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Akinajo OR, Annerstedt KS, Banke-Thomas A, Obi-Jeff C, Sam-Agudu NA, Babah OA, Balogun MR, Beňová L, Afolabi BB. Implementation fidelity of intravenous ferric carboxymaltose administration for iron deficiency anaemia in pregnancy: a mixed-methods study nested in a clinical trial in Nigeria. Implement Sci Commun 2024; 5:81. [PMID: 39044260 PMCID: PMC11264421 DOI: 10.1186/s43058-024-00609-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/26/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Iron deficiency anaemia is common among pregnant women in Nigeria. The standard treatment is oral iron therapy, which can be sub-optimal due to side effects. Intravenous ferric carboxymaltose (FCM) is an evidenced-based alternative treatment with a more favourable side effect profile requiring administration according to a standardized protocol. In this study, we assessed the fidelity of administering a single dose of FCM according to protocol and identified factors influencing implementation fidelity. METHODS We used a mixed-method approach with a sequential explanatory design nested in a clinical trial across 11 facilities in Lagos and Kano States, Nigeria. Guided by a conceptual framework of implementation fidelity, we quantitatively assessed adherence to protocol by directly observing every alternate FCM administration, using an intervention procedure checklist, and compared median adherence by facility and state. Qualitative fidelity assessment was conducted via in-depth interviews with 14 skilled health personnel (SHP) from nine purposively selected health facilities, using a semi-structured interview guide. We analyzed quantitative data using descriptive and inferential statistics in Stata and used thematic analysis to analyze the transcribed interviews in NVivo. RESULTS A total of 254 FCM administrations were observed across the 11 study sites, with the majority in secondary (63%), followed by primary healthcare facilities (PHCs) (30%). Overall, adherence to FCM administration as per protocol was moderate (63%) and varied depending on facility level. The lowest level of adherence was observed in PHCs (36%). Median, adherence level showed significant differences by facility level (p = 0.001) but not by state (p = 0.889). Teamwork and availability of protocols are facilitation strategies that contributed to high fidelity. However, institutional/ logistical barriers are contextual factors that influenced the varied fidelity levels observed in some facilities. CONCLUSIONS Collaborative teams and access to operating protocols resulted in high fidelity in some facilities. However, in some PHCs, fidelity to FCM was low due to contextual factors and intervention complexities, thereby influencing the quality of delivery. In Nigeria, scale-up of FCM will require attention to staff strength, teamwork and availability of administration protocols, in order to optimize its impact on anaemia in pregnancy.
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Affiliation(s)
- Opeyemi R Akinajo
- Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Lagos, Idi-Araba, Nigeria.
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Idi-Araba, Nigeria.
- Centre for Clinical Trials and Implementation Science (CCTRIS), College of Medicine, University of Lagos, Lagos, Idi-Araba, Nigeria.
| | | | - Aduragbemi Banke-Thomas
- Centre for Clinical Trials and Implementation Science (CCTRIS), College of Medicine, University of Lagos, Lagos, Idi-Araba, Nigeria
- Maternal, Adolescent, Reproductive and Child Health (MARCH), Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Chisom Obi-Jeff
- Brooks Insights Limited, Abuja, FCT, Nigeria
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Nadia A Sam-Agudu
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
- Global Pediatrics Program and Division of Infectious Diseases, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ochuwa A Babah
- Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Lagos, Idi-Araba, Nigeria
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Idi-Araba, Nigeria
- Centre for Clinical Trials and Implementation Science (CCTRIS), College of Medicine, University of Lagos, Lagos, Idi-Araba, Nigeria
| | - Mobolanle R Balogun
- Centre for Clinical Trials and Implementation Science (CCTRIS), College of Medicine, University of Lagos, Lagos, Idi-Araba, Nigeria
- Department of Community Health & Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bosede Bukola Afolabi
- Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Lagos, Idi-Araba, Nigeria
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Idi-Araba, Nigeria
- Centre for Clinical Trials and Implementation Science (CCTRIS), College of Medicine, University of Lagos, Lagos, Idi-Araba, Nigeria
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Li M, Wright A, Rahim AM, Tan KH, Tagore S. Retrospective Study Comparing Treatment Outcomes in Obstetric Patients With Iron Deficiency Anemia Treated With and Without Intravenous Ferric Carboxymaltose. Cureus 2024; 16:e55713. [PMID: 38586790 PMCID: PMC10998652 DOI: 10.7759/cureus.55713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Iron deficiency anemia is associated with an increased risk of adverse maternal and perinatal outcomes. Intravenous iron preparation containing ferric carboxymaltose has been shown to be a safe and effective way of increasing hemoglobin (Hb) and mean corpuscular volume (MCV) levels and reducing the need for blood transfusion. In our center, it used to be given as an inpatient procedure because of the risks of potential drug reactions. In 2021, we initiated the administration of intravenous ferric carboxymaltose as an outpatient procedure. We compared the outcomes of patients between 2021 and 2023 after the initiation of outpatient administration of intravenous ferric carboxymaltose in 127 obstetric patients with iron deficiency anemia in the second and third trimesters. Methods In this study conducted in a large maternity unit in Singapore between 2021 to 2023, we compared the changes in maternal hematological parameters among obstetric patients with iron deficiency anemia presenting to the day care unit in the second or third trimester with a Hb level of <8 g/dl treated with a single dose of ferric carboxymaltose injection (Ferinject) against a control group who were referred for treatment but defaulted on and declined treatment. Results Ferric carboxymaltose significantly increased the Hb and MCV levels at delivery in obstetric patients with iron deficiency. The mean Hb at delivery was 10.8 g/dL in the case group compared to 8.8 g/dL in the control group. The percentage of patients with Hb ≥10.0 g/dL was 73.4% in the case group compared to 27.8% in the control group. The incidence of adverse side effects was low and mild (2/127; 1.6%). None of the patients received were hospitalized because of ferric carboxymaltose. Conclusion A single injection dose of ferric carboxymaltose as an outpatient antenatal procedure was easily administered and well tolerated. Obstetric patients with iron deficiency anemia who received intravenous ferric carboxymaltose had a significantly higher level of Hb than those who did not.
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Affiliation(s)
- Mingyue Li
- Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore, SGP
| | - Ann Wright
- Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore, SGP
| | - Asmira M Rahim
- Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore, SGP
| | - Kok Hian Tan
- Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore, SGP
| | - Shephali Tagore
- Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore, SGP
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3
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Bellad MB, Patted A, Derman RJ. Is It Time to Alter the Standard of Care for Iron Deficiency/Iron Deficiency Anemia in Reproductive-Age Women? Biomedicines 2024; 12:278. [PMID: 38397880 PMCID: PMC10886917 DOI: 10.3390/biomedicines12020278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
Two billion people worldwide suffer from anemia, with reproductive-age women being disproportionately affected. Iron plays a crucial role in cellular function and impacts cognition, physical function, and quality of life. Iron deficiency (ID) and iron deficiency anemia (IDA) are associated with adverse effects on pregnancy and fetal development. Oral iron supplementation has been the standard treatment for decades, often producing sub-optimal outcomes. Many babies are still being born with ID and suffer adverse sequelae due to inadequate iron levels in the mothers. Is it time to consider a broad scale-up of parenteral iron as a new standard of care?
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Affiliation(s)
- Mrutyunjaya B. Bellad
- Department of Obstetrics and Gynecology, KAHER’s Jawaharlal Nehru Medical College, Belagavi 590010, Karnataka, India;
| | - Anmol Patted
- Department of Global Affairs, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Richard J. Derman
- Department of Global Affairs, Thomas Jefferson University, Philadelphia, PA 19107, USA;
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Cai QY, Deng BN, Liu TH. The REVAMP trial: key questions remain. Lancet 2024; 403:29. [PMID: 38184335 DOI: 10.1016/s0140-6736(23)01920-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/08/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Qin-Yu Cai
- The Joint International Research Laboratory of Reproduction and Development, Chongqing Medical University, Chongqing 400016, China
| | - Bei-Ning Deng
- The Joint International Research Laboratory of Reproduction and Development, Chongqing Medical University, Chongqing 400016, China
| | - Tai-Hang Liu
- The Joint International Research Laboratory of Reproduction and Development, Chongqing Medical University, Chongqing 400016, China.
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Fan BE. The REVAMP trial: key questions remain. Lancet 2024; 403:27-28. [PMID: 38184331 DOI: 10.1016/s0140-6736(23)01916-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 09/08/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Bingwen Eugene Fan
- Department of Haematology, Tan Tock Seng Hospital, 308433, Singapore; Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Sato T, Yanagisawa R. The REVAMP trial: key questions remain. Lancet 2024; 403:28-29. [PMID: 38184334 DOI: 10.1016/s0140-6736(23)01919-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/08/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Tomohiko Sato
- Division of Transfusion Medicine and Cell Therapy, The Jikei University Hospital, Tokyo 1058471, Japan.
| | - Ryu Yanagisawa
- Division of Blood Transfusion, Shinshu University Hospital, Nagano, Japan
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Pasricha SR, Moya E, Ataide R, Mzembe G, Harding R, Phiri K. The REVAMP trial: key questions remain - Authors' reply. Lancet 2024; 403:29-30. [PMID: 38184336 DOI: 10.1016/s0140-6736(23)01915-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/08/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Clinical Haematology, The Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia.
| | - Ernest Moya
- Training and Research Unit of Excellence, Blantyre, Malawi; Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ricardo Ataide
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medicine at the Peter Doherty Institute, The University of Melbourne, Parkville, VIC, Australia
| | - Glory Mzembe
- Training and Research Unit of Excellence, Blantyre, Malawi; Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Rebecca Harding
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
| | - Kamija Phiri
- Training and Research Unit of Excellence, Blantyre, Malawi; Department of Public Health, School of Public and Global Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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8
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Froeliger A, Madar H, Bouchghoul H, Deneux-Tharaux C, Sentilhes L. The REVAMP trial: key questions remain. Lancet 2024; 403:28. [PMID: 38184333 DOI: 10.1016/s0140-6736(23)01918-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/08/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Alizée Froeliger
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux 33076, France; EPOPé Team, CRESS, INSERM, Université Paris Cité, Paris, France
| | - Hugo Madar
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux 33076, France; EPOPé Team, CRESS, INSERM, Université Paris Cité, Paris, France
| | - Hanane Bouchghoul
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux 33076, France
| | | | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux 33076, France.
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9
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Liang D, Lin Y, He L. The REVAMP trial: key questions remain. Lancet 2024; 403:28. [PMID: 38184332 DOI: 10.1016/s0140-6736(23)01917-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/08/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Deku Liang
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu 610073, China
| | - Yonghong Lin
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu 610073, China
| | - Li He
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu 610073, China.
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Pandey AK, Gautam D, Tolani H, Neogi SB. Clinical outcome post treatment of anemia in pregnancy with intravenous versus oral iron therapy: a systematic review and meta-analysis. Sci Rep 2024; 14:179. [PMID: 38167523 PMCID: PMC10761955 DOI: 10.1038/s41598-023-50234-w] [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: 10/06/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024] Open
Abstract
Oral iron therapy is often the most common way of treating anaemia; however intravenous iron is considered effective due to rapid iron replenishment. We have dearth of evidence on clinical outcomes post treatment of anaemia. We have searched studies published in English in PubMed, Cochrane, Scopus, ProQuest, and Google Scholar. Our study analysed the clinical outcomes amongst neonates and mother and the adverse events post treatment and assessed the mean change in maternal haemoglobin concentration in both the groups. Forest plots for the clinical outcomes are presented. From a total of 370 studies, 34 Randomized and quasi experimental studies comparing clinical outcomes post-treatment of anaemia in pregnancy were included for quantitative evidence synthesis. Pooled results of maternal clinical outcomes using random effect model [OR: 0.79 (95% CI 0.66; 0.95); 10 outcomes; 17 studies] showed statistically significant difference among both the groups [Moderate quality evidence]; however no significant difference [OR: 0.99 (95% CI 0.86; 1.14); 7 outcomes; 8 studies] have been observed for neonatal complications [Low quality evidence]. The study found that pregnant women receiving IV iron were significantly less likely to experience adverse events as compared with those receiving oral iron [OR 0.39; (95% CI 0.26-0.60)]; 34 studies; 13,909 women; [Low quality evidence]. Findings from meta-regression analysis showed that IV iron is more likely to reduce maternal complications by 21% compared to oral iron. Increase in odds of adverse maternal outcomes was observed due to increase in gestational age and publication year but no effect for the type of drug used. IV iron increases Hb more and at a higher pace than oral iron. Intravenous iron is more likely to avert adverse maternal outcomes and adverse reactions. However, there is no conclusive evidence on its effectiveness on individual maternal outcome or neonatal outcome/s. Protocol registered with PROSPERO CRD42022368346).
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Affiliation(s)
- Anuj Kumar Pandey
- Department of Health Management, International Institute of Health Management Research (IIHMR), New Delhi, India
- Institute for Population and Social Research, Mahidol University, Nakhornpathom, Thailand
| | - Diksha Gautam
- Department of Health Management, International Institute of Health Management Research (IIHMR), New Delhi, India
| | - Himanshu Tolani
- Department of Health Management, International Institute of Health Management Research (IIHMR), New Delhi, India
| | - Sutapa Bandyopadhyay Neogi
- Department of Health Management, International Institute of Health Management Research (IIHMR), New Delhi, India.
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Harding R, Moya E, Ataíde R, Truwah Z, Mzembe G, Mhango G, Demir AV, Stones W, Randall L, Seal M, Johnson K, Bode S, Mwangi MN, Pasricha SR, Braat S, Phiri KS. Protocol and statistical analysis plan for a randomized controlled trial of the effect of intravenous iron on anemia in Malawian pregnant women in their third trimester (REVAMP - TT). Gates Open Res 2023; 7:117. [PMID: 38343768 PMCID: PMC10858019 DOI: 10.12688/gatesopenres.14710.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 02/15/2024] Open
Abstract
Background Anemia affects 40% of pregnant women globally, leading to maternal mortality, premature birth, low birth weight, and poor baby development. Iron deficiency causes over 40% of anemia cases in Africa. Oral iron supplementation is insufficient for Low-and-Middle-Income-Countries (LMICs) to meet current WHO targets. We hypothesized that a single intravenous dose of Ferric Carboxymaltose (FCM) may be more effective than oral iron treatment for anemia recovery, particularly in these settings where women present late for antenatal care. Methods This is a two-arm parallel open-label individual-randomized controlled trial in third trimester, in malaria Rapid Diagnostic Test-negative pregnant women with moderate or severe anemia - capillary hemoglobin <10 g/dL - who are randomized to receive either parenteral iron - with FCM - or standard-of-care oral iron for the remainder of pregnancy. This is the sister trial to the second-trimester REVAMP trial, funded by the Bill and Melinda Gates Foundation (trial registration ACTRN12618001268235, Gates Grant number INV-010612). In REVAMP-TT, recruitment and treatment are performed within primary health centers. The trial will recruit 590 women across Zomba district, Malawi. The primary outcome is the proportion of anemic women - venous hemoglobin <11 g/dL - at 36 weeks' gestation or delivery (whichever occurs first). Other pre-specified key secondary clinical and safety outcomes include maternal iron-status and hypophosphatemia, neonate birth weight, infant growth and infant iron and hematological parameters. Discussion This study will determine whether FCM, delivered within primary health centers, is effective, safe and feasible for treating moderate to severe anemia in third-trimester pregnant Malawian women. This intervention could have long-term benefits for maternal and child health, resulting in improved survival and child development.
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Affiliation(s)
- Rebecca Harding
- Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, Parkville, Vic, 3052, Australia
| | - Ernest Moya
- Training and Research Unit of Excellence (TRUE), 1 Kufa Road, P.O. Box 30538, Chichiri, Blantyre, BT3, Malawi
- Department of Public Health, Kamuzu University of Health Sciences, School of Global and Public Health, Private Bag 360, Chichiri, Blantyre, BT3, Malawi
| | - Ricardo Ataíde
- Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, Parkville, Vic, 3052, Australia
- Infectious Diseases, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, 3000, Australia
| | - Zinenani Truwah
- Training and Research Unit of Excellence (TRUE), 1 Kufa Road, P.O. Box 30538, Chichiri, Blantyre, BT3, Malawi
| | - Glory Mzembe
- Training and Research Unit of Excellence (TRUE), 1 Kufa Road, P.O. Box 30538, Chichiri, Blantyre, BT3, Malawi
- Department of Public Health, Kamuzu University of Health Sciences, School of Global and Public Health, Private Bag 360, Chichiri, Blantyre, BT3, Malawi
| | - Gomezgani Mhango
- Training and Research Unit of Excellence (TRUE), 1 Kufa Road, P.O. Box 30538, Chichiri, Blantyre, BT3, Malawi
| | - Ayşe V. Demir
- Meander Medical Center, Laboratory for Clinical Chemistry, Maatweg 3, Amersfoort, 3813 TZ, The Netherlands
| | - William Stones
- Centre for Reproductive Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre, BT3, Malawi
| | - Louise Randall
- Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, Parkville, Vic, 3052, Australia
| | - Marc Seal
- Developmental Imaging, Murdoch Children's Research Institute, Parkville, Victoria, 3052, Australia
| | - Katherine Johnson
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, 3010, Australia
| | - Stefan Bode
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, 3010, Australia
| | - Martin N. Mwangi
- Training and Research Unit of Excellence (TRUE), 1 Kufa Road, P.O. Box 30538, Chichiri, Blantyre, BT3, Malawi
- The Micronutrient Forum, Washington DC, 20005-5905, USA
| | - Sant-Rayn Pasricha
- Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, Parkville, Vic, 3052, Australia
- Diagnostic Haematology and Clinical Haematology, The Peter MacCallum Cancer Centre, The Royal Melbourne Hospital, Parkville, Victoria, 3052, Australia
| | - Sabine Braat
- Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, Parkville, Vic, 3052, Australia
- Centre for Epidemiology and Biostatistics, School of Population and Global Health,, The University of Melbourne, Melbourne, Victoria, 3000, Australia
| | - Kamija S. Phiri
- Training and Research Unit of Excellence (TRUE), 1 Kufa Road, P.O. Box 30538, Chichiri, Blantyre, BT3, Malawi
- Department of Public Health, Kamuzu University of Health Sciences, School of Global and Public Health, Private Bag 360, Chichiri, Blantyre, BT3, Malawi
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Lewkowitz AK. Identifying and treating iron deficiency anemia in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:223-228. [PMID: 38066889 PMCID: PMC10727057 DOI: 10.1182/hematology.2023000474] [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
Anemia is common during pregnancy, and while most anemia is physiologic, the most common pathologic cause is iron deficiency. The American College of Obstetricians and Gynecologists (ACOG) recommends confirmation of iron deficiency anemia with iron studies when anemia is diagnosed during pregnancy but acknowledges that presumptive treatment for suspected iron deficiency anemia is common in practice. Currently ACOG does not recommend treating iron deficiency without anemia during pregnancy. Though the benefits of treating iron deficiency anemia during pregnancy are clear, the optimal route of iron repletion remains uncertain. Results of ongoing large, randomized trials will help define the optimal route of iron treatment for pregnant patients diagnosed with iron deficiency anemia.
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Affiliation(s)
- Adam K. Lewkowitz
- Department of Obstetrics and Gynecology, Warren Alpert Medical School at Brown University, Providence, RI
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Van Doren L, Auerbach M. IV iron formulations and use in adults. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:622-629. [PMID: 38066930 PMCID: PMC10727060 DOI: 10.1182/hematology.2023000495] [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
Intravenous iron has become a major component of the therapeutic armamentarium for iron deficiency and iron deficiency anemia. The earliest formulations were associated with unacceptable toxicity. Newer formulations, with complex carbohydrate cores that bind elemental iron more tightly, allow the administration of full therapeutic doses in 15 to 60 minutes. Nonetheless, a folklore of danger, fueled by earlier formulations no longer available, continues to foment caution. Complement-mediated minor infusion reactions, referred to as complement activation-related pseudo-allergy, resolve without therapy. Inappropriate intervention with vasopressors and H1 blockers converts these minor reactions into hemodynamically significant adverse events. Four new formulations, low-molecular-weight iron dextran, ferumoxytol, ferric carboxymaltose, and ferric derisomaltose, all approved for the treatment of iron deficiency in a host of conditions, are now widely used with an excellent safety profile. Herein, the administration, safety, indications, and management of infusion reactions are discussed. Treatment-emergent hypophosphatemia, a newly recognized side effect for some formulations, is also reviewed. Based on the preponderance of published evidence, intravenous iron should be moved up-front for the treatment of iron deficiency and iron deficiency anemia in those conditions in which oral iron is suboptimal.
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Affiliation(s)
- Layla Van Doren
- Division of Hematology, Yale School of Medicine, New Haven, CT
| | - Michael Auerbach
- Division of Hematology, Georgetown School of Medicine, Baltimore, MD
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Brittenham GM, Moir-Meyer G, Abuga KM, Datta-Mitra A, Cerami C, Green R, Pasricha SR, Atkinson SH. Biology of Anemia: A Public Health Perspective. J Nutr 2023; 153 Suppl 1:S7-S28. [PMID: 37778889 DOI: 10.1016/j.tjnut.2023.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/04/2023] [Accepted: 07/31/2023] [Indexed: 10/03/2023] Open
Abstract
Our goal is to present recent progress in understanding the biological mechanisms underlying anemia from a public health perspective. We describe important advances in understanding common causes of anemia and their interactions, including iron deficiency (ID), lack of other micronutrients, infection, inflammation, and genetic conditions. ID develops if the iron circulating in the blood cannot provide the amounts required for red blood cell production and tissue needs. ID anemia develops as iron-limited red blood cell production fails to maintain the hemoglobin concentration above the threshold used to define anemia. Globally, absolute ID (absent or reduced body iron stores that do not meet the need for iron of an individual but may respond to iron supplementation) contributes to only a limited proportion of anemia. Functional ID (adequate or increased iron stores that cannot meet the need for iron because of the effects of infection or inflammation and does not respond to iron supplementation) is frequently responsible for anemia in low- and middle-income countries. Absolute and functional ID may coexist. We highlight continued improvement in understanding the roles of infections and inflammation in causing a large proportion of anemia. Deficiencies of nutrients other than iron are less common but important in some settings. The importance of genetic conditions as causes of anemia depends upon the specific inherited red blood cell abnormalities and their prevalence in the settings examined. From a public health perspective, each setting has a distinctive composition of components underlying the common causes of anemia. We emphasize the coincidence between regions with a high prevalence of anemia attributed to ID (both absolute and functional), those with endemic infections, and those with widespread genetic conditions affecting red blood cells, especially in sub-Saharan Africa and regions in Asia and Oceania.
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Affiliation(s)
- Gary M Brittenham
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, United States.
| | - Gemma Moir-Meyer
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia
| | - Kelvin Mokaya Abuga
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ananya Datta-Mitra
- Department of Pathology and Laboratory Medicine, University of California, Davis, CA, United States
| | - Carla Cerami
- The Medical Research Council Unit, The Gambia, London School of Hygiene and Tropical Medicine, London, UK
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis, CA, United States
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia; Diagnostic Haematology, The Royal Melbourne Hospital; and Clinical Haematology at the Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC Australia
| | - Sarah H Atkinson
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya; Department of Paediatrics, University of Oxford, Oxford, UK
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Nair M, Choudhury SS, Rani A, Solomi C, Kakoty SD, Medhi R, Rao S, Mahanta P, Zahir F, Roy I, Chhabra S, Deka G, Minz B, Deka R, Opondo C, Churchill D, Lakhal-Littleton S, Nemeth E. The complex relationship between iron status and anemia in pregnant and postpartum women in India: Analysis of two Indian study cohorts of uncomplicated pregnancies. Am J Hematol 2023; 98:1721-1731. [PMID: 37651649 DOI: 10.1002/ajh.27059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 09/02/2023]
Abstract
Low hemoglobin is widely used as an indicator of iron deficiency anemia in India and other low-and-middle income counties, but anemia need not accurately reflect iron deficiency. We examined the relationship between hemoglobin and biomarkers of iron status in antenatal and postnatal period. Secondary analysis of uncomplicated singleton pregnancies in two Indian study cohorts: 1132 antenatal women in third trimester and 837 postnatal women 12-72 h after childbirth. Associations of hemoglobin with ferritin in both data sets, and with sTfR, TSAT, and hepcidin in the postnatal cohort were examined using multivariable linear regression. Multinomial logistic regression was used to examine the association between severity of anemia and iron status. Regression models were adjusted for potential confounders. Over 55% of the women were anemic; 34% of antenatal and 40% of postnatal women had low ferritin, but 4% antenatal and 6% postnatal women had high ferritin. No evidence of association between hemoglobin and ferritin was observed (antenatal: adjusted coefficient [aCoef] -0.0004, 95% confidence interval [CI] -0.001, 0.001; postnatal: aCoef -0.0001, 95% CI -0.001, 0.001). We found a significant linear association of hemoglobin with sTfR (aCoef -0.04, 95% CI -0.07, -0.01), TSAT (aCoef -0.005, 95% CI -0.008, -0.002), and hepcidin (aCoef 0.02, 95% CI 0.02, 0.03) in postnatal women. Likelihood of low ferritin was more common in anemic than non-anemic women, but high ferritin was also more common in women with severe anemia in both cohorts. Causes of anemia in pregnant and postpartum women in India are multifactorial; low hemoglobin alone is not be a useful marker of iron deficiency.
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Affiliation(s)
- Manisha Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Saswati S Choudhury
- Department of Obstetrics and Gynaecology, Gauhati Medical College and Hospital, Guwahati, India
| | - Anjali Rani
- Institute of Medical Sciences, Banaras Hindu University, Banaras Hindu University Campus, Varanasi, India
| | - Carolin Solomi
- Makunda Christian Leprosy and General Hospital, Karimganj, India
| | - Swapna D Kakoty
- Department of Obstetrics and Gynaecology, Fakhruddin Ali Ahmed Medical College and Hospital, Barpeta, India
| | - Robin Medhi
- Department of Obstetrics and Gynaecology, Fakhruddin Ali Ahmed Medical College and Hospital, Barpeta, India
| | - Sereesha Rao
- Department of Obstetrics and Gynaecology, Silchar Medical College and Hospital, Silchar, India
| | - Pranabika Mahanta
- Department of Obstetrics and Gynaecology, Jorhat Medical College and Hospital, Jorhat, India
| | - Farzana Zahir
- Department of Obstetrics and Gynaecology, Assam Medical College, Dibrugarh, India
| | | | - Shakuntala Chhabra
- Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, India
| | - Gitanjali Deka
- Department of Obstetrics and Gynaecology, Tezpur Medical College, Tezpur, India
| | - Bina Minz
- Sewa Bhawan Hospital Society, Basna, India
| | - Rupanjali Deka
- MaatHRI, Srimanta Sankaradeva University of Health Sciences, Guwahati, India
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - David Churchill
- The Royal Wolverhampton Hospitals NHS Trust, University of Wolverhampton, Wolverhampton, UK
| | | | - Elizabeta Nemeth
- David Geffen School of Medicine & the UCLA Center for Iron Disorders, University of California, Los Angeles, California, USA
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Ritter F, Staub BM, Osthoff M. Appropriateness of inpatient intravenous iron therapy in a Swiss tertiary care hospital. Eur J Haematol 2023; 111:601-610. [PMID: 37489058 DOI: 10.1111/ejh.14053] [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: 05/11/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Intravenous (IV) iron replacement is an established treatment for iron deficiency and is recommended in various medical guidelines, but cheaper oral iron formulations remain first-line therapy in several instances. Data on adherence to current prescription standards are lacking in Switzerland. METHODS Retrospective single center quality control study evaluating the appropriateness of IV iron replacement in 400 inpatients during 2019 and 2021 at a Swiss tertiary care hospital. Appropriateness of IV iron was assessed by expert chart review according to national and international guidelines. RESULTS IV iron prescriptions were assessed as inappropriate in 147 (37%) of cases (indication lacking in 13%, oral route preferred in 24%). Inappropriate prescribing was more common (p < .001) in surgical wards (66%) compared to medical units (48%) and the gynecologic ward (19%). Iron studies were lacking in 29% of inappropriate IV administrations. Insufficient replacement dosages were chosen in 38% of patients with appropriate prescription. CONCLUSION Based on current guidelines, inappropriate in-hospital prescription of IV iron was frequently observed. Considerable differences exist between hospital units, which are consistent with conflicting recommendations of professional societies. We recommend increased attention toward the prescription quality to avoid unnecessary, expensive, and potentially harmful use of IV iron.
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Affiliation(s)
- Fabian Ritter
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
- Division of Internal Medicine, Kantonsspital Baselland, Liestal, Switzerland
| | - Benjamin M Staub
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Michael Osthoff
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
- Division of Internal Medicine, Kantonsspital Winterthur, Winterthur, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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Roberts DJ, Dhabangi A. Debate: Should the loss of disability adjusted life years (DALY) define the focus of Global Hematology?: The case for prioritizing capacity building in anemia management and blood transfusion. Semin Hematol 2023; 60:182-188. [PMID: 37863704 DOI: 10.1053/j.seminhematol.2023.09.001] [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: 09/07/2023] [Accepted: 09/11/2023] [Indexed: 10/22/2023]
Abstract
Setting priorities in healthcare is always contentious given the array of possible services at primary, secondary, and tertiary levels of care, not to mention potential public health interventions. The central goals in global policy have been reducing inequity within and between countries, protecting vulnerable groups (particularly women and children) and reducing the major communicable diseases which have historically been a major burden in lower- and middle-income countries. Here limited relative and absolute spending on healthcare have spurred a series of initiatives in Global Health over the last 50 years which have led to significant gains in measures of morbidity and mortality. Against this background there remains the continuing question of how to adapt current medical practice in higher income countries for training and planning of services in lower- and middle-income countries. Here, the historical development of Global Health is outlined, and lessons drawn from the surveys of the global burden of disease and health economic analysis to understand how we can apply these principles to define Global Hematology. It remains likely that in lower-income countries effort should be concentrated on developing laboratory services and blood transfusion, to allow safe and effective support for the assessment of treatment of anemia, sickle cell disease, maternal and child health and urgent surgery and obstetric services. However, the principles of Global Health, could also be used for hematological malignancies to develop a framework for Global Hematology for all settings.
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Affiliation(s)
- David J Roberts
- Clinical Services Directorate, NHSBT Blood and Transplant, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.
| | - Aggrey Dhabangi
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
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18
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Shand AW, Kidson-Gerber GL. Anaemia in pregnancy: a major global health problem. Lancet 2023; 401:1550-1551. [PMID: 37088094 DOI: 10.1016/s0140-6736(23)00396-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 04/25/2023]
Affiliation(s)
- Antonia W Shand
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney 2045, NSW, Australia.
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