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Abstract
Anemia is defined as a low red blood cell count, a low hematocrit, or a low hemoglobin concentration. In pregnancy, a hemoglobin concentration of less than 11.0 g/dL in the first trimester and less than 10.5 or 11.0 g/dL in the second or third trimester (depending on the guideline used) is considered anemia. Anemia is the most common hematologic abnormality in pregnancy. Maternal anemia is associated with adverse fetal, neonatal and childhood outcomes, but causality is not established. Maternal anemia increases the likelihood of transfusion at delivery. Besides hemodilution, iron deficiency is the most common cause of anemia in pregnancy. The American College of Obstetricians and Gynecologists recommends screening for anemia with a complete blood count in the first trimester and again at 24 0/7 to 28 6/7 weeks of gestation. Mild anemia, with a hemoglobin of 10.0 g/dL or higher and a mildly low or normal mean corpuscular volume (MCV) is likely iron deficiency anemia. A trial of oral iron can be both diagnostic and therapeutic. Mild anemia with a very low MCV, macrocytic anemia, moderate anemia (hemoglobin 7.0-9.9 g/dL) or severe anemia (hemoglobin 4.0-6.9 g/dL) requires further investigation. Once a diagnosis of iron deficiency anemia is confirmed, first-line treatment is oral iron. New evidence suggests that intermittent dosing is as effective as daily or twice-daily dosing with fewer side effects. For patients with iron deficiency anemia who cannot tolerate, cannot absorb, or do not respond to oral iron, intravenous iron is preferred. With contemporary formulations, allergic reactions are rare.
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Rogozińska E, Daru J, Nicolaides M, Amezcua-Prieto C, Robinson S, Wang R, Godolphin PJ, Saborido CM, Zamora J, Khan KS, Thangaratinam S. Iron preparations for women of reproductive age with iron deficiency anaemia in pregnancy (FRIDA): a systematic review and network meta-analysis. Lancet Haematol 2021; 8:e503-e512. [PMID: 34171281 PMCID: PMC7612251 DOI: 10.1016/s2352-3026(21)00137-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 04/30/2021] [Accepted: 04/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Numerous iron preparations are available for the treatment of iron deficiency anaemia in pregnancy. We aimed to provide a summary of the effectiveness and safety of iron preparations used in this setting. METHODS We did a systematic review and network meta-analysis of randomised trials. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature for trials published in any language from Jan 1, 2011, to Feb 28, 2021. We included trials including pregnant women with iron deficiency anaemia and evaluating iron preparations, irrespective of administration route, with at least 60 mg of elemental iron, in comparison with another iron or non-iron preparation. Three authors independently selected studies, extracted data, and did a risk of bias assessment using the Cochrane tool (version 1.0). The primary outcome was the effectiveness of iron preparations, evaluated by changes in haemoglobin concentration at 4 weeks from baseline. The secondary outcomes were change in serum ferritin concentration at 4 weeks from baseline and treatment-related severe and non-severe adverse events. We did random-effects pairwise and network meta-analyses. Side-effects were reported descriptively for each trial. This study is registered with PROSPERO, CRD42018100822. FINDINGS Among 3037 records screened, 128 full-text articles were further assessed for eligibility. Of the 53 eligible trials (reporting on 9145 women), 30 (15 interventions; 3243 women) contributed data to the network meta-analysis for haemoglobin and 15 (nine interventions; 1396 women) for serum ferritin. The risk of bias varied across the trials contributing to network meta-analysis, with 22 of 30 trials in the network meta-analysis for haemoglobin judged to have a high or medium global risk of bias. Compared with oral ferrous sulfate, intravenous iron sucrose improved both haemoglobin (mean difference 7·17 g/L, 95% CI 2·62-11·73; seven trials) and serum ferritin (mean difference 49·66 μg/L, 13·63-85·69; four trials), and intravenous ferric carboxymaltose improved haemoglobin (mean difference 8·52 g/L, 0·51-16·53; one trial). The evidence for other interventions compared with ferrous sulfate was insufficient. The most common side-effects with oral iron preparations were gastrointestinal effects (nausea, vomiting, and altered bowel movements). Side-effects were less common with parenteral iron preparations, although these included local pain, skin irratation, and, on rare occasions, allergic reactions. INTERPRETATION Iron preparations for treatment of iron deficiency anaemia in pregnancy vary in effectiveness, with good evidence of benefit for intravenous iron sucrose and some evidence for intravenous ferric carboxymaltose. Clinicians and policy makers should consider the effectiveness of individual preparations before administration, to ensure effective treatment. FUNDING None.
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Affiliation(s)
| | - Jahnavi Daru
- Institute for Population Health Science, Queen Mary University of London, London, UK.
| | - Marios Nicolaides
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Carmen Amezcua-Prieto
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
| | - Susan Robinson
- Department of Haematology, Guy's and St Thomas' Hospital, London, UK
| | - Rui Wang
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Peter J Godolphin
- MRC Clinical Trials Unit at UCL, University College London, London, UK
| | - Carlos Martín Saborido
- Department of Health Planning and Economics, National School of Public Health, Institute of Health Carlos III, Madrid, Spain
| | - Javier Zamora
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Hospital Universitario Ramón y Cajal (IRYCIS), CIBERESP, Madrid, Spain
| | - Khalid S Khan
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Benson CS, Shah A, Frise MC, Frise CJ. Iron deficiency anaemia in pregnancy: A contemporary review. Obstet Med 2021; 14:67-76. [PMID: 34394714 PMCID: PMC8358243 DOI: 10.1177/1753495x20932426] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/13/2020] [Indexed: 01/01/2023] Open
Abstract
Iron deficiency anaemia is a global health problem, which particularly affects pregnant women. Iron deficiency anaemia during pregnancy is associated with increased maternal and perinatal morbidity and mortality. Maternal iron deficiency may also be associated with neurocognitive deficits in infants. Iron requirements increase during pregnancy and are influenced by hepcidin, the master regulator of iron homeostasis. The enduring global burden of maternal anaemia suggests that currently employed iron supplementation strategies are suboptimal. Recent developments in our understanding of systemic and placental iron homeostasis may improve therapeutic effectiveness by altering the dose and frequency of oral iron. Intravenous iron appears to be a safe treatment to correct maternal anaemia rapidly but research on patient-centred outcomes and cost-effectiveness is needed. Future trials should be adequately powered to assess outcomes relevant to pregnant women.
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Affiliation(s)
- Charlotte S Benson
- Department of Obstetrics, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Akshay Shah
- Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - Matthew C Frise
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
- Intensive Care Unit, Royal Berkshire Hospital, NHS Foundation Trust, Reading, UK
| | - Charlotte J Frise
- Fetal Maternal Medicine Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
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Kemppinen L, Mattila M, Ekholm E, Pallasmaa N, Törmä A, Varakas L, Mäkikallio K. Gestational iron deficiency anemia is associated with preterm birth, fetal growth restriction, and postpartum infections. J Perinat Med 2021; 49:431-438. [PMID: 33554586 DOI: 10.1515/jpm-2020-0379] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/02/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Gestational IDA has been linked to adverse maternal and neonatal outcomes, but the impact of iron supplementation on outcome measures remains unclear. Our objective was to assess the effects of gestational IDA on pregnancy outcomes and compare outcomes in pregnancies treated with either oral or intravenous iron supplementation. METHODS We evaluated maternal and neonatal outcomes in 215 pregnancies complicated with gestational IDA (Hb<100 g/L) and delivered in our tertiary unit between January 2016 and October 2018. All pregnancies from the same period served as a reference group (n=11,545). 163 anemic mothers received oral iron supplementation, and 52 mothers received intravenous iron supplementation. RESULTS Gestational IDA was associated with an increased risk of preterm birth (10.2% vs. 6.1%, p=0.009) and fetal growth restriction (FGR) (1.9% vs. 0.3%, p=0.006). The gestational IDA group that received intravenous iron supplementation had a greater increase in Hb levels compared to those who received oral medication (18.0 g/L vs. 10.0 g/L, p<0.001), but no statistically significant differences in maternal and neonatal outcomes were detected. CONCLUSIONS Compared to the reference group, prematurity, FGR, postpartum infections, and extended hospital stays were more common among mothers with gestational IDA, causing an additional burden on the families and the healthcare system.
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Affiliation(s)
- Lotta Kemppinen
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Mirjami Mattila
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Eeva Ekholm
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Nanneli Pallasmaa
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Ari Törmä
- University of Turku, Turku, Finland.,Department of Clinical Laboratory, Turku University Hospital, Turku, Finland
| | - Leila Varakas
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Kaarin Mäkikallio
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
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Numan S, Kaluza K. Systematic review of guidelines for the diagnosis and treatment of iron deficiency anemia using intravenous iron across multiple indications. Curr Med Res Opin 2020; 36:1769-1782. [PMID: 32936683 DOI: 10.1080/03007995.2020.1824898] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To explore current recommendations for intravenous (IV) iron use in clinical guidelines for iron deficiency anemia (IDA) across different therapeutic areas and identify recommendations, if any, for the treatment of IDA. METHODS A literature search was conducted in Medline, EMBASE, BIOSIS, Cochrane Collaboration, and on websites of relevant professional associations. Searches were limited to English publications. 1292 citations were identified, 219 papers were assessed, and 35 guidelines were identified for inclusion. RESULTS The guidelines covered a variety of geographies: United States (US; n = 10); Europe (n = 11); "Rest-of-World" (n = 9); and "Other" organizations (n = 5). These covered a variety of specialties. Guidelines defined iron deficiency and IDA generally by serum ferritin and transferrin saturation levels. One-fifth of the reviewed guidelines (7 of 35) included no mention or recommendation regarding parenteral iron's utility in the management of IDA. Fifteen guidelines recommended using parenteral iron in the management of IDA. Fewer US guidelines included recommendations around IV iron than in Europe or the rest of the world. Approximately 60% of the guidelines have not been updated in ≥5 years and consequently do not reflect current evidence on the safety and efficacy of IV iron. CONCLUSIONS While national and international guidelines for management of IDA exist, many are outdated and do not reflect current evidence including, but not limited to, parenteral iron use. Urgent consideration should be given to updating and clarifying management guidelines for IDA using the latest treatment modalities and options, particularly in the US.
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Affiliation(s)
- Syed Numan
- Medical Affairs, American Regent, Norristown, PA, USA
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Affiliation(s)
- Wen-Ling Lee
- Department of Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC
- Department of Nursing, Oriental Institute of Technology, New Taipei City, Taiwan, ROC
| | - Chang-Ching Yeh
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, ROC
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