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Iron Deficiency Anaemia

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Presentation on theme: "Iron Deficiency Anaemia"— Presentation transcript:

1 Iron Deficiency Anaemia
Tariq Ahmad Sarah

2 Interests Inflammatory bowel disease Nutrition Colonoscopy
Paediatric and adolescent Endoscopy Serious adverse drug reactions

3 Iron Deficiency Anaemia

4 Dull topic – Why talk about IDA?
IDA is common Prevalence in adult men and PM women IDA: 2% ID: 7% Most common indication for referral High risk of malignancy 13% (6.3% colonic, 3.6% gastric, 1.0% renal) RR of malignant diagnosis < 2 yrs ~ 33 (9-107) “Hands off” approach by Gastro team James EJGH 2005

5 Diagnosis Ferritin < 15ng/mL Exclude acute phase response
Specificity 99%, Sensitivity 59% Exclude acute phase response If CRP elevated divide Ferritin by 3 Red cell morphology Normal in 50% of patients with IDA 20-30% of patients with MCV < 75 will not have IDA Low MCV: Think before prescribing iron Trial of iron if ferritin ≤ 40 μg/l (or ≤ 70 μg/l in presence of chronic inflammation)

6 IDA – 5 minute assessment
History Age Menopause Diet Colour blind? Prosthetic heart valve? Blood donor FH Colorectal cancer, Bleeding disorder

7 IDA – 5 minute assessment
Examination Lips Abdominal mass Urine dip Investigations Ferritin CRP Creat TTG / IgA

8 IDA – Who to refer? All men Post-menopausal women
Pre-menopausal women if > 50 years old Strong family history of colorectal cancer GI symptoms which meet criteria for upper or lower 2WW referral Raised CRP or calprotectin Persistent IDA following iron supplementation & correction of potential causes of losses DO NOT START IRON UNTIL AFTER INVESTIGATIONS

9 Should I refer this elderly / frail patient?
Consider: Duration of anaemia First episode vs. recurrence Fitness to withstand investigations Fitness to withstand possible surgery Patient wishes following frank discussion

10 Risk factors for malignancy in patients with IDA
Prospective UK study 550,000 population 695 cases over 2 years 13.1% cancer 6.3% colonic, 3.6% gastric, 1.0% renal OR (95% CI) for Cancer >50 years 7.0 ( ) Male 3.0 ( ) Hb < 9.0 2.2 ( ) NSAIDs, Warfarin, Aspirin NS James EJGH 2005

11 ID without anaemia US Prospective cohort study
9024 participants aged with IDA Follow-up 2 years Men and post-menopausal women 0.9% cancers Pre-menopausal women 0% Investigate men > 50 years and post-menopausal women Ioannou GN, Am J Med 2002

12 2WW misuse “I have taken blood tests – results to follow”
Failure to mention previous investigations for same problem Long-standing anaemia Patient not fit for a hair cut

13 Colonic imaging 2011 ≤ 80 years > 80 years Barium enema RIP
1st choice – Colonoscopy 2nd choice – CT pneumocolon > 80 years Minimal prep CT colon Barium enema RIP

14 CT Colonography (CTC) (CT Pneumocolon, Virtual colonoscopy)
Low residue diet hrs pre Fluid only 24 hrs pre Oral contrast 48hrs No sedation Rectal gas Supine / prone 6-7 secs acquistion time Advantages Superior to DCBE Sensitivity >90% for polyps >10mm Well tolerated Extra-luminal information

15 Normal OGD & Colon – what next?
Reassurance for most patients IDA recurrence after OGD + duodenal biopsy & Colonoscopy – 10% Risk of malignancy in next 5 years < 5%

16 Normal OGD & Colon – what next?
Repeat IDA 5 minute assessment Check duodenal biopsies taken? Erradicate H.pylori Consider Giardia Stop NSAIDs, PPI Check CRP / Calprotectin ?Small bowel Crohn’s If asymptomatic 3+ months oral iron

17 Oral iron preparations
Avoid enteric coated or SR iron Avoid giving with food 250 mg ascorbic acid enhances absorption Ferrous sulphate, fumarate gluconate equal efficacy and side effect profile Low dose as efficacious with fewer side effects Use in patients with IBD controversial

18 Monitoring response Pica disappears within 24 hours
Check FBC at 2-3 weeks and 3 months No indication to repeat Ferritin Expect Hb rise 0.7g/dL per week Continue oral iron for 3 months after normalisation of Hb Retic count up at 2 weeks

19 Indications for outpatient review
Significant GI symptoms. Elevated CRP or calprotectin. Recurrent anaemia.

20 Faecal Calprotectin Acute phase protein Clinical utility
Neutrophil cytosolic protein Neutrophil activation leads to release in serum & stool Clinical utility Differentiating IBD from IBS Monitoring disease activity in IBD

21 Screening of patients with suspected IBD by faecal calprotectin
Calprotectin outperforms ESR, CRP, ASCA, p-ANCA Van Roon Am J Gastro 2007 Meta-analysis of 13 studies Sensitivity (95% CI) Specificity Reduction in endoscopy False negative test Adults 0.93 ( ) 0.96 ( ) 67% 6% Children 0.92 ( ) 0.76 ( ) 35% 8% Van Rheenen BMJ 2010

22 Capsule endoscopy

23 Parenteral iron Advantages Disadvantages Gut not needed
Rare lethal side effects Rapid Expensive No adherence issues Facilities required Single dose Infrequent side effects

24 Parenteral iron preparations
Trade name Max dose Infusion time SAE per million infusions LWM iron dextran Cosmofer 20mg / kg Test dose 4 hrs 3.3 Iron sucrose Venofer 500 mg 30 mins 0.6 Iron gluconate Ferrlecit 125 mg 0.9 Iron carboxymaltose Ferrinject 1000mg 15 mins ? Iron isomaltoside 1000 Monofer 60 mins

25 ID and prognosis in CHF Jankowska et al. Eur Heart J 2010

26 ID and chronic heart failure
FAIR-HF trial 459 patients ID(A) Iv iron carboxymaltose vs. placebo Patient global assessment 50% vs. 28% OR 2.51 (CI 1.75–3.61) Improvement in NYHA class Improvement in 6 min walk test Improvement in QoL Anker N Engl J Med 2009


28 2011 Electronic IBD registry
Facilitates cancer surveillance Facilitates electronic drug monitoring Allows accurate assessment of service needs Allows audit of quality of care

29 Colorectal Cancer surveillance in IBD
Longstanding colitis is associated with an increased risk of colorectal cancer ( % at 30 yrs) Surveillance colonoscopy is recommended Challenges include endoscopic and histologic diagnosis, and interval cancers

30 Exeter Audit Identify avoidable shortcomings in CRC surveillance
All patients with a diagnosis of IBD and colorectal cancer 1969 IBD patients 39 patients had IBD and CRC 18/26 (70%) patients not surveyed according to 2004 BSG guidelines.

31 Reasons for no surveillance
9 managed exclusively in primary care 8 not considered in secondary care 3 surgical clinic 5 gastroenterology clinic 1 refused

32 IBD cancer surveillance
BSG Guidelines 2010

33 Vaccination / chemoprophylaxis strategy
At diagnosis of IBD Varicella vaccine Hepatitis B Pneumococcal polysaccharide vaccine Influenza (trivalent inactivated) Human papilloma virus Annually Influenza (trivalent, inactivated) Booster Pneumococcal polysaccharide vaccine (3–5 years) Discretionary Travel vaccines: live vaccines (eg, yellow fever, oral poliomyelitis) should be avoided if on immunomodulators Chest x ray, interferon release assay prior to anti-TNF therapy Before starting a third immunomodulator Trimethoprim–sulfamethoxazole 80/400 mg daily, or 160/800 mg three times a week as prophylaxis against Pneumococcus jiroveci European evidence-based Consensus on the prevention, diagnosis and management of opportunistic infections in IBD. J Crohn’s Colitis 2009;3:47–91

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