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Jia W, Wang S, Yang S, Zhao Y, Zhu Q, Ning C, Chen Y, Fu S, Chen Y, He Y, Liu M. Association of anemia with all-cause mortality in Chinese centenarians: a prospective cohort study. J Nutr Health Aging 2024; 28:100248. [PMID: 38669839 DOI: 10.1016/j.jnha.2024.100248] [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: 12/15/2023] [Revised: 04/12/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVES This study aimed to examine the relationship between anemia and all-cause mortality in Chinese centenarians. DESIGN Prospective cohort study. SETTING AND PARTICIPANTS We included 1002 Chinese centenarians from the China Hainan Centenarian Cohort Study (CHCCS) MEASUREMENTS: Standard procedures were followed to perform blood analysis, home interviews, and physical examinations. Anemia was defined as a hemoglobin level of less than 130 g/L for men and less than 120 g/L for women. RESULTS During the 9-year follow-up period, a total of 929 (92.7%) deaths were identified. Cox proportional hazards regression models revealed that anemia (hazard ratio [HR] 1.289, 95% confidence interval [CI]: 1.117-1.489) was significantly associated with all-cause mortality. There was an apparent dose-response relationship between anemia and all-cause mortality. Centenarians with severe anemia had approximately 1.6 times higher likelihood of all-cause mortality than those without anemia (HR 1.662; 95% CI: 1.154-2.394). CONCLUSION Anemia is associated with an increased risk of all-cause mortality in Chinese centenarians. Further research will be needed to collect more comprehensive data on the etiology of anemia and causes of death in centenarians.
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Affiliation(s)
- Wangping Jia
- Department of Wound Infection and Drug, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Shengshu Wang
- Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Shanshan Yang
- Department of Disease Prevention and Control, First Medical Center, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Yali Zhao
- Central Laboratory, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya 572013, China
| | - Qiao Zhu
- Central Laboratory, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya 572013, China
| | - Chaoxue Ning
- Central Laboratory, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya 572013, China
| | - Yujian Chen
- Central Laboratory, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya 572013, China
| | - Shihui Fu
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya 572013, China
| | - Yizhi Chen
- Department of Nephrology, Hainan Hospital of Chinese PLA General Hospital, Academician Chen Xiangmei of Hainan Province Kidney Diseases Research Team Innovation Center, Sanya 572013, China; Senior Department of Nephrology, The First Medical Center of Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Yao He
- Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, Beijing 100853, China.
| | - Miao Liu
- Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, Beijing 100853, China; Department of Anti-NBC Medicine, Graduate School, Chinese People's Liberation Army General Hospital, Beijing 100853, China.
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Kara O, Elibol T, Koc Okudur S, Smith L, Soysal P. Associations between anemia and insomnia or excessive daytime sleepiness in older adults. Acta Clin Belg 2022; 78:223-228. [PMID: 36036443 DOI: 10.1080/17843286.2022.2116895] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Sleep disorders including excessive daytime sleepiness (EDS), insomnia and anemia are both common. The aim of this study is to investigate associations between anemia and insomnia/EDS in the elderly. METHODS A total of 744 older outpatients were included in this cross-sectional study. Anemia was defined as a hemoglobin concentration below 12 g/dL in females and <13 g/dl in males. Patients were divided into two groups as anemic and non-anemic. The Epworth Sleepiness Scale score of ≥11 points indicates EDS. Insomnia Severity Index with scores of ≥8 indicates insomnia. RESULTS The mean age was 79.8±7.7 years. The prevalence of insomnia, EDS and anemia was 62.1%, 23.8%, and 47.2%, respectively. Insomnia (66.3% vs 58.5%) and EDS (29.6% vs 18.6%) were more common in patients with anemia compared to those without anemia (p<0.05). In univariate analysis, there were significant associations between anemia and insomnia [odds ratio (OR):1.4, 95% confidence interval (CI):1.0-1.9], and EDS (OR:1.8,95% CI:1.3-2.6). In multivariate analysis, the relationship between insomnia and nocturia, chronic obstructive pulmonary disease (COPD), and number of drugs used persisted, whereas being male, of an older age, coronary arterial disease, COPD, Parkinson's disease, dementia, and urinary incontinence were associated with EDS (p<0.05), but there was no significant relationships between anemia and insomnia/EDS (p>0.05). CONCLUSION The present data suggests that an elderly who has anemia is 1.4 times more likely to experience insomnia and 1.8 times more likely to experience EDS than those without anemia.
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Affiliation(s)
- Osman Kara
- Department of Hematology, Bahcesehir University Medical Park Goztepe Hospital, Istanbul, Turkey
| | - Tayfun Elibol
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Saadet Koc Okudur
- Department of Geriatric Medicine, Manisa State Hospital, Manisa, Turkey
| | - Lee Smith
- Centre for Health, Performance, and Wellbeing, Anglia Ruskin University, Cambridge, UK
| | - Pinar Soysal
- Department of Geriatric Medicine, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
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Guerreiro R, Henriques C, Trevas S, Gouveia C, Roldão M, Egídio de Sousa I, Faria C, Pimenta G, Araújo I, Fonseca C. Predicting Prognosis in Internal Medicine: A Short and Long-Term Mortality Comparison Analysis. Cureus 2022; 14:e21734. [PMID: 35251806 PMCID: PMC8887684 DOI: 10.7759/cureus.21734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction The marked increase in life expectancy seen in Portugal in the last five decades led to a change in the profile of patients being most commonly admitted in internal medicine wards. In deciding the best care for these patients, prognostication models are needed in order to reduce readmissions, mortality, and adequate care. We aimed to study short and long-term mortality and predictors of all-cause mortality, independently of cause admission, of patients admitted in an internal medicine ward. Methods This two-part, single-center study enrolled patients from October 2013 to October 2014 with a follow-up of 60 months. Results A total of 681 patients were included; the mean age was 75.86 years with 60.4% females. The most frequent comorbidities were anemia, hypertension, and renal impairment. More than half of the population died in the follow-up period (51.5%). Deaths were significantly higher in the first six months after discharge (53% of all deaths) and then decreased abruptly to 11.6% in the second half-year after discharge. Based on the multivariate logistic regression model, with age over 80 years, anemia and neoplasm were independent predictors of short-term (p<0.001, p=0.001, p<0.001, respectively) and long-term (p<0.001 for the three conditions) mortality. Heart failure (p=0.018) and diabetes (p=0.025) were also predictors of long-term mortality. Conclusion High mortality, mainly in the first six months after discharge, elicits strategies targeting transition of care and close follow-up in the first months, which can be the key to improving outcomes. Identification of patients at higher risk may help design realistic models aiming to improve care for this frail population and decrease morbimortality.
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Lang Z, Wu Y, Bao M. Coagulation Status and Surgical Approach as Predictors of Postoperative Anemia in Patients Undergoing Thoracic Surgery: A Retrospective Study. Front Surg 2021; 8:744810. [PMID: 34621782 PMCID: PMC8490746 DOI: 10.3389/fsurg.2021.744810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 08/26/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: Postoperative anemia is a common complication after a major surgery. Our study aims to identify factors that are associated with higher risk of developing postoperative anemia after thoracic surgery. Methods: We conducted a retrospective study of 465 patients who underwent pulmonary surgery in 2017 in Shanghai Pulmonary Hospital, China. Of them, 191 patients underwent standard open thoracotomy (OT), and 274 patients underwent video-assisted thoracic surgery (VATS). A total of 350 patients were diagnosed with postoperative anemia, and 115 patients did not have anemia. Multiple logistic regression was used to compute odds ratios for predicting preoperative anemia. Results: Postoperative anemia was associated with significantly lower weight (p < 0.001) and height (p = 0.022) of the patients, as well as higher prothrombin time (PT), and international normalized ratio (INR) (p = 0.012). Open thoracotomy resulted in a 1.2-fold increase in the incidence of postoperative anemia compared to VATS (p = 0.002). Multiple logistic regression analysis identified INR [OR (95% CI) 24.46 (2.05–292.27; p = 0.012] and surgical approach [OR (95% CI) 0.48 (0.31–0.74); p < 0.001] as predictors of postoperative anemia and postoperative drop in hemoglobin (Hb). Conclusion: Postoperative coagulation status and surgical approach are statistically significant predictors of postoperative anemia in patients undergoing thoracic surgery. International normalized ratio and surgical approach are specifically associated with Hb drop immediately after the surgery.
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Affiliation(s)
- Zhongping Lang
- Department of Laboratory Medicine, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
| | - Yue Wu
- Department of Laboratory Medicine, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
| | - Minwei Bao
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital Affiliated to Tongji University, Shanghai, China
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Naranjo-Velasco V, Pastor-Mena M, Rubio-Marín P, Anglada-Pintado JC. Síndrome constitucional y anemia como debut de vasculitis en un adulto mayor. Reporte de caso. CASE REPORTS 2021. [DOI: 10.15446/cr.v7n2.89388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. Las vasculitis son enfermedades graves que suelen tener un debut muy inespecífico y un diagnóstico tardío, lo que implica una alta tasa de fracaso terapéutico. Se presenta un caso de vasculitis que puede contribuir a considerar esta enfermedad como parte del diagnóstico diferencial desde las primeras etapas del proceso de atención para garantizar un abordaje integral y un inicio temprano del tratamiento, lo que reduciría la morbimortalidad asociada a estas entidades y mejoraría la tasa de éxito de los tratamientos.
Presentación del caso. Mujer caucásica de 77 años que como único antecedente presentaba hipertensión arterial de dos años de evolución y quien consultó al servicio de urgencias de una institución de segundo nivel por cuadro clínico de un mes de evolución consistente en astenia, febrícula, hiporexia y pérdida de peso. La paciente fue hospitalizada para completar la historia clínica y dados los hallazgos se sospechó de una posible translocación bacteriana secundaria a una neoplasia intestinal y se inició cobertura antibiótica empírica, pero su condición seguía empeorando. Se realizaron pruebas complementarias que no arrojaron resultados concluyentes; ante la persistencia de la fiebre, la insuficiencia renal y la anemia, se realizó una biopsia de riñón que mostró vaso arterial con necrosis fibrinoide e infiltrados de polimorfonucleares asociados, claros signos de una vasculitis activa del tipo poliangeítis microscópica. Se instauró el tratamiento indicado pero la paciente tuvo una evolución desfavorable y falleció.
Conclusiones. La exposición de este caso inusual contribuye a que los profesionales de la salud consideren el diagnóstico de vasculitis desde el inicio de la atención, aun cuando la sintomatología sugiere otras patologías o incluso cuando se presentan síntomas tan inespecíficos como anemia y pérdida de peso, ya que esto ayudará a establecer un diagnóstico temprano.
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Anaemia of chronic diseases: Pathophysiology, diagnosis and treatment. Med Clin (Barc) 2020; 156:235-242. [PMID: 33358297 DOI: 10.1016/j.medcli.2020.07.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 12/15/2022]
Abstract
Anaemia of chronic disease (ACD) is generated by the activation of the immune system by autoantigens, microbial molecules or tumour antigens resulting in the release of cytokines that cause an elevation of serum hepcidin, hypoferraemia, suppression of erythropoiesis, decrease in erythropoietin (EPO) and shortening of the half-life of red blood cells. Anaemia is usually normocytic and normochromic, which is the most prevalent after iron deficiency anaemia, and it is the most frequent in the elderly and in hospitalized patients. If the anaemia is severe, the patient's quality of life deteriorates, and it can have a negative impact on survival. Treatment is aimed at controlling the underlying disease and correcting anaemia. Sometimes intravenous iron and EPO have been used, but the therapeutic future is directed against hepcidin, which is the final target of anaemia.
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Chueh HW, Jung HL, Shim YJ, Choi HS, Han JY. High anemia prevalence in Korean older adults, an advent healthcare problem: 2007-2016 KNHANES. BMC Geriatr 2020; 20:509. [PMID: 33243179 PMCID: PMC7689998 DOI: 10.1186/s12877-020-01918-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/18/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Anemia is associated with high morbidity and mortality in older people. However, the prevalence and characteristics of anemia in older individuals are not fully understood, and national data on these aspects in older Korean adults are lacking. This study aimed to evaluate the prevalence and characteristics of anemia in older adults using data from the Korea National Health and Nutrition Examination Survey (KNHANES), which is a nationwide cross-sectional epidemiological study conducted by the Korean Ministry of Health and Welfare. METHODS Data from a total of 62,825 participants of the 2007-2016 KNHANES were compiled and analyzed to investigate differences in participant characteristics and potential risk factors for anemia. Differences in clinical characteristics of participants were compared across subgroups using the chi-square test for categorical variables and independent t-test for continuous variables. Univariate and multivariate analyses using logistic regression were performed to identify related clinical factors. RESULTS The prevalence of anemia was higher in the population aged ≥65 years than in the younger population. Anemia was also more prevalent among females than among males, but this difference was not significant in people aged > 85 years. Being underweight, receiving a social allowance, living alone, and having comorbidities such as hypertension, rheumatoid arthritis, diabetes mellitus (DM), cancer, and chronic renal failure (CRF) were more common among older adults with anemia than among the population without anemia. In univariate and multivariate analyses, older age, female sex, underweight, and presence of comorbidities including rheumatoid arthritis, DM, cancer, and CRF were associated with an increased risk of anemia. CONCLUSIONS This study revealed that age, female sex, underweight, and the presence of comorbidities such as rheumatoid arthritis, DM, cancer, and CRF were associated with an increased risk of anemia in older Korean adults. Further study on causal relationships between anemia and other variables in the older population is necessary.
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Affiliation(s)
- Hee Won Chueh
- Department of Pediatrics, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Hye Lim Jung
- Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ye Jee Shim
- Department of Pediatrics, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Hyoung Soo Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jin Yeong Han
- Department of Laboratory Medicine, Dong-A University College of Medicine, 26 Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea.
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Gómez-Ramirez S, Jericó C, Muñoz M. Perioperative anemia: Prevalence, consequences and pathophysiology. Transfus Apher Sci 2019; 58:369-374. [DOI: 10.1016/j.transci.2019.06.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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: 144] [Impact Index Per Article: 24.0] [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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Gómez-Ramírez S, Brilli E, Tarantino G, Muñoz M. Sucrosomial ® Iron: A New Generation Iron for Improving Oral Supplementation. Pharmaceuticals (Basel) 2018; 11:E97. [PMID: 30287781 PMCID: PMC6316120 DOI: 10.3390/ph11040097] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 01/28/2023] Open
Abstract
Iron deficiency (ID) is usually treated with oral iron salts, but up to 50% of patients complain of gastrointestinal side effects, leading to reduced treatment compliance. Intravenous (IV) iron formulations are increasingly safer, but there is still a risk of infusion and hypersensitivity reactions and the need for a venous access and infusion monitoring. Sucrosomial® iron (SI) is an innovative oral iron formulation in which ferric pyrophosphate is protected by a phospholipid bilayer plus a sucrester matrix (sucrosome), which is absorbed through para-cellular and trans-cellular routes (M cells). This confers SI unique structural, physicochemical and pharmacokinetic characteristics, together with high iron bioavailability and excellent gastrointestinal tolerance. The analysis of available evidence supports oral SI iron as a valid option for ID treatment, which is more efficacious and better tolerated than oral iron salts. SI has also demonstrated similar effectiveness, with lower risks, in patients usually receiving IV iron (e.g., chronic kidney disease, cancer, bariatric surgery). Thus, oral SI emerges as a most valuable first option for treating ID, even more for subjects with intolerance to or inefficacy of iron salts. Moreover, SI should be also considered as an alternative to IV iron for initial and/or maintenance treatment in different patient populations.
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Affiliation(s)
- Susana Gómez-Ramírez
- Department of Internal Medicine, University Hospital Virgen de la Victoria. Campus de Teatinos, 2010 Málaga, Spain.
| | - Elisa Brilli
- Scientific Department, Alesco S.r.l. Via delle Lenze, 216/B, 56122 Pisa, Italy.
| | - Germano Tarantino
- Scientific Department, Pharmanutra S.p.A. Via delle Lenze, 216/B, 56122 Pisa, Italy.
| | - Manuel Muñoz
- Perioperative Transfusion Medicine, Department of Surgical Specialties, Biochemistry and Immunology, School of Medicine, Campus de Teatinos, 29071 Málaga, Spain.
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