College London
| | - Daisy Fancourt
- Department of Behavioural Science and Health, University College London
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Macdougall IC, Comin-Colet J, Breymann C, Spahn DR, Koutroubakis IE. Iron Sucrose: A Wealth of Experience in Treating Iron Deficiency. Adv Ther 2020; 37:1960-2002. [PMID: 32297281 PMCID: PMC7467495 DOI: 10.1007/s12325-020-01323-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Indexed: 12/19/2022]
Abstract
Iron deficiency and iron-deficiency anemia are associated with increased morbidity and mortality in a wide range of conditions. In many patient populations, this can be treated effectively with oral iron supplementation; but in patients who are unable to take or who do not respond to oral iron therapy, intravenous iron administration is recommended. Furthermore, in certain conditions, such as end-stage kidney disease, chronic heart failure, and inflammatory bowel disease, intravenous iron administration has become first-line treatment. One of the first available intravenous iron preparations is iron sucrose (Venofer®), a nanomedicine that has been used clinically since 1949. Treatment with iron sucrose is particularly beneficial owing to its ability to rapidly increase hemoglobin, ferritin, and transferrin saturation levels, with an acceptable safety profile. Recently, important new data relating to the use of iron sucrose, including the findings from the landmark PIVOTAL trial in patients with end-stage kidney disease, have been reported. Several years ago, a number of iron sucrose similars became available, although there have been concerns about the clinical appropriateness of substituting the original iron sucrose with an iron sucrose similar because of differences in efficacy and safety. This is a result of the complex and unique physicochemical properties of nanomedicines such as iron sucrose, which make copying the molecule difficult and problematic. In this review, we summarize the evidence accumulated during 70 years of clinical experience with iron sucrose in terms of efficacy, safety, and cost-effectiveness.
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Affiliation(s)
| | - Josep Comin-Colet
- Department of Cardiology, Bellvitge University Hospital and IDIBELL, University of Barcelona, Barcelona, Spain
| | | | - Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zürich, Zurich, Switzerland
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22
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Mattiello V, Schmugge M, Hengartner H, von der Weid N, Renella R. Diagnosis and management of iron deficiency in children with or without anemia: consensus recommendations of the SPOG Pediatric Hematology Working Group. Eur J Pediatr 2020; 179:527-545. [PMID: 32020331 DOI: 10.1007/s00431-020-03597-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 11/26/2022]
Abstract
Iron deficiency is the most prevalent nutritional deficiency affecting children and adolescents worldwide. A consistent body of epidemiological data demonstrates an increased incidence of iron deficiency at three timepoints: in the neonatal period, in preschool children, and in adolescents, where it particularly affects females.Conclusion: This narrative review focuses on the most suggestive symptoms of iron deficiency in childhood, describes the diagnostic procedures in situations with or without anemia, and provides Swiss expert-based management recommendations for the pediatric context.What is Known:• Iron deficiency (ID) is one of the most common challenges faced by pediatricians.• Significant progress in the diagnosis and therapy of ID has been made over the last decade.What is New:• Our expert panel provides ID management recommendations based on the best available evidence.• They include strategies for ID diagnosis and therapy, both oral and intravenous.
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Affiliation(s)
- Veneranda Mattiello
- Department "Woman-Mother-Child and Adolescent", Pediatric Hematology-Oncology Unit, Division of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Markus Schmugge
- Division of Pediatric Hematology, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Heinz Hengartner
- Pediatric Hematology-Oncology Unit, Children's Hospital of Sankt Gallen, Sankt Gallen, Switzerland
| | - Nicolas von der Weid
- Pediatric Hematology-Oncology Department, University Children's Hospital and University of Basel, Basel, Switzerland
| | - Raffaele Renella
- Department "Woman-Mother-Child", Pediatric Hematology-Oncology Unit, Division of Pediatrics, Lausanne University Hospital and University of Lausanne, Vaudois, BH11, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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O'Brien SH, Saini S, Ziegler H, Christian-Rancy M, Ahuja S, Hege K, Savelli SL, Vesely SK. An Open-Label, Single-Arm, Efficacy Study of Tranexamic Acid in Adolescents with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2019; 32:305-311. [PMID: 30731217 DOI: 10.1016/j.jpag.2019.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/25/2019] [Accepted: 01/28/2019] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Heavy menstrual bleeding (HMB) occurs in up to 40% of adolescent girls, significantly affecting their daily activities. Identifying alternative treatment strategies for HMB is particularly important for adolescents who prefer not to take hormonal contraception. Our objective was to determine whether use of tranexamic acid (TA) would increase health-related quality of life and decrease menstrual blood loss (MBL) in adolescents with HMB. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: In an open-label, multi-institutional, single-arm, efficacy study, patients 18 years of age or younger with HMB were treated with oral TA 1300 mg 3 times daily during the first 5 days of menses and monitored over the course of 4 menstrual cycles (1 baseline; 3 treatment cycles). Assessment of MBL was performed using the Menorrhagia Impact Questionnaire (MIQ) and the Pictorial Blood Assessment Chart. The MIQ includes Likert scale items, validated to assess the influence of HMB on quality of life. In previous studies, a 1-point decrease or more in score correlated with clinically significant improvement. RESULTS Thirty-two patients enrolled in the study, and 25 had sufficient follow-up data to be deemed evaluable. The mean age of the participants was 14.7 years (range, 11-18 years). There was an overall improvement in all items of the MIQ, with a greater than 1-point improvement in the MIQ perceived blood loss scale. When using TA, mean Pictorial Blood Assessment Chart score improved by 100 points. There were no medication-related serious adverse events. CONCLUSION Use of TA in female adolescents with HMB is well tolerated and leads to clinically meaningful reduction in MBL.
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio; Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.
| | - Surbhi Saini
- Division of Pediatric Hematology/Oncology, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Heidi Ziegler
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio
| | - Myra Christian-Rancy
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio
| | - Sanjay Ahuja
- Division of Pediatric Hematology/Oncology, Rainbow Babies & Children's Hospitals, Cleveland, Ohio
| | - Kerry Hege
- Division of Pediatric Hematology/Oncology, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Stephanie L Savelli
- Division of Pediatric Hematology/Oncology, Akron Children's Hospital, Akron, Ohio
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Powers JM, Buchanan GR. Disorders of Iron Metabolism: New Diagnostic and Treatment Approaches to Iron Deficiency. Hematol Oncol Clin North Am 2019; 33:393-408. [PMID: 31030809 DOI: 10.1016/j.hoc.2019.01.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Iron deficiency anemia is the leading cause of anemia worldwide and affects many young children and adolescent girls in the United States. Its signs and symptoms are subtle despite significant clinical effects. Iron deficiency anemia is diagnosed clinically by the presence of risk factors and microcytic anemia. Improvement following a trial of oral iron therapy is confirmative. An array of iron laboratory tests is available with variable indications. Clinical trial and iron absorption data support a shift to lower-dose oral iron therapy. Intravenous iron should be considered in children who fail oral iron or who have more complex disorders.
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Affiliation(s)
- Jacquelyn M Powers
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Texas Children's Cancer and Hematology Centers, 6701 Fannin Street, Suite 1580, Houston, TX 77030, USA.
| | - George R Buchanan
- Pediatric Hematology-Oncology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, H3.104A, Dallas, TX 75390-9063, USA
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Powers JM, O'Brien SH. How I approach iron deficiency with and without anemia. Pediatr Blood Cancer 2019; 66:e27544. [PMID: 30393941 DOI: 10.1002/pbc.27544] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/18/2018] [Accepted: 10/19/2018] [Indexed: 12/13/2022]
Abstract
Iron deficiency anemia remains a common referral to the pediatric hematology-oncology subspecialist. Improved understanding of iron homeostasis, including the effects of the regulatory hormone hepcidin, recent adult and pediatric clinical trial data, as well as the availability of safer formulations of intravenous iron, have resulted in additional considerations when making treatment recommendations in such patients. Young children and adolescent females remain the most commonly affected groups, but children with complex medical or chronic inflammatory conditions including comorbid gastrointestinal disorders also require special consideration.
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Affiliation(s)
- Jacquelyn M Powers
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - Sarah H O'Brien
- Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio
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Iron Treatment May Be Difficult in Inflammatory Diseases: Inflammatory Bowel Disease as a Paradigm. Nutrients 2018; 10:nu10121959. [PMID: 30544934 PMCID: PMC6316243 DOI: 10.3390/nu10121959] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 12/13/2022] Open
Abstract
Iron plays a key role in many physiological processes; cells need a very exact quantity of iron. In patients with inflammatory bowel disease, anaemia is a unique example of multifactorial origins, frequently being the result of a combination of iron deficiency and anaemia of chronic disease. The main cause of iron deficiency is the activity of the disease. Therefore, the first aim should be to reach complete clinical remission. The iron supplementation route should be determined according to symptoms, severity of anaemia and taking into account comorbidities and individual risks. Oral iron can only be used in patients with mild anaemia, whose disease is inactive and who have not been previously intolerant to oral iron. Intravenous iron should be the first line treatment in patients with moderate-severe anaemia, in patients with active disease, in patients with poor tolerance to oral iron and when erythropoietin agents or a fast response is needed. Erythropoietin is used in a few patients with anaemia to overcome functional iron deficiency, and blood transfusion is being restricted to refractory cases or acute life-threatening situations.
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Abstract
Anemia of inflammation (AI), also known as anemia of chronic disease (ACD), is regarded as the most frequent anemia in hospitalized and chronically ill patients. It is prevalent in patients with diseases that cause prolonged immune activation, including infection, autoimmune diseases, and cancer. More recently, the list has grown to include chronic kidney disease, congestive heart failure, chronic pulmonary diseases, and obesity. Inflammation-inducible cytokines and the master regulator of iron homeostasis, hepcidin, block intestinal iron absorption and cause iron retention in reticuloendothelial cells, resulting in iron-restricted erythropoiesis. In addition, shortened erythrocyte half-life, suppressed erythropoietin response to anemia, and inhibition of erythroid cell differentiation by inflammatory mediators further contribute to AI in a disease-specific pattern. Although the diagnosis of AI is a diagnosis of exclusion and is supported by characteristic alterations in iron homeostasis, hypoferremia, and hyperferritinemia, the diagnosis of AI patients with coexisting iron deficiency is more difficult. In addition to treatment of the disease underlying AI, the combination of iron therapy and erythropoiesis-stimulating agents can improve anemia in many patients. In the future, emerging therapeutics that antagonize hepcidin function and redistribute endogenous iron for erythropoiesis may offer additional options. However, based on experience with anemia treatment in chronic kidney disease, critical illness, and cancer, finding the appropriate indications for the specific treatment of AI will require improved understanding and a balanced consideration of the contribution of anemia to each patient's morbidity and the impact of anemia treatment on the patient's prognosis in a variety of disease settings.
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Muñoz M, Acheson AG, Bisbe E, Butcher A, Gómez‐Ramírez S, Khalafallah AA, Kehlet H, Kietaibl S, Liumbruno GM, Meybohm P, Rao Baikady R, Shander A, So‐Osman C, Spahn DR, Klein AA. An international consensus statement on the management of postoperative anaemia after major surgical procedures. Anaesthesia 2018; 73:1418-1431. [PMID: 30062700 PMCID: PMC6686161 DOI: 10.1111/anae.14358] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2018] [Indexed: 01/28/2023]
Abstract
Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.
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Affiliation(s)
- M. Muñoz
- Department of Surgical Specialties, Biochemistry and ImmunologySchool of MedicineUniversity of MálagaMálagaSpain
| | - A. G. Acheson
- Department of Colorectal SurgeryNottingham Digestive Diseases CentreNational Institute for Health Research Biomedical Research UnitNottingham University HospitalsNottinghamUK
| | - E. Bisbe
- Department of AnaesthesiaUniversity Hospital Mar‐EsperanzaBarcelonaSpain
| | - A. Butcher
- Division of SurgeryUniversity College LondonLondonUK
| | - S. Gómez‐Ramírez
- Department of Internal MedicineUniversity Hospital Virgen de la VictoriaMálagaSpain
| | - A. A. Khalafallah
- Department of Haematology and MedicineLaunceston General HospitalLauncestonAustralia
- Menzies Institute for Medical ResearchUniversity of TasmaniaAustralia
| | - H. Kehlet
- Section of Surgical PathophysiologyRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - S. Kietaibl
- Department of Anaesthesia and Intensive CareEvangelical HospitalViennaAustria
| | - G. M. Liumbruno
- Italian National Blood CentreNational Institute of HealthRomeItaly
| | - P. Meybohm
- Department of AnaesthesiologyIntensive Care Medicine and Pain TherapyUniversity Hospital FrankfurtFrankfurtGermany
| | - R. Rao Baikady
- Department of AnaesthesiaRoyal Marsden NHS Foundation TrustLondonUK
| | - A. Shander
- AnaesthesiologyCritical Care and Hyperbaric MedicineEnglewood Hospital and Medical CentreEnglewoodNJUSA
- TeamHealth Research InstituteEnglewoodNJUSA
| | - C. So‐Osman
- Department of Transfusion MedicineSanquin Blood BankAmsterdamThe Netherlands
- Department of Internal MedicineGroene Hart HospitalGoudaThe Netherlands
| | - D. R. Spahn
- Institute of AnaesthesiologyUniversity Hospital of ZurichZurichSwitzerland
- Intensive Care Medicine and Operating Room ManagementUniversity Hospital of ZurichZurichSwitzerland
| | - A. A. Klein
- Department of Anaesthesia and Intensive CareRoyal Papworth HospitalCambridgeUK
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Current misconceptions in diagnosis and management of iron deficiency. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 15:422-437. [PMID: 28880842 DOI: 10.2450/2017.0113-17] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 06/30/2017] [Indexed: 12/15/2022]
Abstract
The prevention and treatment of iron deficiency is a major public health goal. Challenges in the treatment of iron deficiency include finding and addressing the underlying cause and the selection of an iron replacement product which meets the needs of the patient. However, there are a number of non-evidence-based misconceptions regarding the diagnosis and management of iron deficiency, with or without anaemia, as well as inconsistency of terminology and lack of clear guidance on clinical pathways. In particular, the pathogenesis of iron deficiency is still frequently not addressed and iron not replaced, with indiscriminate red cell transfusion used as a default therapy. In our experience, this imprudent practice continues to be endorsed by non-evidence-based misconceptions. The intent of the authors is to provide a consensus that effectively challenges these misconceptions, and to highlight evidence-based alternatives for appropriate management (referred to as key points). We believe that this approach to the management of iron deficiency may be beneficial for both patients and healthcare systems. We stress that this paper solely presents the Authors' independent opinions. No pharmaceutical company funded or influenced the conception, development or writing of the manuscript.
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Abstract
Iron deficiency is one of the most common causes of anemia. The 2 main etiologies of iron deficiency are blood loss due to menstrual periods and blood loss due to gastrointestinal bleeding. Beyond anemia, lack of iron has protean manifestations, including fatigue, hair loss, and restless legs. The most efficient test for the diagnosis of iron deficiency is the serum ferritin. Iron replacement can be done orally, or in patients in whom oral iron is not effective or contraindicated, with intravenous iron.
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Affiliation(s)
- Thomas G DeLoughery
- Division of Hematology/Medical Oncology, Department of Medicine, Knight Cancer Institute, Oregon Health and Science University, MC L586, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
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