1
|
Hu S, Wu D, Wu J, Zhang Y, Bøgelund M, Pöhlmann J, Pollock RF. Disutilities Associated with Intravenous Iron Infusions: Results from a Time Trade-off Survey and Diminishing Marginal Utility Model for Treatment Attributes in China. Patient Relat Outcome Meas 2023; 14:253-267. [PMID: 37789883 PMCID: PMC10543423 DOI: 10.2147/prom.s400389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 09/15/2023] [Indexed: 10/05/2023] Open
Abstract
Purpose Treatment process attributes can affect health state utilities associated with therapy. For intravenous iron, used to treat iron deficiency and iron deficiency anemia, research into process attributes is still lacking. This study estimated utilities associated with process attributes for intravenous iron infusions. Methods An online survey including seven health state vignettes and time trade-off tasks was administered to participants, who were not patients living with iron deficiency or iron deficiency anemia, from a Chinese online panel. Vignettes used an identical description of iron deficiency and iron deficiency anemia but differed in the annual number of infusions, infusion duration, and infusion-associated risk of hypophosphatemic osteomalacia. Disutilities and their rate of change as the number of infusions increased were examined using a power model. Results The survey was completed by 1091 participants. The highest utilities were observed for one annual infusion of 15-30 minutes or 30-60 minutes, without risk of hypophosphatemic osteomalacia (0.754 and 0.746, respectively). In comparison, more infusions and infusions with a risk of hypophosphatemic osteomalacia were associated with lower utilities. Utility continued to decrease, but at a diminishing rate, as the annual number of infusions increased, with utility decrements of 0.006 and 0.002, respectively, when going from zero to one and from four to five infusions per year. All marginal disutilities were small (values <0.01). Conclusion This study suggested that treatment attributes of intravenous iron infusions affect health state utilities. Using intravenous iron formulations that allow for fewer and shorter infusions without the risk of hypophosphatemic osteomalacia can reduce the number of visits required and increase patients' quality of life.
Collapse
Affiliation(s)
- Shanlian Hu
- School of Public Health, Fudan University, Shanghai, People’s Republic of China
| | - Depei Wu
- First Affiliated Hospital of Soochow University, Soochow University, Suzhou, People’s Republic of China
| | - Jing Wu
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, People’s Republic of China
| | - Yabing Zhang
- Shanghai Institute of Technology, Shanghai, People’s Republic of China
| | | | | | | |
Collapse
|
2
|
Banasiewicz T, Machała W, Borejsza Wysocki M, Lesiak M, Krych S, Lange M, Hogendorf P, Durczyński A, Cwaliński J, Bartkowiak T, Dziki A, Kielan W, Kłęk S, Krokowicz Ł, Kusza K, Myśliwiec P, Pędziwiatr M, Richter P, Sobocki J, Szczepkowski M, Tarnowski W, Zegarski W, Zembala M, Zieniewicz K, Wallner G. Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects. POLISH JOURNAL OF SURGERY 2023; 95:14-39. [PMID: 38084044 DOI: 10.5604/01.3001.0053.8966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.
Collapse
Affiliation(s)
- Tomasz Banasiewicz
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Instytut Chirurgii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Waldemar Machała
- Klinika Anestezjologii i Intensywnej Terapii - Uniwersytecki Szpital Kliniczny im. Wojskowej Akademii Medycznej - Centralny Szpital Weteranów, Łódź
| | - Maciej Borejsza Wysocki
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Instytut Chirurgii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Maciej Lesiak
- Katedra i Klinika Kardiologii Uniwersytetu Medycznego im. K. Marcinkowskiego w Poznaniu
| | - Sebastian Krych
- Katedra i Klinika Kardiochirurgii, Transplantologii, Chirurgii Naczyniowej i Endowaskularnej SUM. Studenckie Koło Naukowe Kardiochirurgii Dorosłych. Śląski Uniwersytet Medyczny w Katowicach
| | - Małgorzata Lange
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Instytut Chirurgii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Piotr Hogendorf
- Klinika Chirurgii Ogólnej i Transplantacyjnej, Uniwersytet Medyczny w Łodzi
| | - Adam Durczyński
- Klinika Chirurgii Ogólnej i Transplantacyjnej, Uniwersytet Medyczny w Łodzi
| | - Jarosław Cwaliński
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Instytut Chirurgii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Tomasz Bartkowiak
- Oddział Kliniczny Anestezjologii, Intensywnej Terapii i Leczenia Bólu, Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu
| | - Adam Dziki
- Klinika Chirurgii Ogólnej i Kolorektalnej Uniwersytetu Medycznego w Łodzi
| | - Wojciech Kielan
- II Katedra i Klinika Chirurgii Ogólnej i Chirurgii Onkologicznej, Uniwersytet Medyczny we Wrocławiu
| | - Stanisław Kłęk
- Klinika Chirurgii Onkologicznej, Narodowy Instytut Onkologii - Państwowy Instytut Badawczy im. Marii Skłodowskiej-Curie, Oddział w Krakowie, Kraków
| | - Łukasz Krokowicz
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Instytut Chirurgii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Krzysztof Kusza
- Katedra i Klinika Anestezjologii i Intensywnej Terapii, Uniwersytet Medyczny im K. Marcinkowskiego w Poznaniu
| | - Piotr Myśliwiec
- I Klinika Chirurgii Ogólnej i Endokrynologicznej, Uniwersytet Medyczny w Białymstoku
| | - Michał Pędziwiatr
- Katedra Chirurgii Ogólnej, Wydział Lekarski, Uniwersytet Jagielloński - Collegium Medicum, Kraków
| | - Piotr Richter
- Oddział Kliniczny Chirurgii Ogólnej, Onkologicznej i Gastroenterologicznej Szpital Uniwersytecki w Krakowie
| | - Jacek Sobocki
- Katedra i Klinika Chirurgii Ogólnej i Żywienia Klinicznego, Centrum Medyczne Kształcenia Podyplomowego, Warszawski Uniwersytet Medyczny, Warszawa
| | - Marek Szczepkowski
- Klinika Chirurgii Kolorektalnej, Ogólnej i Onkologicznej, Centrum Medyczne Kształcenia Podyplomowego, Szpital Bielański, Warszawa
| | - Wiesław Tarnowski
- Klinika Chirurgii Ogólnej, Onkologicznej i Bariatrycznej CMKP, Szpital im. Prof. W. Orłowskiego, Warszawa
| | | | - Michał Zembala
- Wydział Medyczny, Katolicki Uniwersytet Lubelski Jana Pawła II w Lublinie
| | - Krzysztof Zieniewicz
- Katedra i Klinika Chirurgii Ogólnej, Transplantacyjnej i Wątroby, Warszawski Uniwersytet Medyczny, Warszawa
| | - Grzegorz Wallner
- II Katedra i Klinika Chirurgii Ogólnej, Gastroenterologicznej i Nowotworów Układu Pokarmowego, Uniwersytet Medyczny w Lublinie
| |
Collapse
|
3
|
Cool JA, Nelson RE, Freed JA. Clinical progress note: Inpatient management of iron deficiency anemia. J Hosp Med 2023; 18:249-253. [PMID: 36573406 DOI: 10.1002/jhm.13027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/28/2022]
Affiliation(s)
- Joséphine A Cool
- Section of Hospital Medicine, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Division of General Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan E Nelson
- Section of Hospital Medicine, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Division of General Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason A Freed
- Division of General Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Dahmen AS, Phuoc VH, Cohen JB, Sexton WJ, Patel SY. Bloodless surgery in urologic oncology: A review of hematologic, anesthetic, and surgical considerations. Urol Oncol 2022; 41:192-203. [PMID: 36470804 DOI: 10.1016/j.urolonc.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/01/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
The urologic oncology patient who refuses blood transfusion can present unique challenges in perioperative blood management. Since blood loss and associated transfusion can be expected in many complex urologic oncology surgeries, a multidisciplinary approach may be required for optimal outcomes. Through collaboration with the hematologist, anesthesiologist, and urologist, various techniques can be employed in the perioperative phases to minimize blood loss and the need for transfusion. We review the risks and benefits of these techniques and offer recommendations specific to the urologic oncology patient.
Collapse
Affiliation(s)
- Aaron S Dahmen
- Department of Urology, University of Chicago, Chicago, IL
| | - Vania H Phuoc
- Department of Medical Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jonathan B Cohen
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Sephalie Y Patel
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL.
| |
Collapse
|
5
|
Boots JMM, Quax RAM. High-Dose Intravenous Iron with Either Ferric Carboxymaltose or Ferric Derisomaltose: A Benefit-Risk Assessment. Drug Saf 2022; 45:1019-1036. [PMID: 36068430 PMCID: PMC9492608 DOI: 10.1007/s40264-022-01216-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/22/2022]
Abstract
The intravenous iron formulations ferric carboxymaltose (FCM) and ferric derisomaltose (FDI) offer the possibility of administering a large amount of iron in one infusion. This results in faster correction of anemia and the formulations being better tolerated than oral iron formulations. This triad of logistic advantages, improved patient convenience, and fast correction of anemia explains the fact that intravenous iron formulations nowadays are frequently prescribed worldwide in the treatment of iron deficiency anemia. However, these formulations may result in hypophosphatemia by inducing a strong increase in active fibroblast growth factor-23 (FGF-23), a hormone that stimulates renal phosphate excretion. This effect is much more pronounced with FCM than with FDI, and therefore the risk of developing hypophosphatemia is remarkably higher with FCM than with FDI. Repeated use of FCM may result in severe osteomalacia, which is characterized by bone pain, Looser zones (pseudofractures), and low-trauma fractures. Intravenous iron preparations are also associated with other adverse effects, of which hypersensitivity reactions are the most important and are usually the result of a non-allergic complement activation on nanoparticles of free labile iron-Complement Activation-Related Pseudo-Allergy (CARPA). The risk on these hypersensitivity reactions can be reduced by choosing a slow infusion rate. Severe hypersensitivity reactions were reported in < 1% of prospective trials and the incidence seems comparable between the two formulations. A practical guideline has been developed based on baseline serum phosphate concentrations and predisposing risk factors, derived from published cases and risk factor analyses from trials, in order to establish the safe use of these formulations.
Collapse
Affiliation(s)
- Johannes M M Boots
- Department of Internal Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands.
| | - Rogier A M Quax
- Department of Internal Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands
| |
Collapse
|
6
|
Chandra J, Dewan P, Kumar P, Mahajan A, Singh P, Dhingra B, Radhakrishnan N, Sharma R, Manglani M, Rawat AK, Gupta P, Gomber S, Bhat S, Gaikwad P, Elizabeth KE, Bansal D, Dubey AP, Shah N, Kini P, Trehan A, Datta K, Basavraja GV, Saxena V, Kumar RR. Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric Hematology-Oncology Chapter and Pediatric and Adolescent Nutrition Society of the Indian Academy of Pediatrics. Indian Pediatr 2022. [DOI: 10.1007/s13312-022-2622-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
7
|
Relationship between Preoperative Hemoglobin and Hospital Stays in Patients Receiving Prime Total Knee Arthroplasty. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:3627688. [PMID: 35875776 PMCID: PMC9307341 DOI: 10.1155/2022/3627688] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/05/2022] [Accepted: 06/30/2022] [Indexed: 11/17/2022]
Abstract
Previous evidence has shown that preoperative hemoglobin is related to poor prognosis after primary total knee arthroplasty. Reviewing cohort research was conducted at the third-level academic medical center in Singapore and involved 2,676 patients. Population statistics, complications, preoperative hemoglobin (Hb) levels, length of hospital stay (LOS), and readmission information of thirty days were obtained. Anemia was defined based on the World Health Organization (WHO). LOS extension was with the definition as no less than six days with >1/75 LOS corresponding to the data. According to the study requirements, we finally collected 2273 patients. We plotted the relationship between hemoglobin levels and length of stay. We analyzed 2273 patients, with 140 cases of Hb ≤ 11.0 g/dL, 831 cases of Hb 11.0–12.9 g/dL, and the other 1320 cases of Hb ≥ 13.0 g/dL. The mean age of patients with prolonged LOS (68.4 ± 8.2 years) was higher than that of patients with familiar LOS (65.9 ± 8.0 years). In addition, patients with extended LOS had higher ASA-PS values, a history of cerebrovascular accidents (CVA), diabetes mellitus (DM), and ischemic heart disease (IHD) (P < 0.001), repeated surgery within 30 days, HB, and operative time (min) (P < 0.01). Variables independently related to increased risk of extended LOS included general anesthesia (GA) (adjusted OR (aOR) 1.4, P=0.005, P=0.005), CVA (aOR 3.0, P < 0.001), DM (aOR 1.4, P=0.032), and HB < 11 g/dL. Variables increased LOS included HB ≥ 13 g/dL (aOR 0.4, P < 0.001) and Hb 11.0–12.9 g/dL (aOR 0.5, P=0.001). Hb was 14 g/dL, and LOS decreased by at least 0.24 days for each 1 g increase in preoperative Hb before the inflection point (95%CI 0.12 to 0.36, P=0.0001). Anemia is familiar in patients receiving elective total knee arthroplasty (TKA) in Singapore. Thus, this study describes that the preoperative hemoglobin was associated with length of stay. We found that on the left where HB was 14, length of stay decreased with increased hemoglobin values. We recommend preoperative correction of anemia to determine the diagnosis.
Collapse
|
8
|
Abstract
PURPOSE OF REVIEW Anemia in pregnancy is associated with increased maternal and neonatal morbidity. There is increasing awareness amongst obstetricians about the need to screen for iron deficiency anemia (IDA), as well as growing literature on diagnosis and treatment. This review aims to summarize causes, consequences, treatment, and evaluation of IDA in pregnancy. RECENT FINDINGS National guidelines provide varying guidance on diagnosis and treatment of IDA in pregnancy. Serum ferritin is a helpful adjunct for the diagnosis of IDA. Oral iron remains an option for treatment; absorption is improved with every other day dosing and is effective for patients able to tolerate. Emerging studies on modern generations of intravenous (IV) iron demonstrate shorter infusion times and improved safety profiles. Notably, recent UK guidelines provide consideration for universal IV iron supplementation for treatment of anemia beyond 34 weeks of pregnancy. SUMMARY Iron, in dietary, oral, and IV forms, has been found effective in resolving anemia in pregnancy. Pregnant people with IDA in the third trimester are more likely to benefit from IV iron. Future studies designed and powered to assess maternal and perinatal morbidity indicators and blood transfusion rates can strengthen recommendations.
Collapse
Affiliation(s)
- Irogue Igbinosa
- Stanford University, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine
| | - Caroline Berube
- Stanford University, Department of Medicine, Division of Hematology, Stanford, California, USA
| | - Deirdre J Lyell
- Stanford University, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine
| |
Collapse
|
9
|
LaVallee C, Bansal I, Kamdar S, Kwong WJ, Boccia RV. Relationship Between Initial Parenteral Iron Therapy Dosing and Treatment Effectiveness: A Real-World Retrospective Analysis. J Blood Med 2022; 13:133-142. [PMID: 35299847 PMCID: PMC8922365 DOI: 10.2147/jbm.s349070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/17/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Chris LaVallee
- Health Outcomes Research, Decision Resources Group, Burlington, MA, USA
| | - Isha Bansal
- Analytics, Decision Resources Group, Burlington, MA, USA
| | - Shilpa Kamdar
- Analytics, Decision Resources Group, Burlington, MA, USA
| | - Winghan Jacqueline Kwong
- Health Economics & Outcomes Research, Daiichi Sankyo Inc., Basking Ridge, NJ, USA
- Correspondence: Winghan Jacqueline Kwong, Daiichi Sankyo, Inc., 211 Mt Airy Road, Basking Ridge, NJ, 07920, USA, Tel +1 908 992 7063, Email
| | - Ralph V Boccia
- Center for Cancer and Blood Disorders, P.C, Bethesda, MD, USA
| |
Collapse
|
10
|
Kong R, Hutchinson N, Hill A, Ingoldby F, Skipper N, Jones C, Bremner S, Bruce C, Wright J, Lewis M, Newman S, Chevassut T, Hildick-Smith D. Randomised open-label trial comparing intravenous iron and an erythropoiesis-stimulating agent versus oral iron to treat preoperative anaemia in cardiac surgery (INITIATE trial). Br J Anaesth 2022; 128:796-805. [DOI: 10.1016/j.bja.2022.01.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 01/14/2023] Open
|
11
|
Yefet E, Mruat Rabah S, Sela ND, Hosary Mhamed S, Yossef A, Nachum Z. Addition of oral iron bisglycinate to intravenous iron sucrose for the treatment of postpartum anemia-randomized controlled trial. Am J Obstet Gynecol 2021; 225:668.e1-668.e9. [PMID: 34171389 DOI: 10.1016/j.ajog.2021.06.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/11/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Studies that have compared the effectiveness of oral with intravenous iron supplements to treat postpartum anemia have shown mixed results. The superiority of one mode of treatment vs the other has yet to be demonstrated. Therefore, despite guidelines and standards of care, treatment approaches vary across practices. A single 500 mg dose of iron sucrose, which is higher than what is usually administered, has not been evaluated to treat postpartum moderate to severe anemia. OBJECTIVE This study aimed to compare the efficacy of intravenous iron sucrose alone with intravenous iron sucrose in combination with oral iron bisglycinate supplementation in treating moderate to severe postpartum anemia. STUDY DESIGN A randomized controlled trial was conducted between February 2015 and June 2020. Women with postpartum hemoglobin level of ≤9.5 g/dL were treated with 500 mg intravenous iron sucrose after an anemia workup, which ruled out other causes for anemia. In addition to receiving intravenous iron, women were randomly allocated to receive either 60 mg of oral iron bisglycinate for 45 days or no further iron supplementation. The primary outcome was hemoglobin level at 6 weeks after delivery. Secondary outcomes were iron storage parameters and quality of life. RESULTS Of 158 patients who participated, 63 women receiving intravenous and oral iron, and 44 women receiving intravenous iron-only, completed the study and were included in the analysis. Baseline and obstetrical characteristics were similar between the study cohorts. Although statistically significant, postpartum hemoglobin levels were only 0.4 g/dL higher in the intravenous and oral iron than intravenous iron-only cohort (12.4 g/dL vs 12.0 g/dL, respectively; P=.03), with a respective increase from baseline of 4.2 g/dL vs 3.7 g/dL (P=.03). There was no difference in the rate of women with hemoglobin level of <12.0 or 11.0 g/dL. Iron storage and health quality were not different between the cohorts. Oral iron treatment was associated with 29% rate of adverse effects. Compliance and satisfaction from treatment protocol were high in both cohorts. CONCLUSION Intravenous 500 mg iron sucrose treatment alone is sufficient to treat postpartum anemia without the necessity of adding oral iron treatment.
Collapse
|
12
|
Recent advancements and future submissions of silica core-shell nanoparticles. Int J Pharm 2021; 609:121173. [PMID: 34627997 DOI: 10.1016/j.ijpharm.2021.121173] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/22/2021] [Accepted: 10/04/2021] [Indexed: 12/18/2022]
Abstract
The core-shell silica-based nanoparticles (CSNPs) possess outstanding properties for developing next-generation therapeutics. CSNPs provide greater surface area owing to their mesoporous structure, which offers a high opportunity for surface modification. This review highlights the potential of core-shell silica-based nanoparticle (CSNP) based injectable nanotherapeutics (INT); its role in drug delivery, biomedical imaging, light-triggered phototherapy, Plasmonic enhancers, gene delivery, magnetic hyperthermia, immunotherapy, and potential as next-generation theragnostic. Specifically, the conceptual crosstalk on modern synthetic strategies, biodistribution profiles with a mechanistic view on the therapeutics loading and release modeling are dealt in detail. The manuscript also converses the challenges associated with CSNPs, regulatory hurdles, and their current market position.
Collapse
|
13
|
Yang SS, Al Kharusi L, Gosselin A, Chirico A, Baradari PG, Cameron MJ. Iron supplementation for patients undergoing cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2021; 69:129-139. [PMID: 34559371 DOI: 10.1007/s12630-021-02113-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Iron supplementation has been evaluated in several randomized controlled trials (RCTs) for its potential to increase baseline hemoglobin and decrease red blood cell transfusion during cardiac surgery. This study's main objective was to evaluate the current evidence for iron administration in cardiac surgery patients. METHODS We searched MEDLINE, EMBASE, CENTRAL, Web of Science databases, and Google Scholar from inception to 19 November 2020 for RCTs evaluating perioperative iron administration in adult patients undergoing cardiac surgery. The RCTs were assessed using a risk of bias assessment and the quality of evidence was assessed using the grading of recommendations, assessments, development, and evaluations. RESULTS We reviewed 1,767 citations, and five studies (n = 554) met the inclusion criteria. The use of iron showed no statistical difference in incidence of transfusion (risk ratio, 0.86; 95% confidence interval, 0.65 to 1.13). Trial sequential analysis suggested an optimal information size of 1,132 participants, which the accrued information size did not reach. CONCLUSION The current literature does not support or refute the routine use of iron therapy in cardiac surgery patients. TRIAL REGISTRATION PROSPERO (CRD42020161927); registered 19 December 2019.
Collapse
Affiliation(s)
- Stephen Su Yang
- Faculty of Medicine, McGill University, Montreal, QC, Canada. .,Division of Critical Care, Department of Anesthesia, Jewish General Hospital, K1400-3755, Cote Sainte Catherine, Montreal, QC, H3T 1E2, Canada.
| | | | - Adam Gosselin
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Anissa Chirico
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | | | - Matthew J Cameron
- Faculty of Medicine, McGill University, Montreal, QC, Canada.,Division of Critical Care, Department of Anesthesia, Jewish General Hospital, K1400-3755, Cote Sainte Catherine, Montreal, QC, H3T 1E2, Canada
| |
Collapse
|
14
|
Myles PS, Richards T, Klein A, Smith J, Wood EM, Heritier S, McGiffin D, Zavarsek S, Symons J, McQuilten ZK, Baker RA, Karkouti K, Wallace S. Rationale and design of the intravenous iron for treatment of anemia before cardiac surgery trial. Am Heart J 2021; 239:64-72. [PMID: 34033804 DOI: 10.1016/j.ahj.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/15/2021] [Indexed: 12/13/2022]
Abstract
Background Approximately 20% to 30% of patients awaiting cardiac surgery are anemic. Anemia increases the likelihood of requiring a red cell transfusion and is associated with increased complications, intensive care, and hospital stay following surgery. Iron deficiency is the commonest cause of anemia and preoperative intravenous (IV) iron therapy thus may improve anemia and therefore patient outcome following cardiac surgery. We have initiated the intravenous iron for treatment of anemia before cardiac surgery (ITACS) Trial to test the hypothesis that in patients with anemia awaiting elective cardiac surgery, IV iron will reduce complications, and facilitate recovery after surgery. Methods ITACS is a 1,000 patient, international randomized trial in patients with anemia undergoing elective cardiac surgery. The patients, health care providers, data collectors, and statistician are blinded to whether patients receive IV iron 1,000 mg, or placebo, at 1-26 weeks before their planned date of surgery. The primary endpoint is the number of days alive and at home up to 90 days after surgery. Results To date, ITACS has enrolled 615 patients in 30 hospitals in 9 countries. Patient mean (SD) age is 66 (12) years, 63% are male, with a mean (SD) hemoglobin at baseline of 118 (12) g/L; 40% have evidence (ferritin <100 ng/mL and/or transferrin saturation <25%) suggestive of iron deficiency. Most (59%) patients have undergone coronary artery surgery with or without valve surgery. Conclusions The ITACS Trial will be the largest study yet conducted to ascertain the benefits and risks of IV iron administration in anemic patients awaiting cardiac surgery.
Collapse
Affiliation(s)
- Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Toby Richards
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia; Department of Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Klein
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia; Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Julian Smith
- Department of Cardiothoracic Surgery, Monash Health, Clayton, Victoria, Australia; Department of Surgery, Monash University, Clayton, Victoria, Australia
| | - Erica M Wood
- Department of Clinical Haematology, Monash Health and University, Clayton, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University; Melbourne, Victoria, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University; Melbourne, Victoria, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Silva Zavarsek
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Joel Symons
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zoe K McQuilten
- Department of Clinical Haematology, Monash Health and University, Clayton, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University; Melbourne, Victoria, Australia
| | - Robert A Baker
- Cardiothoracic Quality and Outcomes, SALHN Perfusion Service, Flinders Medical Centre and Flinders University, Adelaide, South Australia, Australia
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sophia Wallace
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
15
|
Tilea I, Petra DN, Serban RC, Gabor MR, Tilinca MC, Azamfirei L, Varga A. Short-Term Impact of Iron Deficiency in Different Subsets of Patients with Precapillary Pulmonary Hypertension from an Eastern European Pulmonary Hypertension Referral Center. Int J Gen Med 2021; 14:3355-3366. [PMID: 34285560 PMCID: PMC8285229 DOI: 10.2147/ijgm.s318343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background Over the last few decades, interest in the role of iron status in pulmonary hypertension (PH) has grown considerably due to its potential impact on symptoms, exercise capacity (as assessed by the 6-minute walk distance [6MWD]), prognosis, and mortality. The aim of the present study was to identify iron deficiency (ID) prevalence in specific precapillary PH subgroups of Romanian patients and its short-term impact on 6MWD. Patients and Methods Complete datasets from 25 precapillary PH adults were examined and included in the analysis. Data were collected at baseline and after continuous follow-up of an average of 13.5 months. Enrolled patients were assigned to group 1 (pulmonary arterial hypertension) or subgroup 4.1 (chronic thromboembolic pulmonary hypertension), and individualized targeted therapy was prescribed. General characteristics, World Health Organization functional class, 6MWD, pulse oximetry, laboratory parameters, and echocardiographic and hemodynamic parameters were recorded. Ferritin values and transferrin saturation were used to assess ID. Results At baseline, 16 out of 25 patients were iron deficient. The univariate linear regression analysis did not show a statistically significant impact of ID on 6MWD (p=0.428). In multivariate regression analysis, possible predictors of 6MWD, including ID, were not statistically significant at baseline or after an average of 13.5 months follow-up (p=0.438, 0.361, respectively) and ID indicates a negative impact on 6MWD independent of applied corrections. Conclusion The results of this study demonstrate that 1.4.1 subgroup PAH patients have an increased prevalence of ID compared with other etiologies. ID has a negative impact on the functional status (assessed by 6MWD), in specific groups and subgroups of patients with precapillary PH, albeit not independently nor significant to other known predictors such as age, gender, oxygen saturation, and hemoglobin value. These data can be integrated with global research and are consistent with phenotypes of patients diagnosed with PH of different etiologies.
Collapse
Affiliation(s)
- Ioan Tilea
- Department of Internal Medicine, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania.,Department of Cardiology II, County Emergency Clinical Hospital, Targu Mures, 540042, Romania
| | - Dorina Nastasia Petra
- Department of Family Medicine, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania.,Department of Internal Medicine II, County Emergency Clinical Hospital, Targu Mures, 540042, Romania
| | - Razvan Constantin Serban
- Cardiac Catheterization Laboratory, The Emergency Institute for Cardiovascular Diseases and Transplantation, Targu Mures, 540136, Romania
| | - Manuela Rozalia Gabor
- Department of Economics and Law, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania
| | - Mariana Cornelia Tilinca
- Department of Internal Medicine, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania
| | - Leonard Azamfirei
- Department of Anesthesiology and Intensive Care, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania.,Department of Anesthesiology and Intensive Care, County Emergency Clinical Hospital, Targu Mures, 540042, Romania
| | - Andreea Varga
- Department of Cardiology II, County Emergency Clinical Hospital, Targu Mures, 540042, Romania.,Department of Family Medicine, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, 540142, Romania
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW As the surgical population ages, preoperative diagnosis and optimization of frailty becomes increasingly important. Various concepts are used to define frailty, and several tools have been validated for use in the perioperative period. This article reviews current conceptual frameworks of frailty, references current literature and provides a practical approach to the preoperative frailty assessment with a focus on potential interventions. RECENT FINDINGS A multipronged approach toward preoperative optimization should be used in patients with frailty syndrome. Oral protein supplementation and immunonutrition therapy can reduce complications in patients with malnutrition. Initiating a preoperative physical exercise regimen may mitigate frailty. Nonpharmacologic interventions to reduce preoperative anxiety and improve mood are effective, low-cost adjuncts associated with improvement in postoperative outcomes. Engaging in shared decision making is a critical component of the preoperative evaluation of frail patients. SUMMARY Emerging evidence suggests that frailty may be mitigated with patient-specific, multidimensional preoperative interventions, thus potentially improving postoperative outcomes in this vulnerable patient population.
Collapse
Affiliation(s)
| | - Jeanna Blitz
- Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
17
|
Shin HW, Go DY, Lee SW, Choi YJ, Ko EJ, You HS, Jang YK. Comparative efficacy and safety of intravenous ferric carboxymaltose and iron sucrose for iron deficiency anemia in obstetric and gynecologic patients: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24571. [PMID: 34011020 PMCID: PMC8137003 DOI: 10.1097/md.0000000000024571] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/14/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Iron deficiency anemia (IDA) is common among obstetric and gynecologic patients. This systematic review aimed to assess the comparative efficacy and safety of commonly used intravenous (IV) iron formulations, ferric carboxymaltose (FCM), and iron sucrose (IS) in the treatment of IDA in obstetric and gynecologic patients. METHODS We systematically searched PubMed, EMBASE, Cochrane CENTRAL, and Google Scholar for eligible randomized controlled trials (RCTs) comparing IV iron replacement using FCM and IS up to October 2019. The primary outcome was to compare the efficacy of FCM and IS, assessed by measuring serum hemoglobin (Hb) and ferritin levels before and after iron replacement. The secondary outcome was to compare the safety of FCM and IS, assessed by the incidence of adverse events during iron replacement. The meta-analysis was performed using RevMan 5.3. RESULTS We identified 9 RCTs with 910 patients (FCM group, n = 456; IS group, n = 454). Before iron replacement, FCM and IS group patients had similar baseline Hb (mean difference [MD], 0.04 g/dL; 95% confidence interval [CI], -0.07 to 015; I2 = 0%; P = 0.48) and ferritin levels (MD, -0.42 ng/mL; 95% CI, -1.61 to 0.78; I2 = 45%; P = 0.49). Following iron replacement, patients who received FCM had higher Hb (MD, 0.67; 95% CI, 0.25-1.08; I2 = 92%; P = 0.002) and ferritin levels (MD, 24.41; 95% CI, 12.06-36.76; I2 = 75%; P = 0.0001) than patients who received IS. FCM group showed a lower incidence of adverse events following iron replacement than IS group (risk ratio, 0.53; 95% CI, 0.35-0.80; I2 = 0%; P = 0.003). Serious adverse events were not reported in any group. CONCLUSION FCM group showed better efficacy in increasing Hb and ferritin levels and a favorable safety profile with fewer adverse events compared with IS group for IDA treatment among obstetric and gynecologic patients. However, this meta-analysis was limited by the small number of RCTs and high heterogeneity. TRIAL REGISTRATION The review was prospectively registered with the International Prospective Registry of Systematic Reviews (https://www.crd.york.ac.uk/prospero/, registration number CRD42019148905).
Collapse
MESH Headings
- Administration, Intravenous
- Anemia, Iron-Deficiency/blood
- Anemia, Iron-Deficiency/diagnosis
- Anemia, Iron-Deficiency/drug therapy
- Anemia, Iron-Deficiency/etiology
- Female
- Ferric Compounds/administration & dosage
- Ferric Compounds/adverse effects
- Ferric Oxide, Saccharated/administration & dosage
- Ferric Oxide, Saccharated/adverse effects
- Ferritins/blood
- Hematinics/administration & dosage
- Hematinics/adverse effects
- Hemoglobins/analysis
- Humans
- Maltose/administration & dosage
- Maltose/adverse effects
- Maltose/analogs & derivatives
- Pregnancy
- Pregnancy Complications, Hematologic/blood
- Pregnancy Complications, Hematologic/diagnosis
- Pregnancy Complications, Hematologic/drug therapy
- Randomized Controlled Trials as Topic
- Treatment Outcome
Collapse
|
18
|
Cameron MJ, Al Kharusi L, Gosselin A, Baradari PG, Chirico A, Amar-Zifkin A, Yang SS. Iron supplementation for patients undergoing cardiac surgery: a protocol for a systematic review and meta-analysis of randomized controlled trials. CMAJ Open 2021; 9:E623-E626. [PMID: 34088733 PMCID: PMC8191589 DOI: 10.9778/cmajo.20200204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Iron administration has been evaluated in several randomized controlled trials for the potential of increasing baseline hemoglobin values and decreasing the incidence of red blood cell transfusion during cardiac surgery. We describe the protocol for a study aiming to evaluate the efficacy and safety of perioperative iron administration in patients undergoing cardiac surgery. METHODS We will search MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and the Web of Science, from inception to Nov. 19, 2020, for randomized controlled trials in any language evaluating the perioperative administration of iron in adult patients undergoing cardiac surgery; we will also include the first 50 results from Google Scholar. The primary outcome will be the incidence of red blood cell transfusion from the study intervention time until 8 weeks postoperatively. The secondary outcomes will be the number of red blood cell units transfused; change in ferritin level, reticulocyte count and hemoglobin concentration after iron administration; and adverse events. We will assess the risk of bias with the Cochrane Collaboration Risk of Bias Tool, and will analyze the primary and secondary outcomes using a random-effects model. INTERPRETATION This study will summarize the current evidence about perioperative iron administration in patients undergoing cardiac surgery, help determine whether this intervention should be included in enhanced-recovery protocols, and shape future research if needed. The final manuscript will be submitted to a peer-reviewed journal. TRIAL REGISTRATION PROSPERO no. CRD42020161927.
Collapse
Affiliation(s)
- Matthew J Cameron
- Faculty of Medicine (Cameron, Gosselin, Gholipour Baradari, Chirico, Yang), McGill University; Department of Anesthesia (Cameron, Al Kharusi, Yang), McGill University; Department of Anesthesia (Cameron, Yang), Jewish General Hospital; McGill University Health Centre Medical Libraries (Amar-Zifkin), Montréal, Que.
| | - Latifa Al Kharusi
- Faculty of Medicine (Cameron, Gosselin, Gholipour Baradari, Chirico, Yang), McGill University; Department of Anesthesia (Cameron, Al Kharusi, Yang), McGill University; Department of Anesthesia (Cameron, Yang), Jewish General Hospital; McGill University Health Centre Medical Libraries (Amar-Zifkin), Montréal, Que
| | - Adam Gosselin
- Faculty of Medicine (Cameron, Gosselin, Gholipour Baradari, Chirico, Yang), McGill University; Department of Anesthesia (Cameron, Al Kharusi, Yang), McGill University; Department of Anesthesia (Cameron, Yang), Jewish General Hospital; McGill University Health Centre Medical Libraries (Amar-Zifkin), Montréal, Que
| | - Pouya Gholipour Baradari
- Faculty of Medicine (Cameron, Gosselin, Gholipour Baradari, Chirico, Yang), McGill University; Department of Anesthesia (Cameron, Al Kharusi, Yang), McGill University; Department of Anesthesia (Cameron, Yang), Jewish General Hospital; McGill University Health Centre Medical Libraries (Amar-Zifkin), Montréal, Que
| | - Anissa Chirico
- Faculty of Medicine (Cameron, Gosselin, Gholipour Baradari, Chirico, Yang), McGill University; Department of Anesthesia (Cameron, Al Kharusi, Yang), McGill University; Department of Anesthesia (Cameron, Yang), Jewish General Hospital; McGill University Health Centre Medical Libraries (Amar-Zifkin), Montréal, Que
| | - Alexandre Amar-Zifkin
- Faculty of Medicine (Cameron, Gosselin, Gholipour Baradari, Chirico, Yang), McGill University; Department of Anesthesia (Cameron, Al Kharusi, Yang), McGill University; Department of Anesthesia (Cameron, Yang), Jewish General Hospital; McGill University Health Centre Medical Libraries (Amar-Zifkin), Montréal, Que
| | - Stephen S Yang
- Faculty of Medicine (Cameron, Gosselin, Gholipour Baradari, Chirico, Yang), McGill University; Department of Anesthesia (Cameron, Al Kharusi, Yang), McGill University; Department of Anesthesia (Cameron, Yang), Jewish General Hospital; McGill University Health Centre Medical Libraries (Amar-Zifkin), Montréal, Que
| |
Collapse
|
19
|
Karim S, Butler JM, Barclay ML. A 1 g dose of intravenous iron is sufficient to treat iron deficiency anaemia. Intern Med J 2020; 50:1563-1566. [PMID: 33354887 DOI: 10.1111/imj.15110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 11/28/2022]
Abstract
One hundred and ninety-four patient episodes were audited for response to a standardised 1 g intravenous iron infusion for medical outpatients with iron deficiency anaemia. Patients received either ferric carboxymaltose or iron polymaltose. At 5-7 weeks after infusion, mean increase in Hb was 26.7 g/L and ferritin was 161 mcg/L, and only one patient had Hb <100 g/L. This reassures that 1 g dose of intravenous iron is sufficient for most patients, with benefits for treatment costs and patient convenience.
Collapse
Affiliation(s)
- Syarihan Karim
- Department of General Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Jennifer M Butler
- Department of General Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Murray L Barclay
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| |
Collapse
|
20
|
Kalra PA, Bhandari S, Spyridon M, Davison R, Lawman S, Mikhail A, Reaich D, Pritchard N, McCafferty K, Moore J. NIMO-CKD-UK: a real-world, observational study of iron isomaltoside in patients with iron deficiency anaemia and chronic kidney disease. BMC Nephrol 2020; 21:539. [PMID: 33302891 PMCID: PMC7726614 DOI: 10.1186/s12882-020-02180-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 11/19/2020] [Indexed: 12/21/2022] Open
Abstract
Background Intravenous iron is often used to treat iron deficiency anaemia in non-dialysis chronic kidney disease (ND-CKD), but the optimal dosing regimen remains unclear. We evaluated the impact of high- versus low-dose intravenous iron isomaltoside on the probability of retreatment with intravenous iron in iron-deficient ND-CKD patients. Methods This real-world, prospective, observational study collected data from 256 ND-CKD patients treated for anaemia in the UK. Following an initial course of iron isomaltoside, patients were followed for ≥12 months. Iron dose and the need for retreatment were determined at the investigators’ discretion. The primary study outcome was the need for retreatment at 52 weeks compared between patients who received >1000 mg of iron during Course 1 and those who received ≤1000 mg. Safety was evaluated through adverse drug reactions. Results The probability of retreatment at Week 52 was significantly lower in the >1000 mg iron group (n = 58) versus the ≤1000 mg group (n = 198); hazard ratio (95% confidence interval [CI]): 0.46 (0.20, 0.91); p = 0.012. Mean (95% CI) haemoglobin increased by 6.58 (4.94, 8.21) g/L in the ≤1000 mg group and by 10.59 (7.52, 13.66) g/L in the >1000 mg group (p = 0.024). Changes in other blood and iron parameters were not significantly different between the two groups. Administering >1000 mg of iron isomaltoside saved 8.6 appointments per 100 patients compared to ≤1000 mg. No serious adverse drug reactions were reported. Of the patients who received ≤1000 mg of iron in this study, 82.3% were eligible for a dose >1000 mg. Conclusions The >1000 mg iron isomaltoside regimen reduced the probability of retreatment, achieved a greater haemoglobin response irrespective of erythropoiesis-stimulating agent treatment, and reduced the total number of appointments required, compared to the ≤1000 mg regimen. Many of the patients who received ≤1000 mg of iron were eligible for >1000 mg, indicating that there was considerable underdosing in this study. Trial registration ClinicalTrials.gov NCT02546154, 10 September 2015.
Collapse
Affiliation(s)
| | | | | | | | | | | | - David Reaich
- The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Jason Moore
- Royal Devon and Exeter University Hospital, Exeter, UK
| |
Collapse
|
21
|
Kumar A, Brookes MJ. Iron Therapy in Inflammatory Bowel Disease. Nutrients 2020; 12:nu12113478. [PMID: 33198376 PMCID: PMC7697745 DOI: 10.3390/nu12113478] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/08/2020] [Accepted: 11/10/2020] [Indexed: 12/12/2022] Open
Abstract
The most common complication seen in inflammatory bowel disease (IBD) patients is iron deficiency anaemia (IDA). Symptoms such as chronic fatigue can be as debilitating to IBD patients as pathological symptoms of abdominal pain and diarrhoea. Recognising and correcting anaemia may be as important as managing IBD symptoms and improving overall quality of life. Thus, iron replacement should be commenced the moment IDA is identified. Although intravenous iron is now considered standard treatment for IBD patients in Europe, oral iron still appears to be the preferred option. Advantages of oral iron include greater availability, lower costs and ease of applicability. However, its multitude of side effects, impact on the microbiome and further exacerbating IBD activity can have consequences on patient compliance. The newer oral iron formulations show promising safety and efficacy data with a good side effect profile. Intravenous iron formulations bypass the gastrointestinal tract absorption thereby leading to less side effects. Multiple studies have shown its superiority compared to oral formulations although its risk for hypersensitivity reactions continue to lead to clinician hesitancy in prescribing this formulation. This article provides an updated review on diagnosis and management of IDA in IBD patients, discussing the newer oral and intravenous formulations.
Collapse
Affiliation(s)
- Aditi Kumar
- The Royal Wolverhampton NHS Trust, Wolverhampton WV10 0QP, UK;
- Correspondence:
| | - Matthew J. Brookes
- The Royal Wolverhampton NHS Trust, Wolverhampton WV10 0QP, UK;
- Research Institute in Healthcare Science (RIHS), University of Wolverhampton, Wolverhampton WV1 1LY, UK
| |
Collapse
|
22
|
Intravenous iron administered to anaemic patients before surgery and hospital readmission in the PREVENTT study: one answer, a potentially important health benefit, and new questions. Br J Anaesth 2020; 126:9-11. [PMID: 33012514 DOI: 10.1016/j.bja.2020.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/07/2020] [Accepted: 09/07/2020] [Indexed: 11/21/2022] Open
|
23
|
Schaefer B, Meindl E, Wagner S, Tilg H, Zoller H. Intravenous iron supplementation therapy. Mol Aspects Med 2020; 75:100862. [DOI: 10.1016/j.mam.2020.100862] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 12/12/2022]
|
24
|
Kwak S, Chang MC. Compression of the Lateral Antebrachial Cutaneous Nerve due to Leakage of Iron after an Intravenous Iron Infusion. Diagnostics (Basel) 2020; 10:diagnostics10080516. [PMID: 32722513 PMCID: PMC7460076 DOI: 10.3390/diagnostics10080516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 11/16/2022] Open
Abstract
Skin staining due to iron leakage into the subcutaneous tissue can sometimes occur during intravenous iron infusion. We describe a case of lateral antebrachial cutaneous nerve (LACN) entrapment due to extravasated iron after an intravenous iron infusion. A 41-year-old woman received an intravenous ferric carboxymaltose infusion for iron deficiency anemia. However, during the infusion, extravasation of iron occurred and brown pigmentation developed on the lateral side of the cubital fossa. Sixteen months later, the patient still had some staining in her anterolateral elbow and proximal forearm. In addition, she complained of tingling pain over her left forearm. Ultrasonography (US) revealed a lateral antebrachial cutaneous nerve (LACN) under the stained area. When we swept the stained area with the US transducer, she reported a tingling pain on her left lateral forearm, the region innervated by the left LACN. Therefore, we considered that the pain resulted from the compression of the left LACN by the leaked iron during the intravenous infusion. Leaked iron can compress the cutaneous nerve and result in neuropathic pain and cosmetic problems. When patients with skin staining after iron infusion have neuropathic pain, clinicians should consider the possibility of entrapment of the cutaneous nerves.
Collapse
|
25
|
Guinn NR, Cooter ML, Maisonave Y, Grimsley A, Cellura C, Grotegut CA, Lamon A, Aronson S. How do I develop a process to effectively treat parturients with iron deficiency anemia? Transfusion 2020; 60:2476-2481. [DOI: 10.1111/trf.15930] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/19/2020] [Accepted: 05/19/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Nicole R. Guinn
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - Mary L. Cooter
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - Yasmin Maisonave
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - Aime Grimsley
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - Cindy Cellura
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - Chad A. Grotegut
- Department of Obstetrics and Gynecology Duke University Medical Center Durham North Carolina USA
| | - Agnes Lamon
- Department of Anesthesiology Penn Medicine Princeton Health Plainsboro New Jersey USA
| | - Solomon Aronson
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | | |
Collapse
|
26
|
Kearns J, Jacob SG. Real-world evaluation of an intravenous iron service for the treatment of iron deficiency in patients with gastroenterological disorders. Frontline Gastroenterol 2020; 12:265-271. [PMID: 34249310 PMCID: PMC8231433 DOI: 10.1136/flgastro-2020-101406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In gastroenterological disorders, iron deficiency (ID) is often treated with intravenous iron. This real-world study assessed the effectiveness and safety of iron isomaltoside (IIM), a high-dose intravenous iron, for the treatment of ID in patients with gastroenterological disorders, as part of a service evaluation and improvement process. METHODS Medical records of 117 patients with gastroenterological disorders, who received IIM, were examined retrospectively. Study outcomes included dose of IIM (estimated iron need versus actual dose received), number of appointments required to deliver the dose and changes in haemoglobin (Hb) and ferritin at ~1 month and ~6 months post-treatment. Safety was assessed through adverse drug reactions (ADRs). RESULTS Overall, 76.1% of patients received their estimated iron need; 23.9% were underdosed. The mean (SD) iron dose was 1317 (409.7) mg; 62.4% of patients received their dose in one appointment. From baseline, mean (SD) Hb increased by 20.9 (15.4) g/L at 1 month post-treatment (p<0.0001) and by 22.0 (17.9) g/L at 6 months post-treatment (p<0.0001). Mean (SD) baseline ferritin was 26.6 (37.8) μg/L, which increased to 234.6 (142.9) μg/L at 1 month post-treatment (p<0.0001), and remained increased at 6 months post-treatment (122.8 (99.2) μg/L; p<0.0001). A substantial proportion of patients were non-anaemic at 1 month (57.5%) and 6 months (61.8%) post-treatment. At both post-treatment timepoints, the proportion of non-anaemic patients was higher in those receiving their total iron need versus those who were underdosed. No serious ADRs were reported. CONCLUSION IIM was efficacious and well tolerated in patients with gastroenterological disorders. This real-world study highlights the importance of administering the full iron need to maximise treatment response.
Collapse
|
27
|
Patel K, Memon Z, Mazurkiewicz R. Management of Iron-Deficiency Anemia on Inpatients and Appropriate Discharge and Follow-Up. J Hematol 2020; 9:5-8. [PMID: 32362978 PMCID: PMC7188379 DOI: 10.14740/jh626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/13/2020] [Indexed: 11/24/2022] Open
Abstract
Background The aims of the study were to identify appropriate supplementation of iron for inpatients and to identify factors involved in appropriate discharge documentation and follow-up. Methods This was a retrospective analysis of 103 patients at a community hospital in New York City. Results A total of 57 (57/103, 55.3%) patients were admitted due to symptomatic anemia. Twenty (20/103, 19.4%) of those with iron-deficiency anemia had either esophagogastroduodenoscopy or colonoscopy. Gastroenterologist or hematologist was consulted for 45/103 (43.7%). Inpatient iron supplementation was given for 62/103 (60.2%) of patients; and 43/103 (41.7%) had blood transfusion. Upon discharge, 50/103 (48.5%) had appropriate documentation of iron-deficiency anemia on discharge paperwork. Appropriate follow-up was done for 54/103 (52.4%). Iron supplementation was provided for 53/103 (51.5%) of patients. Having inpatient esophagogastroduodenoscopy or colonoscopy, blood transfusion, or symptomatic anemia had a statistical significance for likelihood of appropriate discharge documentation. Conclusions Iron-deficiency anemia can have high rates of mortality and morbidity in the population. Appropriate discharge of patients with iron-deficiency anemia and factors related to this are paramount for clinicians in order to have the best patient outcomes.
Collapse
Affiliation(s)
- Kishan Patel
- Department of Internal Medicine, Lenox Hill Hospital, New York, NY, USA
| | - Zain Memon
- Department of Internal Medicine, Lenox Hill Hospital, New York, NY, USA
| | | |
Collapse
|
28
|
Loughnane F, Muduma G, Pollock RF. Development of a Resource Impact Model for Clinics Treating Pre-Operative Iron Deficiency Anemia in Ireland. Adv Ther 2020; 37:1218-1232. [PMID: 32030608 PMCID: PMC7089757 DOI: 10.1007/s12325-020-01241-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Indexed: 11/28/2022]
Abstract
Introduction Intravenous (IV) iron is typically the preferred treatment for patients with iron deficiency anemia (IDA) who cannot tolerate or absorb oral iron, or who require fast replenishment of iron stores pre-operatively. Several IV iron formulations are available with different dosing characteristics affecting infusion speed and maximum dose. The aim was to develop a resource impact model to calculate the cost of establishing an IV iron clinic and model resource impact of different IV irons to inform clinicians and service providers implementing innovative pre-operative IV iron services in Ireland. Methods A resource impact tool was developed to model resource utilization and IDA treatment costs. Two fast-administration, high-dose formulations of IV iron are available in Ireland: iron isomaltoside 1000/ferric derisomaltose (IIM) and ferric carboxymaltose (FCM). The tool modeled clinic throughput based on their different dosing characteristics in a specific IDA population, capturing fixed overheads, variable costs, clinic income from private and publicly-funded patients, and savings associated with IV iron. Results Based on a 70:30 split between public and private patients in a new pre-operative service with capacity for 12 infusion slots weekly, IIM would facilitate correction of iron deficits in 474 patients annually, resulting in a net annual clinic balance of €42,736 on income of €159,887 and net costs of €117,151. FCM would facilitate treatment of 353 patients, resulting in a net annual clinic balance of €36,327 on income of €116,050 and costs of €79,722, a difference of €6408 and 121 patients treated in favor of using IIM over FCM. Conclusion Based on this provider-perspective analysis, IIM would maximize clinic throughput relative to other IV iron formulations, allowing clinicians in Ireland to optimize their current service provision and expenditure, and model the impact of introducing IV iron clinics for pre-operative patients with IDA.
Collapse
|
29
|
Moussa S, Ibrahim AAA, Ahmed NM. Evaluation of Urinary Hepcidin as a Marker for the Early Diagnosis of Iron Deficiency Anemia in Children. OPEN JOURNAL OF PEDIATRICS 2020; 10:347-355. [DOI: 10.4236/ojped.2020.102035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
|
30
|
García Erce J, Altés A, López Rubio M, Remacha A, de la O Abío M, Benéitez D, de la Iglesia S, Dolores de la Maya M, Flores E, Pérez G, Pilar Ricard M, Manuel Vagace J. Manejo del déficit de hierro en distintas situaciones clínicas y papel del hierro intravenoso: recomendaciones del Grupo Español de Eritropatología de la SEHH. Rev Clin Esp 2020; 220:31-42. [DOI: 10.1016/j.rce.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 08/21/2019] [Accepted: 09/05/2019] [Indexed: 12/17/2022]
|
31
|
Management of iron deficiency in various clinical conditions and the role of intravenous iron: Recommendations of the Spanish erythropathology group of the Spanish society of hematology and hemotherapy. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
32
|
Ning S, Zeller MP. Management of iron deficiency. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:315-322. [PMID: 31808874 PMCID: PMC6913441 DOI: 10.1182/hematology.2019000034] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Iron deficiency (ID) affects billions of people worldwide and remains the leading cause of anemia with significant negative impacts on health. Our approach to ID and iron deficiency anemia (IDA) involves three steps (I3): (1) identification of ID/IDA, (2) investigation of and management of the underlying etiology of ID, and (3) iron repletion. Iron repletion options include oral and intravenous (IV) iron formulations. Oral iron remains a therapeutic option for the treatment of ID in stable patients, but there are many populations for whom IV iron is more effective. Therefore, IV iron should be considered when there are no contraindications, when poor response to oral iron is anticipated, when rapid hematologic responses are desired, and/or when there is availability of and accessibility to the product. Judicious use of red cell blood transfusion is recommended and should be considered only for severe, symptomatic IDA with hemodynamic instability. Identification and management of ID and IDA is a central pillar in patient blood management.
Collapse
Affiliation(s)
- Shuoyan Ning
- Division of Hematology and Thromboembolism and
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada; and
| | - Michelle P Zeller
- Division of Hematology and Thromboembolism and
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada; and
- Canadian Blood Services, Ancaster, ON, Canada
| |
Collapse
|
33
|
Lin Y. Preoperative anemia-screening clinics. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:570-576. [PMID: 31808909 PMCID: PMC6913451 DOI: 10.1182/hematology.2019000061] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Preoperative anemia is associated with increased postoperative morbidity and mortality and with increased risk of perioperative transfusion. It is an important and modifiable risk factor for surgical patients. For high-blood-loss surgery, preoperative anemia is defined as hemoglobin <13 g/dL for both male and female patients. Preoperative anemia is common, ranging from 25% to 40% in large observational studies. The most common treatable cause of preoperative anemia is iron-deficiency anemia; the initial laboratory tests should focus on making this diagnosis. Management of iron-deficiency anemia includes iron supplementation with IV iron therapy when oral iron is ineffective or not tolerated, there is severe anemia, and there is insufficient time to surgery (<4 weeks). In other situations, erythropoiesis-stimulating agents may be considered, particularly for those patients with multiple alloantibodies or religious objections to transfusion. To facilitate the diagnosis and management of preoperative anemia, establishment of preoperative anemia-screening clinics is essential. The goals of management of preoperative anemia are to treat anemia, reduce the need for transfusion, and improve patient outcomes.
Collapse
Affiliation(s)
- Yulia Lin
- Transfusion Medicine and Tissue Bank, Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
34
|
LaVallee C, Cronin P, Bansal I, Kwong WJ, Boccia R. Importance of Initial Complete Parenteral Iron Repletion on Hemoglobin Level Normalization and Health Care Resource Utilization: A Retrospective Analysis. Pharmacotherapy 2019; 39:983-993. [PMID: 31411763 DOI: 10.1002/phar.2319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVE Iron deficiency anemia is the most common form of anemia, and parenteral iron therapy is necessary in select patients. The objective of this analysis was to assess the impact of initial complete parenteral iron repletion on serum hemoglobin (Hgb) level normalization and on health care resource utilization in real-world practice. DESIGN Retrospective observational study. DATA SOURCE Decision Resources Group Real-World Data Repository (United States databases). PATIENTS A total of 2966 patients who had a baseline Hgb level below normal (< 12 g/dl for females and < 13.5 g/dl for males) and were treated with parenteral iron between March 2015 and February 2017. MEASUREMENTS AND MAIN RESULTS The effect of receiving the required parenteral iron dose to replete the deficit, calculated by a modified Ganzoni formula, within 3 weeks of the first parenteral iron therapy claim (index date) on the likelihood of Hgb level normalization, was estimated by using logistic regression. All analyses were adjusted for sex, age, comorbidities, and use of prescription oral iron therapy. The adjusted mean numbers of all-cause inpatient admissions, outpatient visits, and emergency department (ED) visits within 6 months and 1 year after the index date were compared between patients with and without normalized Hgb levels by using negative binomial regression. Of the 2966 included patients, 33.9% received the required iron dose within 3 weeks of the index date, and 19.6%, 48.2%, and 53.9% had a normalized Hgb level within 8 weeks of the index date, within 1 year of the index date, and until the end of data availability, respectively. Patients who received the required iron dose within 3 weeks of the index date were significantly more likely to have a normalized Hgb level within 8 weeks of the index date and at any time during the study period than those who did not: adjusted odds ratio (OR) (95% confidence interval [CI]) 2.67 (2.20, 3.24) and 2.33 (1.96, 2.77), respectively. Hgb level normalization within 1 year of the index date was associated with fewer inpatient admissions and outpatient visits and a similar number of ED visits compared with no Hgb level normalization 1 year after the index date. CONCLUSION The results of these analyses underscore the importance of initial complete parenteral iron repletion for rapidly improving clinical outcomes. Prompt achievement of a normalized Hgb level may also provide an opportunity to reduce health care resource utilization in patients with iron deficiency anemia receiving parenteral iron therapy.
Collapse
Affiliation(s)
- Chris LaVallee
- Health Outcomes Research, Decision Resources Group, Boston, Massachusetts
| | - Patrick Cronin
- Analytics, Decision Resources Group, Boston, Massachusetts
| | - Isha Bansal
- Analytics, Decision Resources Group, Boston, Massachusetts
| | | | - Ralph Boccia
- Center for Cancer and Blood Disorders, Bethesda, Maryland
| |
Collapse
|
35
|
Treatment of iron deficiency in patients with chronic kidney disease: A prospective observational study of iron isomaltoside (NIMO Scandinavia)
. Clin Nephrol 2019; 91:246-253. [PMID: 30614439 PMCID: PMC6434427 DOI: 10.5414/cn109474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2019] [Indexed: 11/18/2022] Open
Abstract
Aims: Iron deficiency is common in patients with chronic kidney disease (CKD). Appropriate iron substitution is critical and intravenous iron is an established therapy for these patients. The objective of this study was to assess treatment routine, effectiveness, and safety of iron isomaltoside (Monofer®, Pharmacosmos A/S, Holbaek, Denmark) in CKD patients in clinical practice. Materials and methods: This was a prospective observational study conducted in predialysis CKD patients treated with iron isomaltoside according to the product label and to routine clinical care. Results: The study included 108 patients with predialysis CKD: 22 were in stage 2 – 3, 41 in stage 4, and 45 in stage 5. The mean (standard deviation) age was 67 (15) years, and 55% of patients were male. The majority of patients (65%) received one iron isomaltoside treatment. In patients with a baseline Hb < 10 g/dL, the mean dose of iron isomaltoside in the study was lower than the estimated total iron requirement (567 mg versus 921 mg). A treatment response of Hb ≥ 1 g/dL was achieved in 16/28 (57%) of patients, and the mean post-treatment Hb level was 10.5 g/dL. The probability of retreatment did not correlate with dose, but no dose administered was > 1,000 mg. There were no serious adverse drug reactions. One nonserious adverse drug reaction – injection site discoloration – was reported, and the patient had an uneventful recovery. Conclusion: Iron isomaltoside shows a good effectiveness and safety profile in predialysis CKD patients. However, some patients did not receive adequate iron doses to allow for optimal correction of their iron deficiency anemia.
Collapse
|
36
|
Pollock RF, Muduma G. An Economic Evaluation of Iron Isomaltoside 1000 Versus Ferric Carboxymaltose in Patients with Inflammatory Bowel Disease and Iron Deficiency Anemia in Denmark. Adv Ther 2018; 35:2128-2137. [PMID: 30456520 DOI: 10.1007/s12325-018-0827-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The incidence of inflammatory bowel disease (IBD) in Denmark is among the highest in the world, with Crohn's disease and ulcerative colitis occurring at rates of 9.1 and 18.6 per 100,000 person-years respectively in 2010-2013. Anemia is the most prevalent extraintestinal complication of IBD, most commonly caused by iron deficiency. In treating IBD-associated iron deficiency anemia (IDA), intravenous iron is more effective and better tolerated and shows a faster response than oral iron. The present study evaluated resource use and costs associated with using iron isomaltoside (Monofer; IIM) versus ferric carboxymaltose (Ferinject; FCM) in patients with IDA and IBD in Denmark. METHODS A budget impact model was developed to evaluate the cost of IIM compared with FCM from a Danish healthcare payer perspective. Iron deficits were modeled using dosing tables and a joint distribution of bodyweight [mean 75.4 kg, standard deviation (SD) 17.4 kg] and hemoglobin (mean 10.8 g/dL, SD 1.4 g/dl) based on observational data from patients with IBD. Retreatment frequency was modeled using a pooled retrospective analysis of randomized trial data, and costs were modeled using diagnosis-related groups with an outpatient infusion cost of DKK 2855. RESULTS Using IIM required 1.2 infusions (per treatment) to correct the mean iron deficit compared with 1.6 with FCM. Treating 2.54 patients with IIM would therefore avoid one infusion compared with FCM. Patients using IIM required multiple infusions in 25.0% of cases compared with 64.3% with FCM. Over 5 years, total estimated costs were DKK 21,406 per patient with IIM compared with DKK 28,137 with FCM, corresponding to savings of DKK 6731 with IIM. CONCLUSION Using IIM in place of FCM markedly reduced the number of iron infusions required in patients with IBD and IDA in Denmark. The reduction in infusions was accompanied by reductions in cost compared with FCM. FUNDING Pharmacosmos A/S.
Collapse
|
37
|
Abstract
Iron deficiency anemia is both a comorbid condition and an indicator of poor prognosis in heart failure. The mechanisms by which this occurs are multiple and complex. Recent robust randomized clinical trials have shown significant improvements in quality of life and rates of hospitalization with intravenous repletion of iron. In this article, we review the mechanisms by which iron deficiency impacts heart failure and the evidence behind repletion. There remains a good deal to learn about long-term effects of intravenous iron repletion, and clinical trials are ongoing in this regard.
Collapse
Affiliation(s)
- Natasha L Altman
- Section of Advanced Heart Failure and Transplant, Division of Cardiology, Department of Medicine, University of Colorado Denver, 12631 East 17th Avenue, Aurora, CO 80045, USA.
| | - Amit Patel
- Advanced Heart Failure and Cardiac Transplantation, St. Vincent Medical Group, 8333 Naab Road, Suite 400, Indianapolis, IN 46260, USA
| |
Collapse
|
38
|
Nixon CP, Sweeney JD. Severe iron deficiency anemia: red blood cell transfusion or intravenous iron? Transfusion 2018; 58:1824-1826. [PMID: 30198610 PMCID: PMC7465692 DOI: 10.1111/trf.14819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Christian P Nixon
- Center for International Health Research Rhode Island Hospital and Alpert Medical School of Brown University Providence, Rhode, Island
- Department of Transfusion Medicine, Rhode Island Hospital and The Miriam Hospitals Alpert Medical School of Brown University, Providence, Rhode, Island
| | - Joseph D Sweeney
- Department of Transfusion Medicine, Rhode Island Hospital and The Miriam Hospitals Alpert Medical School of Brown University, Providence, Rhode, Island
| |
Collapse
|
39
|
Affiliation(s)
- Inder S. Anand
- VA Medical Center, Minneapolis, MN (I.A., P.G.)
- VA Medical Center, San Diego, CA (I.A.)
- University of Minnesota, Minneapolis (I.A., P.G.)
| | - Pankaj Gupta
- VA Medical Center, Minneapolis, MN (I.A., P.G.)
- University of Minnesota, Minneapolis (I.A., P.G.)
| |
Collapse
|
40
|
Prion protein modulates glucose homeostasis by altering intracellular iron. Sci Rep 2018; 8:6556. [PMID: 29700330 PMCID: PMC5919926 DOI: 10.1038/s41598-018-24786-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 03/20/2018] [Indexed: 11/08/2022] Open
Abstract
The prion protein (PrPC), a mainly neuronal protein, is known to modulate glucose homeostasis in mouse models. We explored the underlying mechanism in mouse models and the human pancreatic β-cell line 1.1B4. We report expression of PrPC on mouse pancreatic β-cells, where it promoted uptake of iron through divalent-metal-transporters. Accordingly, pancreatic iron stores in PrP knockout mice (PrP-/-) were significantly lower than wild type (PrP+/+) controls. Silencing of PrPC in 1.1B4 cells resulted in significant depletion of intracellular (IC) iron, and remarkably, upregulation of glucose transporter GLUT2 and insulin. Iron overloading, on the other hand, resulted in downregulation of GLUT2 and insulin in a PrPC-dependent manner. Similar observations were noted in the brain, liver, and neuroretina of iron overloaded PrP+/+ but not PrP-/- mice, indicating PrPC-mediated modulation of insulin and glucose homeostasis through iron. Peripheral challenge with glucose and insulin revealed blunting of the response in iron-overloaded PrP+/+ relative to PrP-/- mice, suggesting that PrPC-mediated modulation of IC iron influences both secretion and sensitivity of peripheral organs to insulin. These observations have implications for Alzheimer's disease and diabetic retinopathy, known complications of type-2-diabetes associated with brain and ocular iron-dyshomeostasis.
Collapse
|
41
|
Tandon R, Jain A, Malhotra P. Management of Iron Deficiency Anemia in Pregnancy in India. Indian J Hematol Blood Transfus 2018; 34:204-215. [PMID: 29622861 PMCID: PMC5885006 DOI: 10.1007/s12288-018-0949-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/08/2018] [Indexed: 01/28/2023] Open
Abstract
Iron deficiency anemia (IDA) continues to be the commonest etiology of anemia in pregnancy. The prevalence of iron deficiency (ID) in pregnant Indian women is amongst the highest in the world. Untreated iron deficiency (ID) has significant adverse feto-maternal consequences. Plethora of investigations are available for diagnosis of IDA, each having specific advantages and disadvantages when used in the pregnancy setting. Therapy for ID includes dietary modification, oral iron supplementation, intravenous iron and blood transfusion. Newer parenteral iron preparations are safe and there is mounting evidence to suggest their use in frontline settings for pregnancy associated IDA in the second and third trimester. Through this review, we suggest an algorithm for diagnosis and treatment of IDA in pregnancy depending on the severity of anemia and period of gestation suited for widespread use in resource limited settings. Also, we recommend ways for increasing public awareness and tackling this health issue including the observance of "National Anemia Awareness and Treatment Day."
Collapse
Affiliation(s)
- Rimpy Tandon
- Department of Obstetrics and Gynaecology, Government Medical College and Hospital-32, Chandigarh, India
| | - Arihant Jain
- Department of Internal Medicine (Clinical Hematology Division), PGIMER, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine (Clinical Hematology Division), PGIMER, Chandigarh, India
| |
Collapse
|
42
|
Rineau E, Stoyanov A, Samson E, Hubert L, Lasocki S. Patient Blood Management in Major Orthopedic Surgery. Anesth Analg 2017; 125:1597-1599. [DOI: 10.1213/ane.0000000000002086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
43
|
Pollock RF, Muduma G. Intravenous iron treatments for iron deficiency anemia in inflammatory bowel disease: a budget impact analysis of iron isomaltoside 1000 (Monofer) in the UK. Expert Opin Drug Deliv 2017; 14:1439-1446. [DOI: 10.1080/17425247.2017.1393412] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- R. F. Pollock
- Health Economics and Outcomes Research, Ossian Health Economics and Communications GmbH, Basel, Switzerland
| | - G. Muduma
- International Market Access, Pharmacosmos A/S, Holbaek, Denmark
| |
Collapse
|
44
|
Breymann C, Honegger C, Hösli I, Surbek D. Diagnosis and treatment of iron-deficiency anaemia in pregnancy and postpartum. Arch Gynecol Obstet 2017; 296:1229-1234. [DOI: 10.1007/s00404-017-4526-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 08/07/2017] [Indexed: 11/28/2022]
|
45
|
Verhaeghe L, Bruyneel L, Stragier E, Ferrante M, Dierickx D, Prenen H. The effectiveness of intravenous iron for iron deficiency anemia in gastrointestinal cancer patients: a retrospective study. Ann Gastroenterol 2017; 30:654-663. [PMID: 29118560 PMCID: PMC5670285 DOI: 10.20524/aog.2017.0189] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/03/2017] [Indexed: 01/04/2023] Open
Abstract
Background: Knowledge of the role of intravenous iron without the use of additional erythropoietic stimulating agents in anemic cancer patients is limited. This study evaluated the effect of ferric carboxymaltose (FCM) in a group of digestive oncology (DIO) patients and aimed to differentiate therapy response according to different types of iron deficiency (ID) anemia. Methods: In this retrospective study, we identified DIO patients who were receiving FCM and had eligible baseline and follow-up hemoglobin (Hb) levels that did not require red blood cell transfusion. Subgroup analyses examined adequately versus inadequately treated patients and low (<100 µg/L) vs. high (>100 µg/L) baseline ferritin levels. Inadequate treatment was defined as administration of an insufficient dose of FCM, based on the modified Ganzoni formula. Results: A total of 414 patients were receiving FCM, of whom 41 were excluded because of transfusion and another 70 because of unknown or inadequate baseline iron status. Thus, the study group consisted of 303 patients. Follow-up serum levels were evaluated after a median of 4 weeks. Overall, the median change between baseline and follow-up Hb was 0.5 (interquartile range [IQR]: -0.1–1.6) g/dL. No significant difference in this change was found between the adequately and inadequately dosed groups. The median change in Hb was significantly greater in the low baseline ferritin group than in the high baseline ferritin group: 1.2 (IQR: 0.3–2.2) vs. 0.4 (IQR: -0.3–1.4) g/dL, respectively; P=0.004. Conclusions: Intravenous administration of iron in DIO patients with ID anemia leads to a significant increase in Hb. Moreover, differentiating between the types of ID anemia based on ferritin levels could be applied to predict therapy response, although better biomarkers are needed.
Collapse
Affiliation(s)
- Laurens Verhaeghe
- Department of Internal Medicine, University Hospitals Leuven (Laurens Verhaeghe), KU Leuven, Belgium
| | - Luk Bruyneel
- Institute for Healthcare Policy (Luk Bruyneel), KU Leuven, Belgium
| | - Elisabeth Stragier
- Department of Gastroenterology and Hepatology, University Hospitals Leuven (Elisabeth Stragier, Marc Ferrante, Hans Prenen), KU Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven (Elisabeth Stragier, Marc Ferrante, Hans Prenen), KU Leuven, Belgium
| | - Daan Dierickx
- Department of Hematology, University Hospitals Leuven (Daan Dierickx), KU Leuven, Belgium
| | - Hans Prenen
- Department of Gastroenterology and Hepatology, University Hospitals Leuven (Elisabeth Stragier, Marc Ferrante, Hans Prenen), KU Leuven, Belgium
| |
Collapse
|
46
|
Noronha V, Joshi A, Patil VM, Banavali SD, Gupta S, Parikh PM, Marfatia S, Punatar S, More S, Goud S, Nakti D, Prabhash K. Phase III randomized trial comparing intravenous to oral iron in patients with cancer-related iron deficiency anemia not on erythropoiesis stimulating agents. Asia Pac J Clin Oncol 2017; 14:e129-e137. [PMID: 28849623 DOI: 10.1111/ajco.12762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 06/18/2017] [Indexed: 12/26/2022]
Abstract
AIM We aimed to find the optimal route of iron supplementation in patients with malignancy and iron deficiency (true or functional) anemia not receiving erythropoiesis stimulating agents (ESA). METHODS Adult patients with malignancy requiring chemotherapy, hemoglobin (Hb) <12 g/dL and serum ferritin <100 mcg/mL, transferrin saturation <20% or hypochromic red blood cells >10% were randomized to intravenous (IV) iron sucrose or oral ferrous sulfate. The primary endpoint was change in Hb from baseline to 6 weeks. Secondary endpoints included blood transfusion, quality of life (QoL), toxicity, response and overall survival. RESULTS A total of 192 patients were enrolled over 5 years: 98 on IV arm and 94 on oral arm. Median age was 51 years; over 95% patients had solid tumors. The mean absolute increase in Hb at 6 weeks was 0.11 g/dL (standard deviation [SD]: 1.48) in IV arm and -0.16 g/dL (SD: 1.36) in oral arm, P = 0.23. Twenty-three percent patients on IV iron and 18% patients on oral iron had a rise in Hb of ≥1 g/dL at 6 weeks, P = 0.45. Thirteen patients (13.3%) on the IV iron arm and 14 patients (14.9%) on the oral arm required blood transfusion, P = 1.0. Gastrointestinal toxicity (any grade) developed in 41% patients on IV iron and 44% patients on oral iron, P = 1.0. 5 patients on IV iron and none on oral iron had hypersensitivity, P = 0.06. QoL was not significantly different between the two arms. CONCLUSION IV iron was not superior to oral iron in patients with malignancy on chemotherapy and iron deficiency anemia.
Collapse
Affiliation(s)
- Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Vijay Maruti Patil
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Shripad D Banavali
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Purvish M Parikh
- Department of Medical Oncology, Asian Cancer Institute, K.J. Somaiya Ayurvihar, Mumbai, Maharashtra, India
| | | | - Sachin Punatar
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Sucheta More
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Supriya Goud
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Dipti Nakti
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| |
Collapse
|
47
|
Pollock RF, Muduma G. A budget impact analysis of parenteral iron treatments for iron deficiency anemia in the UK: reduced resource utilization with iron isomaltoside 1000. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:475-483. [PMID: 28848355 PMCID: PMC5557122 DOI: 10.2147/ceor.s139525] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background and aims The reported prevalence of iron deficiency anemia (IDA) varies widely but estimates suggest that 3% of men and 8% of women have IDA in the UK. Parenteral iron is indicated for patients intolerant or unresponsive to oral iron or requiring rapid iron replenishment. This study evaluated differences in the cost of treating these patients with iron isomaltoside (Monofer®, IIM) relative to other intravenous iron formulations. Methods A budget impact model was developed to evaluate the cost of using IIM relative to ferric carboxymaltose (Ferinject®, FCM), low molecular weight iron dextran (Cosmofer®, LMWID), and iron sucrose (Venofer®, IS) in patients with IDA. To establish iron need, iron deficits were modeled using a simplified dosing table. The base case analysis was conducted over 1 year in patients with IDA with mean bodyweight of 82.4 kg (SD 22.5 kg) and hemoglobin levels of 9.99 g/dL (SD 1.03 g/dL) based on an analysis of patient characteristics in IDA trials. Costs were modeled using UK health care resource groups. Results Using IIM required 1.3 infusions to correct the mean iron deficit, compared with 1.3, 1.8, and 7.7 with LMWID, FCM, and IS, respectively. Patients using IIM required multiple infusions in 35% of cases, compared with 35%, 77%, and 100% of patients with LMWID, FCM, and IS, respectively. Total costs were estimated to be GBP 451 per patient with IIM or LMWID, relative to GBP 594 with FCM (a GBP 143 or 24% saving with IIM) or GBP 2,600 with IS (a GBP 2,149 or 83% saving with IIM). Conclusion Using IIM or LMWID in place of FCM or IS resulted in a marked reduction in the number of infusions required to correct iron deficits in patients with IDA. The reduction in infusions was accompanied by substantial reductions in cost relative to FCM and IS over 1 year.
Collapse
|
48
|
Efficacy and Tolerability of Intravenous Ferric Carboxymaltose in Patients with Iron Deficiency at a Hospital Outpatient Clinic: A Retrospective Cohort Study of Real-World Clinical Practice. Anemia 2017; 2017:3106890. [PMID: 28758033 PMCID: PMC5512038 DOI: 10.1155/2017/3106890] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/29/2017] [Accepted: 06/01/2017] [Indexed: 01/27/2023] Open
Abstract
Ferric carboxymaltose (FCM) is an intravenous iron formulation to correct iron deficiency. Although its use has been extensively studied in clinical trials, real-world evidence regarding FCM treatment is scarce. Our aim was to evaluate the efficacy and tolerability of FCM treatment in patients with iron deficiency, with or without anemia, at a hospital outpatient clinic. Data was collected retrospectively from medical records. During this 2-year study, 459 patients were included. Mean age was 58.6 ± 17.5 years and most patients received cumulative FCM doses of 501–1000 mg (63.2%). Six weeks after administration of FCM, efficacy endpoints hemoglobin increase ≥2 g/dL, hemoglobin increase ≥3 g/dL, and transferrin saturation > 20% were attained by 41%, 20%, and 63% of patients, respectively. Patients who received higher FCM doses showed significant reduced odds of not achieving hemoglobin increase ≥2 g/dL (501–1000 mg, adjusted odds ratio [OR]: 0.34, 95% confidence interval [CI] 0.18–0.62; 1001–3000 mg, OR: 0.19, 95% CI 0.07–0.49), compared to 500 mg doses. Treatment-emergent adverse events were documented in <4% of patients. In conclusion, FCM treatment was effective and well-tolerated by outpatients with iron deficiency at a hospital clinic, and its dosage should be adjusted to improve iron deficiency management in clinical practice.
Collapse
|
49
|
Meybohm P, Goehring M, Choorapoikayil S, Fischer D, Rey J, Herrmann E, Mueller M, Geisen C, Schmitz-Rixen T, Zacharowski K. Feasibility and efficiency of a preoperative anaemia walk-in clinic: secondary data from a prospective observational trial. Br J Anaesth 2017; 118:625-626. [DOI: 10.1093/bja/aex024] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
|
50
|
Affiliation(s)
- Michelle P Zeller
- Division of Hematology and Thromboembolism (Zeller, Verhovsek), Department of Medicine, McMaster University, Hamilton, Ont.; Canadian Blood Services (Zeller), Ottawa, Ont.
| | - Madeleine Verhovsek
- Division of Hematology and Thromboembolism (Zeller, Verhovsek), Department of Medicine, McMaster University, Hamilton, Ont.; Canadian Blood Services (Zeller), Ottawa, Ont
| |
Collapse
|