European consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases

Synergistic Benefits of Dietary Strategies in the Management of IBD

PURPOSE OF REVIEW

Inflammatory bowel disease (IBD) patients commonly inquire about the role of diet in the onset and management of their disease process. This review sought to assess the impact of the inflammatory bowel diseases on the nutritional state of patients and evaluate the evidence supporting nutritional interventions as therapy.

RECENT FINDINGS

The role of nutrition has evolved from one of deficient nutrient and calorie replacement alone into a proactive therapeutic for treating active inflammatory disease symptoms. The realization that initiating total parenteral nutrition (TPN) in place of oral take could improve disease symptoms provided the first indication that food intake played a causative role in the IBD. The evolution of TPN to enteral nutrition improved tolerance and reduced side effects but clouded the role of oral intake in the pathophysiology of IBD. Advanced understanding of the role of the microbiota in IBD combined with recognition of the influence of nutrients on microbial composition have ushered in a new era of food as therapy. The role of nutrition in IBD has evolved significantly over the past 30-40 years. From complete elimination of oral intake to the carefully curated menu intended to mold the intestinal microbiota to a non-inflammatory milieu has revolutionized the approach to dietary intervention. Additional studies are warranted to optimize dietary intervention strategies.

Management of paediatric ulcerative colitis, part 2: Acute severe colitis-An updated evidence-based consensus guideline from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition and the European Crohn's and Colitis Organization

Acute severe colitis (ASC) is a relatively frequent manifestation in children with ulcerative colitis and one of the few emergencies in paediatric gastroenterology. A standardized proactive approach based on tight monitoring and timely medical and surgical interventions may improve patients' outcomes. We aimed to update the previous ASC guidelines using detailed recommendations and practice points, based on a systematic review of the literature and consensus of experts. These guidelines update is a joint effort of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition and the European Crohn's and Colitis Organization. A systematic search was performed in Pubmed Ovid Medline, Embase and Cochrane databases using 13 predefined PICO (patient, intervention, comparison, outcomes) based questions and 30 non-PICO based questions. Grading methodology was based on the Oxford Centre for Evidence-Based Medicine-Levels of evidence. The questions were addressed by working subgroups following an iterative consensus voting process, including three online voting meetings and one face-to-face meeting. A total of 36 recommendations and 72 practice points were endorsed with a consensus rate of at least 88% for all statements, regarding initial evaluation, monitoring, medical and surgical treatment of ASC in children. Several topics have been revised since the previous 2018 guidelines and differ from corresponding published adult guidelines. These guidelines present a comprehensive overview of the management of ASC in children, offering practical recommendations and practice points aiming to standardize clinical and surgical treatment and improve outcomes of this severe scenario.

Iron at the crossroads of host-microbiome interactions in health and disease

Iron is an essential dietary micronutrient for both humans and microorganisms. Disruption of iron homeostasis is closely linked, as both a cause and an effect, to the development and progression of gut microbiota dysbiosis and multiple diseases. Iron absorption in humans is impacted by diverse environmental factors, including diet, medication and microbiota-derived molecules. Accordingly, treatment outcomes for iron-associated diseases may depend on an individual patient's microbiome. Here we describe various iron acquisition strategies used by the host, commensal microorganisms and pathogens to benefit or outcompete each other in the complex gut environment. We further explore recently discovered microbial species and metabolites modulating host iron absorption, which represent potential effectors of disease and therapeutic targets. Finally, we discuss the need for mechanistic studies on iron-host-microbiome interactions that can affect disease and treatment outcomes, with the ultimate aim of supporting the development of microbiome-based personalized medicine.

Key updates in Crohn's disease surgery for the gastroenterologist in 2025

PURPOSE OF REVIEW

The field of inflammatory bowel disease (IBD) has been evolving at an unprecedented rate. Not only does this apply to the medical management of IBD but also to its surgical management. This review aims to highlight the major updates in the current surgical approach in Crohn's disease.

RECENT FINDINGS

Surgery for Crohn's disease is no longer considered only for medically refractory disease or for disease-related complications but can rather be considered as an effective first-line treatment option. The concept of multimodal prehabilitation is becoming more solidified in Crohn's disease, as strong evidence continues to indicate its positive impact on surgical outcomes. The impact of the mesentery as well as the type of surgical anastomosis on postsurgical Crohn's disease recurrence is being closely reexamined. The optimal approach for surgical management of perianal Crohn's disease is also being redefined.

SUMMARY

Surgery is an integral part of the care of Crohn's disease patients and keeping up with the evolving paradigm of surgery in Crohn's disease is critical for all providers taking care of Crohn's disease patients to ensure patients are getting the best care possible.

Iron deficiency should not be accepted in patients with inflammatory bowel disease - a Scandinavian expert opinion

AIM

In this paper, we aim to explain the reason why iron deficiency (ID) is common in patients with inflammatory bowel disease (IBD), how to better apply diagnostic tools to uncover the state of ID as well as how to interpret the results, and not least, how to treat ID in this group of patients.

METHODS

This article is an expert review and opinion paper on a topic that is too often forgotten in clinical practice. We have not performed a systematic review, but we present the most important research allocated to the topic to substantiate an expert opinion.

RESULTS

This position paper summarises the pathophysiology of ID and gives recommendations on the monitoring and treatment of ID in IBD. ID with or without concurrent anaemia (IDA) is the most common systemic complication in patients with IBD, related to both disease activity and severity. It has consequences both for health-related quality of life and future course of disease of the IBD patient. Intravenous iron is an efficacious and well tolerated, but still underused, therapy for ID and IDA. Iron deficiency should be treated before symptoms of anaemia appear and quality of life is impacted. However, there is still limited awareness of how to detect and treat ID in clinical practice. Uncertainty regarding which diagnostic tests to use and how to interpret the results may also be responsible for variations in clinical practice. In addition, opinions on how to correct ID and IDA differ, in relation to both clinical efficacy and safety.

CONCLUSION

The consequences of ID in patients with IBD are significant. Guidelines on diagnosis, treatment and follow-up of ID should be implemented. IDA is a manifestation of severe ID and preventive strategies focusing on efficient treatment of ID regardless of the level of haemoglobin should therefore be explored.

Effect of Iron Deficiency on Short-Term Response to Treatment in Cats With Chronic Enteropathies

BACKGROUND

Iron deficiency in humans with chronic inflammatory enteropathies (CIE) is associated with active disease and anemia-related morbidity.

OBJECTIVES

To compare iron deficiency prevalence in cats with CIE versus low-grade alimentary lymphoma (LGAL) and secondarily, determine the effect of iron deficiency on short-term clinical response in CIE cats.

ANIMALS

Twenty-eight client-owned cats with primary gastrointestinal disease, including 14 CIE cats and 14 LGAL cats.

METHODS

Prospective study. Cats were enrolled when they presented for gastrointestinal endoscopy. Iron panel (serum iron, ferritin, total iron binding capacity), CBC, cobalamin, serum amyloid A, methylmalonic acid, and clinical disease severity were evaluated. Cats were categorized as "normal" or "iron deficient" using calculated transferrin saturation. CIE cats were reevaluated 14, 30, and 90 days after initiation of non-standardized gastrointestinal disease treatment. Clinical response was compared based on iron and anemia status.

RESULTS

Iron deficiency was diagnosed in 7/28 cats (2/14 CIE, 5/14 LGAL cats) at enrollment and developed in four additional CIE cats during follow-up. While 9/28 cats were anemic at enrollment, neither anemia (relative risk [RR], 0.90; 95% confidence interval [CI], 0.13-5.50) nor iron status (RR, 0.4; 95% CI, 0.10-1.5) was associated with treatment response. Transferrin saturation was lower in LGAL cats (22%; 95% CI, 20%-27%) than in CIE cats (30%; 95% CI, 26%-39%).

CONCLUSIONS AND CLINICAL IMPORTANCE

There was high prevalence of iron deficiency over the first 90 days of treatment in CIE cats. Iron deficiency did not affect short-term response to individualized treatment of gastrointestinal disease.

Comparative analysis of dietary iron deprivation and supplementation in a murine model of colitis

Inflammatory bowel diseases are chronic inflammatory conditions with growing prevalence in western populations. Iron is an essential component of erythrocytes hemoglobin. Under the influence of elevated hepcidin production, iron is sequestered in cells during inflammation which, in turn, leads to iron restriction for red blood cell synthesis. As a consequence, iron deficiency and anemia of inflammation are the most prevalent extraintestinal complications in IBD patients. Iron deficiency is commonly treated with oral iron supplements, with limited efficacy as iron absorption is blunted during intestinal inflammation. Moreover, iron supplementation can cause intestinal complications, as previous studies have shown that it can worsen the inflammatory response. However, a comparative analysis of the effects of low, adequate, and high dietary iron content matching the iron supplementation given to patients has not been performed in mice. We therefore tested the impact of dietary iron deprivation and supplementation in a murine model of colitis induced by dextran sodium sulfate. We found that both dietary iron deprivation and supplementation were accompanied by a more severe inflammation with earlier signs of gastrointestinal bleeding compared to mice fed an iron-adequate diet. The manipulation of dietary iron led to a profound dysbiosis in the colon of control mice that differed depending on the dietary iron content. Analysis of this dysbiosis is in line with a pronounced susceptibility to colonic inflammation, thus questioning the benefit/risk balance of oral iron supplementation for IBD patients.

Management of iron deficiency in children, adults, and pregnant individuals: evidence-based and expert consensus recommendations

Iron deficiency is the most common micronutrient deficiency worldwide. Oral iron is often recommended as first-line treatment, but there is no consensus on the optimal formulation, dosing strategy, or which patients should be treated preferentially with intravenous iron. To address these challenges, the Iron Consortium at Oregon Health & Science University (OHSU) convened an international panel of 26 experts in haematology, primary care, paediatrics, obstetrics, gastroenterology, cancer, and patient advocacy among its members. This panel was supplemented by insights from a four-person patient focus group to develop current recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel developed clinically relevant questions in five priority topic areas, a systematic literature search was performed, and studies meeting a priori criteria were included to generate evidence tables for recommendation development. Evidence-based and expert opinion-based recommendations were made through a structured anonymous consensus voting process at an in-person meeting in Portland, OR, USA, hosted by OHSU on Feb 16-17, 2024. The expert panel made seven evidence-based recommendations for three demographic groups with iron deficiency: non-pregnant adults, pregnant individuals, and infants, children, and adolescents. Expert opinions supported the recommendations on 21 aspects of care for which there is insufficient evidence. This Review provides evidence-based recommendations and expert consensus on the diagnosis, treatment, and management of iron deficiency, detailing best practices for oral and intravenous iron repletion across diverse patient populations.

Initial effectiveness and safety data on intravenous ferric derisomaltose for iron deficiency anaemia management in paediatric gastroenterology patients: a multicentre retrospective cohort study

OBJECTIVE

Iron deficiency anaemia (IDA) is common in paediatric gastroenterology with intravenous iron increasingly utilised. While adult data are published for ferric derisomaltose (FDI), no paediatric data exist. Our aim was to assess the effectiveness and safety profile of FDI in paediatric gastroenterology.

DESIGN

Retrospective cohort study.

SETTING

Two UK referral centres (Edinburgh and Sheffield).

PATIENTS

All paediatric gastroenterology patients who received FDI from June 2020 to June 2023.

MAIN OUTCOME MEASURES

Haematological and biochemical parameters were collected before and at 1, 3, 6 and 12 months after treatment, when available, together with the need for repeated FDI infusions and FDI adverse events.

RESULTS

Sixty-five patients were identified (54% male; median age 12.8 years, IQR 9.6-15.2), receiving 78 FDI infusions. After a single infusion, 38/59 (64%) patients (effectiveness analysis) completely corrected their anaemia and 6/59 (10%) improved from moderate-severe to mild anaemia. Median haemoglobin increased from 92 (IQR 85-108) to 126 (IQR 115-132) g/L at 1 month (p<0.001) and peaked at 12 months (134 g/L, IQR 125-142; p<0.001) post infusion. A second infusion was performed in 12/59 (20%) patients with 9/12 correcting their anaemia. No significant biochemical alterations, including hypophosphataemia, were detected. Overall, 4/65 (6%) patients (safety analysis) experienced adverse events, with three discontinuing FDI infusion.

CONCLUSIONS

Our real-world data reveal FDI is rapidly and persistently effective in correcting IDA in paediatric gastroenterology. No significant biochemical alterations or new safety signals were identified.

Micronutrient Deficiencies in Pediatric IBD: How Often, Why, and What to Do?

Inflammatory bowel disease (IBDs), including Crohn's disease (CD), and ulcerative colitis (UC) are complex diseases with a multifactorial etiology, associated with genetic, dietetic, and other environmental risk factors. Children with IBD are at increased risk for nutritional inadequacies, resulting from decreased oral intake, restrictive dietary patterns, malabsorption, enhanced nutrient loss, surgery, and medications. Follow-up of IBD children should routinely include evaluation of specific nutritional deficits and dietetic and/or supplementation strategies should be implemented in case deficiencies are detected. This narrative review focuses on the prevalence, risk factors, detection strategy, and management of micronutrient deficiencies in pediatric IBD.

Real-world evaluation of an intravenous iron service for the treatment of iron deficiency with or without anemia

Intravenous (IV) iron is a guideline-recommended treatment for iron deficiency when oral iron is contraindicated, ineffective, or not tolerated, or when rapid iron delivery is necessary. However, evidence suggests that some patients receive less IV iron than needed. This retrospective audit assessed the effectiveness and safety of ferric derisomaltose (FDI), a high-dose IV iron, in 2,468 patients. Efficacy outcomes assessed at 4-12 weeks post-infusion included changes in hemoglobin (Hb) and ferritin, proportion of courses (a course was defined as the treatment episode required to administer one total dose) after which patients were non-anemic (Hb ≥ 130 g/L [men] or ≥ 120 g/L [women]), and response rate (proportion of courses after which patients were non-anemic or Hb increased by ≥ 20 g/L). Safety was assessed through adverse events. Across 2,775 FDI courses, the mean dose was 1,244 mg, but mean estimated iron need was 1,580 mg. At follow-up, mean Hb had increased by 20.9 g/L and mean ferritin by 188.8 µg/L. Patients were non-anemic after 33.4% (n = 494/1,478) of courses and responded after 65.1% (n = 962/1,478) of courses. One patient (n = 1/2,468; 0.04%) had a serious allergic reaction. Patients remained anemic after > 65% of courses, demonstrating the need to optimize dosing based on iron need.

PTPN2 Regulates Iron Handling Protein Expression in Inflammatory Bowel Disease Patients and Prevents Iron Deficiency in Mice

Anemia is the most common extraintestinal manifestation of inflammatory bowel disease (IBD). Iron deficiency is the most frequent cause of anemia in IBD; however, the mechanisms involved are still poorly understood. Here, we investigated the role of the IBD risk gene, protein tyrosine phosphatase non-receptor type 2 (PTPN2), in regulating iron homeostasis. Proteomic analyses were performed on serum from IBD patients genotyped for the IBD-associated loss-of-function rs1893217 PTPN2 variant. Constitutive Ptpn2 wild type (WT), heterozygous (Het), and knockout (KO) mice were analyzed for iron content, blood parameters, and expression of iron handling proteins. Iron absorption was assessed through radiotracer assays. Serum proteomic analyses revealed that the "iron homeostasis signaling pathway" was the main pathway downregulated in Crohn's disease (CD) patients carrying the PTPN2 risk allele, independent of disease activity. Ptpn2-KO mice showed characteristics of anemia, including reduced hemoglobin concentrations along with serum and tissue iron deficiency and elevated serum hepcidin levels vs. Ptpn2-WT and Het mice. 55Fe absorption via oral gavage was significantly impaired in Ptpn2-KO mice. Correspondingly, Ptpn2-KO mice showed reduced apical membrane expression of the iron transporter DMT1. CD patients with the PTPN2 loss-of-function rs1893217 variant display alterations in serum iron handling proteins. Loss of Ptpn2 in mice caused features of anemia, including iron deficiency associated with reduced apical membrane expression of DMT1. These findings identify an important role for PTPN2 in regulating systemic iron homeostasis.

Oral Extraintestinal Manifestations of Inflammatory Bowel Disease: The Temporal Relationship Between Oral and Intestinal Symptoms

Objectives

Oral extraintestinal manifestations (OEIMs) of inflammatory bowel disease (IBD) may impact IBD treatment. The aims of this study were to: (1) determine which OEIMs are most prevalent among patients with IBD, (2) investigate the presence of a temporal association between GI luminal disease activity and OEIMs, and (3) determine how often changes in therapeutic management of IBD are needed in the presence of OEIMs.

Study Design

A retrospective cohort study was performed for adult patients with IBD evaluated between January 2017 and November 2021 with at least 1 oral complaint. Demographic data were collected from the charts of these patients. Kruskal-Wallis test for continuous measures and Fisher's Exact test for categorical measures were used.

Results

A total of 116 patients with IBD who had presented with at least 1 oral finding during the study time period were identified. Aphthous ulcers were the most common oral presentation in both Crohn's disease (CD) (85.1%) and ulcerative colitis (UC) (75.0%). OEIMs were associated with CD activity in the small intestine (P = .004) and colon (P < .001). UC pancolitis was associated with OEIMs (P = .002). In 32.7% of patients, OEIMs led to either an increase in dose or frequency of IBD therapy. In an additional 16.4% of patients, new systemic agents were started because of the OEIMs.

Conclusions

This study provides evidence that patients with IBD may develop OEIMs synchronous with IBD flares and may require escalation of IBD therapy when OEIMs occur.

[Position statement of the Spanish Society of Primary Care Physicians (SEMERGEN) and Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the management of inflammatory bowel disease in Primary Care]

Primary Care is the first point of contact for most patients after the onset of symptoms of inflammatory bowel disease (IBD). Establishing an initial diagnostic process based on compatible symptoms and agreed criteria and referral pathways, depending on the degree of suspicion and the patient's situation, can reduce diagnostic delays. Once the patient is referred to the Digestive specialist and the diagnosis of IBD is established, a treatment and follow-up plan is structured. The management of the patient must be shared with the participation of the family practitioners in the diagnosis and treatment of concomitant or intercurrent pathologies, the recognition of flare-ups or complications (of IBD or treatments), education tasks or adherence control. With the purpose of developing a comprehensive guide on the management of IBD aimed at Primary Care doctors, we have developed this positioning document collaboratively between the Spanish Society of Primary Care Physicians (SEMERGEN) and the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU).

Iron deficiency anaemia in a stable chronic intestinal failure cohort: Prevalence, associations and outcomes

BACKGROUND & AIMS

Current estimates of the prevalence of iron deficiency anaemia (IDA) in patients with chronic intestinal failure (CIF) exceed those seen in general population, however, the studies to-date are limited. The aim of this study was to determine the point prevalence of IDA in a large cohort of stable home parenteral nutrition (HPN) dependent adults managed by a specialist Intestinal Failure Unit.

METHODS

This was a retrospective cohort study of HPN-dependent adults managed by a national UK IF Reference Centre between 01/01/2019 and 31/12/2019. Patients with IDA were followed up until death or the end of the follow-up on 01/05/2024.

RESULTS

241 patients were included in the analysis. 27/241 (11.2 %) were diagnosed with IDA. Previous hypoferritinaemia, previous IDA and not receiving the recommended amount of iron via parenteral nutrition as per ESPEN guidelines were associated with higher likelihood of IDA diagnosis. Only 2/27 patients with IDA at inclusion fulfilled IDA criteria by the end of the follow up. Long-term outcomes in the patient cohort with IDA were good with no patients displaying evidence of malignancy until the end of the study period.

CONCLUSION

Our study shows that while IDA is common in patients with CIF, its clinical implications may differ from those in the general non-IF population. Further larger collaborative multi-centre research is necessary to confirm these findings with a view to develop evidence-based guidelines for the investigation of IDA in CIF.

Association Between the Anemia During Pregnancy and Maternal Intensive Care Unit Admissions: A Systematic Review and Meta-Analysis

Anemia during pregnancy is one of the most common conditions that may have adverse consequences on maternal and fetal health. Current evidence is inconsistent with regards to the effects of anemia on maternal ICU admissions. This meta-analysis aimed to examine the overall effect of anemia during pregnancy on maternal ICU admissions. We searched PubMed, Embase, Cochrane Library, and Web of Science for observational studies that compared the risk of ICU admission between anemic and non-anemic pregnant women. We pooled the odds ratios (ORs) for ICU admission using a random-effects model. Heterogeneity among studies was assessed using prediction intervals (PIs), Tau2 and I2 statistics. Sensitivity analysis by excluding outlier studies, meta-regression by sample size and age, and publication bias detection by LFK index and Doi plot was undertaken. Eight studies with a total of 21,997,574 participants in both anemic and non-anemic groups were included. Of them, meta-analysis was conducted in seven studies which yielded a pooled OR for anemia and ICU admission as 1.32 (95% CI 0.62-2.81). There was also a very high level of heterogeneity among studies (PI: 0.10-18.16, I2 = 100%). When an influential study was omitted, the pooled OR 1.16 (95% CI - 1.13; 1.20) for ICU admission was significant. The LFK index was - 3.64, indicating publication bias. Anemia in pregnant women might be associated with a higher risk of ICU admission, but it is essential to interpret this cautiously due to significant heterogeneity and potential publication bias. Registration : PROSPERO database (CRD42023466529).

Supplementary Information

The online version contains supplementary material available at 10.1007/s12288-024-01849-0.

Understanding and Managing Infusion Reactions and Hypophosphataemia With Intravenous Iron-A Nurses' Consensus Paper

AIM

To provide evidence-based guidance on practical aspects and potential safety concerns (infusion reactions and hypophosphataemia) related to the use of intravenous iron from a nursing perspective.

DESIGN

A modified Delphi consensus method.

METHODS

Literature searches were conducted and used to support the development of 16 consensus statements. Six nurses with expertise in the field of gastroenterology and experience with the administration of intravenous iron participated in a modified Delphi process to develop a final set of statements.

RESULTS

Overall, 16 statements achieved consensus and covered the practicalities of administration, infusion reactions and hypophosphataemia. Patient preparation is a key step in the administration of intravenous iron, but information should be communicated carefully to prevent undue anxiety. Highlighting the nurse's confidence in the management of any reactions may help to reduce anxiety. The patient should be observed during the first 5-10 min of an infusion to allow prompt management of immediate infusion reactions, although severe hypersensitivity reactions are rare. Nurses should be vigilant for symptoms of hypophosphataemia (such as fatigue, weakness and muscle/bone pain), which can develop following treatment with ferric carboxymaltose, saccharated ferric oxide and iron polymaltose. Serum phosphate levels should be measured in patients receiving ferric carboxymaltose who are at risk of low phosphate.

IMPACT

Infusion reactions and hypophosphataemia with intravenous iron are documented in the literature, but existing publications do not approach these topics from a nursing perspective. This consensus paper highlights the importance of patient preparation, monitoring and prompt management when administering intravenous iron to ensure patient safety. Considering that nurses have a central role in the administration of intravenous iron, the availability of evidence-based guidance is essential for both nurse confidence and patient safety.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was involved in the consensus process.

Prevalence and trend of anemia in children with inflammatory bowel disease: A national register-based cohort study

OBJECTIVES

We determined the prevalence of anemia and its characteristics in children with newly diagnosed inflammatory bowel disease (IBD) and investigated its trend during follow-up.

METHODS

An observational, multicenter cohort study of IBD children with anemia at the diagnosis enrolled in the Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition IBD registry. Data were collected at the diagnosis and at 1 year.

RESULTS

Five hundred eighty-nine (295 Crohn's disease [CD] [50%] and 294 ulcerative colitis [UC]/IBD unclassified [IBDU] [50%]) of 1634 patients with IBD presented with anemia (36%). Anemia rate was higher in CD than in UC (39% vs. 33%, p = 0.009), and most patients had moderate anemia (55%). Children with CD had higher rates of mild anemia than UC (38% vs. 33%, p < 0.0001), while severe anemia was more common in UC (13% vs. 6%, p = 0.001). In CD, lower age at the diagnosis and lower albumin level correlated with anemia severity (p = 0.0007 and <0.0001, respectively). In UC, severe disease was more common in patients with severe anemia compared to those with mild and moderate anemia (20.6% vs. 43.6%, p = 0.01; 17% vs. 43.6%, p = 0.001). At 1 year, 99 children (22.9%) were persistently anemic and were characterized by a more severe disease compared to those who had resolved their anemia.

CONCLUSIONS

More than one third of IBD children present with anemia, most commonly moderate. Severe anemia is more common in UC compared to CD. One in four patients is still anemic after 1 year from the diagnosis, suggesting inadequate attention to the issue and the need for dedicated therapeutic management and careful monitoring.

Introducing a Novel Personalized Microbiome-Based Treatment for Inflammatory Bowel Disease: Results from NostraBiome's Internal Validation Study

Background/Objectives: Inflammatory bowel disease (IBD), encompassing ulcerative colitis and Crohn's disease, is characterized by chronic gut inflammation driven by microbial dysbiosis and immune dysfunction. Current therapies primarily involve anti-inflammatory and immunomodulatory strategies; however, many patients experience an inadequate response or a gradual loss of efficacy over time. This study evaluates the clinical efficacy of personalized microbiome modulation (PMM)-an AI-driven intervention designed to restore microbial balance and improve key treatment outcomes such as symptom control and remission rates. Methods: This was a single-arm, open-label validation trial involving 27 patients with moderate-to-severe IBD who had experienced prior treatment failure. Participants underwent three months of PMM, which included personalized dietary modifications, targeted probiotic supplementation, and antimicrobial interventions based on gut microbiome sequencing. Primary outcomes included stool frequency and consistency as well as inflammatory markers (C-reactive protein and fecal calprotectin), while secondary outcomes assessed nutritional status, metabolic function, and quality of life. Statistical analyses included paired t-tests and repeated measures ANOVA to determine significant changes over time. Results: PMM led to significant clinical improvements, including a 58% reduction in stool frequency (p < 0.001) and improved stool consistency. CRP and fecal calprotectin levels decreased markedly (p < 0.001), suggesting reduced systemic inflammation. Additionally, iron, vitamin B12, and vitamin D deficiencies improved (p < 0.001), alongside weight gain and increased energy levels. Notably, patients on anti-TNF biologics showed enhanced response rates, suggesting potential synergistic effects between microbiome modulation and biologic therapy. Conclusions: This study highlights PMM as a promising adjunctive therapy for IBD, demonstrating benefits across clinical, inflammatory, and metabolic parameters. While findings support the role of microbiome-targeted interventions in disease management, larger randomized controlled trials are required to confirm the long-term efficacy and applicability in broader patient populations.

Cytopenias in Autoimmune Liver Diseases-A Review

Autoimmune liver diseases (AiLDs), including autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC), are immune-mediated conditions associated with significant hepatic and systemic manifestations. Among these, cytopenias-defined as reductions in blood cell counts affecting single or multiple lineages-represent a clinically important, though often under-recognized, complication. Cytopenias in AiLDs arise from diverse mechanisms, including immune-mediated destruction, hypersplenism due to portal hypertension, bone marrow suppression, and nutritional deficiencies. These abnormalities can exacerbate bleeding, infections, or fatigue, complicating the disease course and impacting therapeutic strategies. Immune-mediated cytopenias, such as autoimmune hemolytic anemia (AIHA), immune thrombocytopenic purpura (ITP), and autoimmune neutropenia (AIN), are more frequently associated with AIH, whereas cytopenias in PBC and PSC are largely attributed to hypersplenism. Diagnostic evaluation involves a systematic approach combining clinical history, laboratory testing (e.g., complete blood counts, Coombs tests, and nutritional assessments), imaging studies, and bone marrow evaluation in complex cases. Treatment strategies aim to address the underlying cause of cytopenias, including immunosuppressive therapy for autoimmune mechanisms, beta-blockers or splenectomy for hypersplenism, and supplementation for nutritional deficiencies. Challenges include distinguishing between immune- and hypersplenism-related cytopenias, managing drug-induced cytopenias, and optimizing care in transplant candidates. The recently recognized IgG4-related disease, often mimicking cholestatic AiLDs, adds another layer of complexity, given its association with autoimmune cytopenias and hypersplenism. This review aims to act as a guide for the clinician dealing with patients with AiLDs with respect to the occurrence of cytopenias, with a specific focus on pathophysiology and management of these cytopenias. Furthermore, there need to be enhanced multidisciplinary discussions about those patients between the hematologists and hepatologists, with a maintenance of a high index of suspicion for the rarer causes of cytopenias in AiLDs on the part of the treating physician, and there is a need for further studies to elucidate the mechanisms behind the occurrence of cytopenias in AiLDs.

Iron Deficiency Anemia in Patients with Inflammatory Bowel Disease: A Call to Action to Improve Patient Care

There is an urgent need for gastroenterologists and other clinicians involved in inflammatory bowel disease patient care to emphasize the screening and treatment of iron deficiency anemia.

Position statement of the Spanish Society of Primary Care Physicians (SEMERGEN) and Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the management of inflammatory bowel disease in Primary Care

Primary Care is the first point of contact for most patients after the onset of symptoms of inflammatory bowel disease (IBD). Establishing an initial diagnostic process based on compatible symptoms and agreed criteria and referral pathways, depending on the degree of suspicion and the patient's situation, can reduce diagnostic delays. Once the patient is referred to the Digestive specialist and the diagnosis of IBD is established, a treatment and follow-up plan is structured. The management of the patient must be shared with the participation of the family practitioners in the diagnosis and treatment of concomitant or intercurrent pathologies, the recognition of flare-ups or complications (of IBD or treatments), education tasks or adherence control. With the purpose of developing a comprehensive guide on the management of IBD aimed at Primary Care doctors, we have developed this positioning document collaboratively between the Spanish Society of Primary Care Physicians (SEMERGEN) and the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU).

Iron and Inflammatory Cytokines Synergistically Induce Colonic Epithelial Cell Ferroptosis in Colitis

Inflammatory bowel disease (IBD) is an inflammatory disease that occurs to the intestinal tract. Many patients with IBD often develop anemia and often receive oral iron supplementation. Many of them develop non-compliance with oral iron therapy, but the mechanisms are not well understood. We interrogated whether colonic epithelial iron overload impacts cell viability and disease severity. We observed increased expression of iron importers and iron accumulation in mature colonocytes in dextran sulfate sodium (DSS)-induced acute colitis and in humans with active colitis. Administration of hepcidin increased epithelial iron overload and aggravated colonic inflammation in DSS-treated mice and IL10-/- mice. Hepcidin-induced iron accumulation increased colonic epithelial death, which was prevented by treatment with Trolox, a vitamin E analog and a scavenger of lipid peroxides. By using cultured Caco-2 cells, we showed that iron and inflammatory cytokines (TNF-α and IL-1β) induced a synergistic increase in the number of necrotic cells. We then showed that the combined treatment by hepcidin and cytokines increased labile iron content and lipid peroxidation in Caco-2 cells. Moreover, liproxstatin-1, a ferroptosis inhibitor, and deferoxamine, an iron chelator, both abolished the hepcidin/cytokines induced death of Caco-2 cells, suggesting ferroptosis. We further elucidated that inflammatory cytokines promote lipid peroxidation and ferroptosis by inducing NOX1-dependent exhaustion of reduced glutathione (GSH). Collectively, our findings demonstrate that the inflammatory context predisposes colonic epithelial cells to iron overload mediated ferroptosis, exacerbating colonic inflammation.

Preoperative Optimization of Crohn's Patients before Abdominopelvic Surgery

In this article, we review and identify modifiable risk factors associated with postoperative complications of Crohn's disease. We highlight the importance of factors such as nutrition, corticosteroids, immunomodulators, abscesses, ideal timing of surgery, and biologic and small-molecule therapy on surgical outcomes. Herein, we discuss the strategies for attenuating these risk factors. Special consideration is given to venous thromboembolism prophylaxis in this patient population.

Approach to anaemia in gastrointestinal disease: A position paper by the ESPGHAN Gastroenterology Committee

Anaemia is a frequent consequence of many gastrointestinal (GI) diseases in children and it can even be the initial presenting symptom of underlying chronic GI disease. The definition of anaemia is age and gender-dependent and it can be classified based on pathophysiology, red cell morphology, and clinical presentation. Although nutritional deficiencies, including GI malabsorption of nutrients and GI bleeding, play a major role, other pathophysiologic mechanisms seen in chronic GI diseases, whether inflammatory (e.g., inflammatory bowel disease) or not (e.g., coeliac disease and dysmotility), are causing anaemia. Drugs, such as proton pump inhibitors, mesalamine, methotrexate and sulfasalazine, are also a potential cause of anaemia. Not uncommonly, due to a combination of factors, such as iron deficiency and a chronic inflammatory state, the underlying pathophysiology may be difficult to decipher and a broad diagnostic work-up is required. The goal of treatment is correction of anaemia by supplementation of iron and vitamins. The first therapeutic step is to treat the underlying cause of anaemia including bleeding control, restoration of intestinal integrity and reduction of inflammatory burden. The route of iron and vitamin supplementation is guided by the severity of anaemia.

Anemia in inflammatory bowel disease-A comprehensive review

Anemia is a frequent complication in inflammatory bowel disease (IBD) patients. The etiology is multifactorial, with iron deficiency and anemia of chronic disease being the main reasons. Other causes include vitamin B12 and folate deficiency, hemolytic anemia and medications such as azathioprine and sulfasalazine. Apart from physical symptoms, it is associated with several negative outcomes, including poor quality of life, increased risk of hospital admission, increased risk of surgery and higher treatment costs. Diagnostic evaluation aims to identify the underlying cause and severity to determine the appropriate therapeutic strategy. Investigations include a complete blood count, iron indices, inflammatory markers and vitamin B12 and folate levels. Patients with iron deficiency need adequate replacement therapy to improve hemoglobin and replenish iron stores. Those with moderate to severe anemia and/or active disease need intravenous iron, while mild anemia can be treated with oral iron. Multiple parenteral iron formulations are available which differ in dose and frequency of administration. Traditional oral iron supplements are available in ferrous forms, which, although effective, are associated with gastrointestinal side effects. Newer oral iron formulations have helped reduce these adverse effects but are expensive. Anemia of chronic disease is mainly driven by the effects of inflammatory mediators on iron metabolism and erythropoiesis and treatment requires control of disease activity. Relapse of anemia after therapy is frequent; hence, patients need to be closely followed up for early detection and appropriate management. Significant advances have been made in understanding the pathophysiology of anemia in IBD and better and safer iron formulations are available. However, a significant proportion of IBD patients with anemia go undetected or untreated and there is a need for improved recognition and better management practices. This review discusses various aspects of anemia in IBD and the current approach to diagnosis and management.

Intravenous Sodium Ferric Gluconate Complex for Hospitalized Pediatric Patients with Iron Deficiency Anemia

Background/Objectives: Iron deficiency anemia is common in the pediatric population. Red blood cell transfusions, a common acute treatment, pose well-recognized risks including lung injury, circulatory overload, and immune dysfunction. Intravenous iron, specifically sodium ferric gluconate complex (SFGC), is a potential alternative, however investigation on its use in hospitalized children is lacking. This study aims to describe the physiologic response via change in hematologic values to cumulative dose of SFGC, investigate the effect of cumulative dosing on the amount of RBC transfusions received, and comment on its safety. Methods: This is a retrospective investigation of pediatric patients with iron deficiency who received SFGC during their admission to the Helen DeVos Children's Hospital between 2016 and 2018 (N = 85). Results: A total of 258 doses of intravenous SFGC were provided to 85 patients. The average pre-treatment serum hemoglobin was 8.73 ± 1.33, and 7 days post-treatment this increased to 10.41 ± 1.43. Mean corpuscular volume, ferritin, serum ion, total iron binding capacity, reticulocyte percentage, and reticulocyte hemoglobin all increased 7 days post-treatment, as would be suspected, but without any statistically significant difference between hematologic outcomes and cumulative dose of SFGC. Our study did not reveal any correlation between the cumulative dose of SFGC administered and the amount of RBC transfusions received. Only one adverse event was recorded. Conclusions: Our results complement the trend of increased use and emerging evidence of favorable safety profiles of IV iron in the pediatric population. This descriptive investigation revealed that administering higher cumulative doses of SFGC provided no further benefits in terms of hematologic response or RBC transfusion administration.

Explorative study on the value of hepcidin in predicting iron non-responsiveness in paediatric inflammatory bowel disease

BACKGROUND

In a considerable proportion of anaemic children with inflammatory bowel disease (IBD), haemoglobin (Hb) does not normalise after iron therapy. We evaluated the added value of novel iron markers (hepcidin and soluble transferrin receptor [sTfR]) as compared to traditional iron markers (ferritin and transferrin saturation [TSAT]) to determine the best strategy for the prediction of non-responsiveness to iron suppletion.

METHODS

In this secondary analysis of prospectively collected data, we measured iron markers in anaemic children (Hb Z-score < -2.0) with IBD at baseline and one month after the initiation of iron therapy. Non-responsiveness was defined as an increase in Hb Z-score of less than 1 within a month. Logistic regression analysis was used to construct multi-biomarker prognostic models.

RESULTS

Of 40 anaemic paediatric IBD patients, sixteen (40%) were non-responsive to iron therapy after one month. Hb Z-score and hepcidin Z-score had the highest predictive ability (area under the ROC curve [AUROC] 0.80) providing sensitivity of 69% and specificity 92%. In a post-hoc analysis we defined hepcidin cut-off values to predict iron non-responsiveness.

CONCLUSION

A diagnostic strategy that involves baseline Hb Z-score and hepcidin Z-score in anaemic children with IBD reliably identifies those who will not respond to iron therapy.

IMPACT

Non-response to oral and intravenous iron suppletion therapy is high in paediatric IBD and should be identified early. Prediction models using baseline hepcidin demonstrated higher sensitivity and specificity to predict iron non-response compared to models using baseline traditional iron indicators (ferritin and transferrin saturation). In a post hoc analysis, we defined cut-off values for hepcidin to facilitate the correct timing of iron treatment in young anaemic patients with chronic inflammatory bowel disease.

Iron deficiency and fatigue in inflammatory bowel disease: A systematic review

BACKGROUND

It is unclear what impact iron deficiency has on fatigue in people with inflammatory bowel disease (IBD). This systematic review examined the evidence of whether iron deficiency, with or without anaemia, was associated with fatigue in IBD. Fatigue is a common symptom in patients with IBD that can be difficult to manage and treat. A greater understanding of the role and contribution of iron deficiency to fatigue may help improve the management of this condition.

METHODS

The databases searched were MEDLINE, OVID, CINAHL and Web of Science. Inclusion criteria were studies measuring iron status for iron deficiency (ID) and patient-reported outcome measures (PROMs) for fatigue in patients with IBD of any level of disease activity. Assessment of bias was conducted using the Newcastle Ottawa Scale. Studies were grouped for syntheses according to whether exposure was iron deficiency without anaemia (IDWA) or ID regardless of haemoglobin level.

RESULTS

Two hundred and eighty-five individual database results were identified and screened; 32 complete records were reviewed, from which seven studies with 1425 individuals were deemed eligible for inclusion in the results synthesis. Considerable variation in the methods and statistical analysis used to investigate the relationship between ID and fatigue prevented any quantitative synthesis. Studies varied by population disease activity levels, approaches used to define ID and PROMs used to measure fatigue. Three studies directly compared fatigue scores in IDWA to those not iron deficient, two of which showed patients with IDWA had significantly lower fatigue scores. Four studies used ID irrespective of anaemia as the exposure and reported mixed results on fatigue, with only one study reporting a higher prevalence of fatigue in the ID group.

CONCLUSIONS

There was marked heterogeneity between studies in this review. Two studies found evidence of a slight increase in fatigue levels in patients with IDWA. Though this does not explain all fatigue in patients with IBD, iron replacement should be considered to improve fatigue in iron-deficient patients.

Adherence to patient blood management strategy in patients with gastrointestinal bleeding: a prospective nationwide multicenter study

INTRODUCTION

Patient blood management (PBM) adherence in clinical practice is unclear. This real-world practice study assessed the management of patients with gastrointestinal (GI) bleeding after the implementation of the PBM strategy.

METHODS

This was a nationwide multicenter and prospective study involving consecutive adults with GI bleeding between March 2019 and March 2021. Patients were examined according to hemoglobin (Hb) level at admission (<7 g/dl, n  = 93; 7-8 g/dl, n  = 47; 8-9 g/dl, n  = 61; and >9 g/dl, n  = 249). Study outcomes measures were morbidity and mortality during hospitalization and at 3- and 6-month follow-up. Appropriate anemia or iron deficiency management was considered when adherence to PBM policy was higher than 75%.

RESULTS

A total of 450 patients (57.6% men, median age: 74 years, interquartile range: 63-82) were included. Overall, 55.1% and 59.3% of patients received transfusion and iron supplementation, respectively. The rates of appropriate transfusion and iron supplementation adherence were 90.9% (range: 86.9-93.5%, P  = 0.109) and 81.8% (range: 78.5-85.1%, P  = 0.041), depending on Hb level, respectively. No associations were observed between adherence to the PBM strategy and length of stay ( P  = 0.263) or risk of further bleeding ( P  = 0.742). Patients who were transfused [hazard ratio (HR): 0.79, 95% confidence interval (CI): 0.27-0.85] and iron supplemented (HR: 0.91, 95% CI: 0.38-1.41), however, appropriately achieved a lower risk of death. Age (HR: 1.12, 95% CI: 1.12-1.25) and further bleeding (HR: 39.08, 95% CI: 4.01-181.24) were poor prognostic factors. No serious adverse events were reported.

CONCLUSIONS

In this nationwide study, there is a high level of adherence and safety of PBM for the treatment of GI bleeding. Adherence to the PBM strategy improved outcomes in patients with GI bleeding.

Fatigue Is Strongly Associated with Depressive Symptoms in Patients with Inflammatory Bowel Disease

Introduction

Fatigue is an extraintestinal manifestation in patients with inflammatory bowel disease (IBD), such as Crohn's disease (CD) and ulcerative colitis (UC), with limited information on the underlying factors. This study aimed to determine the prevalence of fatigue and associated factors in IBD patients.

Methods

This prospective observational study assessed 216 IBD patients treated with intravenous infliximab or vedolizumab. Clinically meaningful fatigue was defined using a visual analog scale with a score ≥4 (VAS-F, range 0-10). Further assessments included the patient health questionnaire (PHQ-8) for depressive symptoms, the IBD-control-8 questionnaire to evaluate subjective disease control and the fatigue impact scale (FIS) for patients' quality of life (QoL). Demographic, clinical and laboratory data of the study population were collected and compared to identify fatigue-associated factors.

Results

Overall, 53.2% (n = 115) of the IBD patients reported clinically meaningful fatigue with a higher prevalence in UC (63.0%) versus CD (47.4%). Among patients with CD, disease activity was significantly associated with fatigue symptoms (p < 0.001), whereas no such correlation was observed in UC patients (p = 0.85). Clinically meaningful fatigue symptoms were reported in 90.9% of patients with depressive symptoms (PHQ-8 ≥10). Furthermore, patients with fatigue were younger (40 vs. 42 years, p = 0.04), reported more frequent use of concomitant psychoactive and/or sedative medication (p = 0.03) and had lower IBD-control-8 scores (median 12 vs. 16 points, p < 0.001). Only minor differences were observed when comparing serum and fecal laboratory values of patients with fatigue symptoms to those without.

Conclusion

Fatigue is highly prevalent among IBD patients treated with vedolizumab or infliximab and has a substantial impact on patients' QoL. Fatigue and depressive symptoms were strongly associated, suggesting closer monitoring for depression and the use of psychoactive medication in patients with IBD.

Recent Advances in the Management of Acute Severe Ulcerative Colitis

Acute severe ulcerative colitis is a medical emergency requiring inpatient treatment with intravenous steroids. Approximately one-third of patients do not respond to steroids sufficiently and require medical rescue therapy. Infliximab and cyclosporine are equally effective rescue agents, though infliximab is often preferred by clinicians for ease of use and greater familiarity. The use of cyclosporine is becoming more frequent, however, in patients previously exposed to infliximab. Those patients not exhibiting an adequate response to rescue therapy require colectomy. There is increasing interest in modified medical treatment to rescue the need for surgery. Janus kinase inhibitors may provide benefits when used alongside steroids from admission or as a rescue agent, but further randomised trials are needed to clearly establish their role. Intensified dosing of infliximab when used as a rescue therapy has shown mixed results but seems sensible in patients with low albumin and high disease burden. In this review, we describe the current established treatment pathways and report newer developments and evolving concepts that may in the future improve the care of patients with acute severe ulcerative colitis.

Safety and Efficacy of Ferric Carboxymaltose for Iron Deficiency Anemia in Inflammatory Bowel Disease: A Systematic Review

Ulcerative colitis and Crohn's disease, two types of inflammatory bowel disease (IBD), often cause anemia, primarily due to iron deficiency and chronic inflammation. Anemia negatively affects patients' daily functioning and quality of life, causing symptoms including headaches, exhaustion, and dyspnea. In IBD, iron deficiency arises from reduced intake, chronic blood loss, and impaired absorption. While oral iron supplements are commonly used, their poor absorption and gastrointestinal side effects limit their effectiveness, especially in IBD patients. The European Crohn's and Colitis Organization (ECCO) recommends intravenous iron, such as ferric carboxymaltose (FCM), as iron deficiency anemia in IBD can be managed using a safe and efficient substitute. With regard to treating iron deficiency anemia in patients with IBD, the purpose of this study is to investigate the safety and effectiveness of intravenous ferric carboxymaltose. We conducted a thorough search of medical databases, such as the Cochrane library, PubMed, and ResearchGate, to gather relevant literature. Using the databases, we found a total of 297 relevant articles. The identified studies have been screened, eligibility criteria have been introduced, and 14 research studies were selected for inclusion. This review adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, with quality assessments conducted using the Cochrane risk of bias 2 scale for randomized tests and the Newcastle-Ottawa scale for observational examination. We reviewed 14 research articles involving 2,493 patients. Among these, five were randomized controlled trials (RCTs), and the remaining nine were observational studies. The primary outcomes assessed were the therapeutic response (defined as hemoglobin ≥2 g/dL rise or normalization, improvement in iron profile parameters) and any adverse effects after FCM is administered to IBD patients. FCM was found to be highly effective in improving hemoglobin and iron profile parameters, with a generally good safety profile. Ferric carboxymaltose was the most efficient and well-tolerated intravenous (IV) iron formulation, proving safer and more effective than other iron therapies in patients suffering from IBD. However, severe hypophosphatemia can lead to serious complications, including heart failure, pulmonary failure, rhabdomyolysis, fractures, and osteomalacia, which may worsen its long-term impact. Therefore, the risk of hypophosphatemia associated with prolonged FCM use requires careful monitoring and further research to ensure its long-term safety and assess its effects on patients' quality of life.

Addressing Venous Extravasation, a Concern in Intravenous Iron Administration

Intravenous iron is commonly used to treat anemia related to chronic illnesses, but venous extravasation, an uncommon side effect of intravenous iron, can result in persistent skin discoloration. This report presents the case of a female patient who experienced venous extravasation following intravenous iron administration, with data collected from her patient record. Although venous extravasation is a rare adverse effect, it is important for both patients and healthcare providers to recognize this potential complication. Adhering to established criteria to minimize the occurrence of extravasation and its associated risks is essential for improving patient outcomes.

Intravenous iron therapy results in rapid and sustained rise in myocardial iron content through a novel pathway

BACKGROUND AND AIMS

Intravenous iron therapies contain iron-carbohydrate complexes, designed to ensure iron becomes bioavailable via the intermediary of spleen and liver reticuloendothelial macrophages. How other tissues obtain and handle this iron remains unknown. This study addresses this question in the context of the heart.

METHODS

A prospective observational study was conducted in 12 patients receiving ferric carboxymaltose (FCM) for iron deficiency. Myocardial, spleen, and liver magnetic resonance relaxation times and plasma iron markers were collected longitudinally. To examine the handling of iron taken up by the myocardium, intracellular labile iron pool (LIP) was imaged in FCM-treated mice and cells.

RESULTS

In patients, myocardial relaxation time T1 dropped maximally 3 h post-FCM, remaining low 42 days later, while splenic T1 dropped maximally at 14 days, recovering by 42 days. In plasma, non-transferrin-bound iron (NTBI) peaked at 3 h, while ferritin peaked at 14 days. Changes in liver T1 diverged among patients. In mice, myocardial LIP rose 1 h and remained elevated 42 days after FCM. In cardiomyocytes, FCM exposure raised LIP rapidly. This was prevented by inhibitors of NTBI transporters T-type and L-type calcium channels and divalent metal transporter 1.

CONCLUSIONS

Intravenous iron therapy with FCM delivers iron to the myocardium rapidly through NTBI transporters, independently of reticuloendothelial macrophages. This iron remains labile for weeks, reflecting the myocardium's limited iron storage capacity. These findings challenge current notions of how the heart obtains iron from these therapies and highlight the potential for long-term dosing to cause cumulative iron build-up in the heart.

Absolute and functional iron deficiency: Biomarkers, impact on immune system, and therapy

Iron is essential for numerous physiological processes and its deficiency often leads to anemia. Iron deficiency (ID) is a global problem, primarily affecting reproductive-age women and children, especially in developing countries. Diagnosis uses classical biomarkers like ferritin or transferrin saturation. Recent advancements include using soluble transferrin receptor (sTfR) or hepcidin for improved detection and classification of absolute and functional iron deficiencies, though mostly used in research. ID without anemia may present symptoms like asthenia and fatigue, even without relevant clinical consequences. ID impacts not only red-blood cells but also immune system cells, highlighting its importance in global health and immune-related comorbidities. Managing ID, requires addressing its cause and selecting appropriate iron supplementation. Various improved oral and intravenous products are available, but further research is needed to refine treatment strategies. This review updates on absolute and functional iron deficiencies, their relationships with the immune system and advancements in diagnosis and therapies.

Medication Burden Before and After Prescription of Biologics in Patients with Inflammatory Bowel Disease

Background: Biologics are a cornerstone in the treatment of severe cases of inflammatory bowel disease (IBD) and aim to control the disease and improve quality of life. This study investigated changes in nonbiologic medication prescriptions for IBD patients initiating biologic therapy in Germany. Methods: This study used data from anonymized pharmacy records in the German longitudinal prescription (LRx) database and included biologic-naive IBD patients who received their first biologic therapy prescription between 2016 and 2022. Changes in prescription rates and pill counts for nonbiologic medications (corticosteroids, 5-aminosalicylates (5-ASA), proton pump inhibitors, analgesics, immunosuppressants, Vitamin D, iron, and antibiotics) before and after the initiation of biologic therapy were assessed using descriptive statistics, McNemar's tests, and Poisson regression models, adjusting for age and sex. Results: A total of 29,559 biologic-naive IBD patients were included. Prior to index, 91.2% received at least one nonbiologic medication prescription, where corticosteroids and 5-ASA were the most common. Postindex, the overall prescription rate decreased to 87.7%, with significant reductions in prescriptions observed for corticosteroids, 5-ASA, and immunosuppressants (p-values < 0.001). The mean (SD) pill count dropped from 704 (1712) to 514 (1651), with the largest mean differences (95% CI) having been for corticosteroids (-77.9 [-80.3 to -75.5]), 5-ASA (-61.6 [-65.2 to -58.1]), and immunosuppressants (-55.0 [-57.5 to -52.6]). Older patients tended to have greater decreases in pill counts for corticosteroids and 5-ASA, while males showed statistically significant reductions in pill count for immunosuppressants compared with females. Conclusions: This study demonstrates that the prescription of nonbiologic medications significantly decreased after biologic therapy initiation. The use of biologics may therefore lead to improved disease management and potentially better patient outcomes.

Micronutrient deficiencies in inflammatory bowel disease: an incidence analysis

BACKGROUND

Micronutrient deficiencies associated with malnutrition in patients with inflammatory bowel disease (IBD) can lead to complications including anemia, coagulopathy, poor wound healing, and colorectal cancer. This study aimed to investigate micronutrient deficiencies (copper, vitamins A, B 9 , E, and K) in IBD patients and highlight associated symptoms to aid in the recognition of micronutrient deficiencies.

METHODS

A retrospective electronic chart review was performed on adults diagnosed with Crohn's disease or ulcerative colitis hospitalized at a tertiary care center for IBD flare between January 2013 and June 2017. Patients with serum or whole blood micronutrient levels were included. Pregnant and incarcerated patients were excluded.

RESULTS

A total of 611 IBD patients (440 Crohn's disease, 171 ulcerative colitis) met the inclusion criteria. Micronutrients were assessed in a subset of IBD patients (copper: 12.3%, A: 10.1%, B 9  : 95.9%, E: 10.3%, and K: 4.6%). Overall, 10.1% of patients had micronutrient deficiencies. The proportion of patients with copper, A, B 9 , E, and K deficiencies were 25.4, 53.3, 1.9, 23.7, and 29.4% for Crohn's disease and 50, 52.9, 1.2, 43.8, and 18.2% for ulcerative colitis, respectively. The most common symptoms or historical features associated with micronutrient deficiency were anemia (copper, B 9 ), muscle weakness (copper, E) thrombocytopenia, fatigue (copper, B 9 ), diarrhea (B 9 ), dry skin, hyperkeratosis, pruritus, significant weight loss, elevated C-reactive protein (A), bleeding, and osteoporosis (K).

CONCLUSION

Micronutrient deficiencies are common in IBD patients, yet they are not routinely assessed. Copper, vitamins A, E, and K deficiencies are particularly underrecognized. Associated historical features should raise suspicion and prompt assessment and treatment.

Management of acute severe ulcerative colitis-an update for generalist and specialist clinicians

BACKGROUND

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening medical emergency that occurs in up to 25% of patients with ulcerative colitis. Although intravenous corticosteroids remain the cornerstone of therapy, 30-40% of patients will not respond and need timely consideration of rescue therapy with (currently) either infliximab or ciclosporin or indeed colectomy, underscoring the importance of multidisciplinary care to ensure favourable outcomes for patients. We discuss the current evidence and present an approach to the management of ASUC for general and specialist clinicians caring for patients with ASUC.

SOURCES OF DATA

The information in this review is derived from data published in peer- reviewed academic journals and registered clinical trials.

AREAS OF AGREEMENT

Management of acute severe colitis requires a multidisciplinary approach with early initiation with steroids and timely escalation of treatment to either medical rescue therapy or surgery.

AREAS OF CONTROVERSY

Balancing the risks of delayed surgery vs. optimizing medical therapy, including accelerated dosing schedules for biologics, remains ambiguous.

GROWING POINTS

The position on newer molecules like Janus Kinase inhibitors, such as tofacitinib, is a growing area with early real-world data showing promise for steroid refractory ASUC.

AREAS TIMELY FOR DEVELOPING RESEARCH

Developing predictive biomarkers and clinical risk scores for personalized rescue therapy selection is an evolving area of research.

Role of iron deficiency anemia in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a relapsing chronic inflammatory disorder of the small and large gut with rising incidence and prevalence worldwide. Iron deficiency anemia is one of the most common extraintestinal manifestations of IBD, which correlates with the disease activity and tendency to relapse even after successful management. Anemia affects various aspects of quality of life, such as physical, cognitive, emotional, and workability, as well as healthcare costs. The anemia in IBD can be due to iron deficiency (ID) or chronic disease. The relative frequency of ID in IBD is 60%, according to some studies, and only 14% receive treatment. The evaluation of ID is also tricky as ferritin, being an inflammatory marker, also rises in chronic inflammatory diseases like IBD. The review of anemia in IBD patients involves other investigations like transferrin saturation and exploration of other nutritional deficiencies to curb the marker asthenia with which these patients often present. It underscores the importance of timely investigation and treatment to prevent long-term sequelae. We can start oral iron therapy in certain circumstances. Still, as inflammation of the gut hampers iron absorption, an alternative route to bypass the inflamed gut is usually recommended to avoid the requirement for blood transfusions.

[Iron supplementation in patients with chronic inflammatory bowel disease: recommendations for a practical approach]

Iron deficiency is the predominant cause of anemia. Iron deficiency anemia plays a major role, especially in patients with inflammatory bowel disease (IBD), and is the most common extraintestinal manifestation and IBD-associated systemic complication. The presence of anemia leads to a reduction in quality of life in patients with IBD associated with limitations in physical, emotional, and cognitive function. In addition, it is associated with an increased hospitalization rate. For this reason, iron supplementation is of particular importance. Oral and intravenous iron supplements are used to treat iron deficiency. Due to the lack of absorption and gastrointestinal side effects of oral substitution, intravenous supplementation is becoming increasingly important. However, there are still certain concerns about intravenous administration.With the help of this review, we want to address the topic of iron substitution in patients with IBD, summarize current guideline recommendations, and provide a practical approach.

Follow-up evaluation and management of anemia in inflammatory bowel disease: A study by the Italian Group for Inflammatory Bowel Diseases (IG-IBD)

BACKGROUND

The RIDART I study found a 13.6% prevalence of anemia in Italian patients with inflammatory bowel disease (IBD); most cases were due to iron-deficiency anemia (IDA).

AIMS

To evaluate changes in hemoglobin concentration during a 24-week follow-up of anemic patients with IBD.

METHODS

Follow-up laboratory and clinical data were obtained from RIDART I study patients with anemia. Factors affecting hemoglobin concentration, the impact of anemia on fatigue and quality of life (QoL), and its relationship with treatment, disease activity and disease complications were investigated.

RESULTS

Hemoglobin was 108 g/L at baseline, increased to 121 g/L at follow-up week 12 (p < 0.001) and then stabilized until week 24, but most patients remained anemic, with IDA, throughout the study. Hemoglobin improvement was greater in patients receiving either oral or parenteral iron supplementation. Following hemoglobin normalization, anemia relapse rate during follow-up was 30%. Oral iron did not cause disease reactivation. Lower follow-up hemoglobin was associated with a higher probability of having active disease, clinical complications, increased fatigue and reduced QoL.

CONCLUSIONS

In anemic patients with IBD, anemia represents a long-lasting problem, in most cases persisting for up to 24 weeks, with high relapse rate and a negative impact on fatigue and QoL.

Common Mistakes in Managing Patients with Inflammatory Bowel Disease

Introduction: Errors are very common in medical practice and in particular, in the healthcare of patients with inflammatory bowel disease (IBD); however, most of these can be prevented. Aim: To address common errors in the management of IBD. Methods: Our approach to this problem consists in identifying mistakes frequently observed in clinical practice (according to our experience) in the management of patients with IBD, then reviewing the scientific evidence available on the subject, and finally proposing the most appropriate recommendation for each case. Results: The most common mistakes in the management of IBD include those related to diagnosis and differential diagnosis, prevention, nutrition and diet, treatment with different drugs (mainly 5-aminosalicylates, corticosteroids, thiopurines, and anti-TNF agents), extraintestinal manifestations, anemia, elderly patients, pregnancy, and surgery. Conclusions: Despite the availability of guidelines for both disease management and preventive aspects of IBD care, a considerable variation in clinical practice still remains. In this review, we have identified common mistakes in the management of patients with IBD in clinical practice. There is a clear need for a greater dissemination of clinical practice guidelines among gastroenterologists and for the implementation of ongoing training activities supported by scientific societies. Finally, it is desirable to follow IBD patients in specialized units, which would undoubtedly be associated with higher-quality healthcare and a lower likelihood of errors in managing these patients.

Extraintestinal Manifestations in Inflammatory Bowel Disease: From Pathophysiology to Treatment

The inflammatory bowel diseases (IBDs) are systemic conditions that affect not only the gastrointestinal tract but also other parts of the body. The presence of extraintestinal manifestations can significantly impact the quality of life in IBD patients. Peripheral arthritis, episcleritis, and erythema nodosum are frequently associated with active intestinal inflammation and often improve with standard treatment targeting intestinal inflammation. In contrast, anterior uveitis, ankylosing spondylitis, and primary sclerosing cholangitis typically occur independently of disease flares. The incidence of these conditions in individuals with IBD can reach up to 50% of patients over the course of their lifetime. In addition, some advanced therapies utilized for the treatment of IBD potentially result in side effects that may resemble extraintestinal manifestations. This review provides a thorough analysis of the pathophysiology and treatment of extraintestinal manifestations associated with Crohn's disease and ulcerative colitis.

Iron Deficiency and Sleep/Wake Behaviors: A Scoping Review of Clinical Practice Guidelines-How to Overcome the Current Conundrum?

Current evidence suggests that iron deficiency (ID) plays a key role in the pathogenesis of conditions presenting with restlessness such as attention deficit hyperactivity disorder (ADHD) and restless legs syndrome (RLS). In clinical practice, ID and iron supplementation are not routinely considered in the diagnostic work-up and/or as a treatment option in such conditions. Therefore, we conducted a scoping literature review of ID guidelines. Of the 58 guidelines included, only 9 included RLS, and 3 included ADHD. Ferritin was the most frequently cited biomarker, though cutoff values varied between guidelines and depending on additional factors such as age, sex, and comorbidities. Recommendations surrounding measurable iron biomarkers and cutoff values varied between guidelines; moreover, despite capturing the role of inflammation as a concept, most guidelines often did not include recommendations for how to assess this. This lack of harmonization on the interpretation of iron and inflammation biomarkers raises questions about the applicability of current guidelines in clinical practice. Further, the majority of ID guidelines in this review did not include the ID-associated disorders, ADHD and RLS. As ID can be associated with altered movement patterns, a novel consensus is needed for investigating and interpreting iron status in the context of different clinical phenotypes.

Hypophosphatemia attenuates improvements in vitality after intravenous iron treatment in patients with inflammatory bowel disease

PURPOSE

Iron deficiency anemia is common in people with inflammatory bowel disease (IBD), causing deterioration in quality of life, which can be reversed by treatment that increases iron stores and hemoglobin levels. The present post hoc analyses estimate health state utility values for patients with IBD after treatment with ferric derisomaltose or ferric carboxymaltose and evaluate the health domains driving the changes.

METHODS

SF-36v2 responses were recorded at baseline and day 14, 35, 49, and 70 from 97 patients enrolled in the randomized, double-blind, PHOSPHARE-IBD trial (ClinicalTrials.gov ID: NCT03466983), in which patients with IBD across five European countries were randomly allocated to either ferric derisomaltose or ferric carboxymaltose. Changes in SF-36v2 scale scores and SF-6Dv2 health utility values were analyzed by mixed models.

RESULTS

In both treatment arms, SF-6Dv2 utility values and all SF-36v2 scale scores, except Bodily Pain, improved significantly (p =  < 0.0001). The improvement in SF-6Dv2 utility values showed no significant treatment group difference. The improvement in utility values was completely explained by improvement in Vitality scores. Vitality scores showed significantly larger improvement with ferric derisomaltose versus ferric carboxymaltose (p = 0.026). Patients with the smallest decrease in phosphate had significantly larger improvements in Vitality scores at each time point (p =  < 0.05 for all comparisons) and overall (p = 0.0006).

CONCLUSIONS

Utility values improved significantly with intravenous iron treatment. Improvement in utility values was primarily driven by Vitality scores, which showed significantly greater improvement in the ferric derisomaltose arm. Smaller decreases in phosphate were associated with significantly higher Vitality scores, suggesting that quality of life improvement is attenuated by hypophosphatemia. The utility values can inform future cost-utility analysis.

Diagnosis and management of anemia in pediatric inflammatory bowel diseases: Clinical practice guidelines on behalf of the SIGENP IBD Working group

Anemia is one of the most frequent extra-intestinal manifestations of inflammatory bowel disease. Insidious onset, variability of symptoms and lack of standardized screening practices may increase the risk of underestimating its burden in children with IBD. Despite its relevance and peculiarity in everyday clinical practice, this topic is only dealt with in a few documents specifically for the pediatric field. The aim of the current guidelines is therefore to provide pediatric gastroenterologists with a practical update to support the clinical and therapeutic management of children with IBD and anemia. A panel of 19 pediatric gastroenterologists and 1 pediatric hematologist with experience in the field of pediatric IBD was agreed by IBD Working group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) to produce the present article outlining practical clinical approaches to the pediatric patient with IBD and anemia. The levels of evidence and recommendations have been defined for each part of the statement according to the GRADE system.

LLL 44 - Module 3: Micronutrients in Chronic disease

Micronutrients (MN), i.e. trace elements and vitamins, are essential organic molecules, which are required in the diet in relatively small amounts in any form of nutrition (oral, enteral, parenteral). The probability of MN depletion or deficiencies should be considered in all chronic illnesses, especially in those that can interfere with intake, digestion, or intestinal absorption. Low socio-economic status and food deprivation are recognized as the most prevalent reasons for MN deficiencies world-wide. Elderly multimorbid patients with multimodal therapy, as well as patients with long-lasting menu restrictions, are at high risk for both disease related malnutrition as well as multiple MN deficiencies, needing careful specific follow-up. The importance of monitoring MN blood levels along with CRP is essential for optimal care. Drug interactions are also highlighted. In patients with chronic conditions depending on medical nutrition therapy, the provision of adequate dietary reference intakes (DRI) of MN doses and monitoring of their adequacy belongs to standard of care.