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Iron Deficiency Anaemia Tariq Ahmad 07739 858203 Sarah - 01392 406218.

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Presentation on theme: "Iron Deficiency Anaemia Tariq Ahmad 07739 858203 Sarah - 01392 406218."— 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 –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: 1.Duration of anaemia 2.First episode vs. recurrence 3.Fitness to withstand investigations 4.Fitness to withstand possible surgery 5.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 years7.0 ( ) Male3.0 ( ) Hb < ( ) NSAIDs, Warfarin, AspirinNS 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% Ioannou GNIoannou GN, Am J Med 2002 Investigate men > 50 years and post-menopausal women

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 –1 st choice – Colonoscopy –2 nd 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

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

20 Faecal Calprotectin Acute phase protein –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 Meta-analysis of 13 studies Sensitivity (95% CI) Specificity (95% CI) Reduction in endoscopy False negative test Adults0.93 ( ) 0.96 ( ) 67%6% Children0.92 ( ) 0.76 ( ) 35%8% Van Rheenen BMJ 2010 Van Roon Am J Gastro 2007

22 Capsule endoscopy

23 Parenteral iron AdvantagesDisadvantages Gut not neededRare lethal side effects RapidExpensive No adherence issuesFacilities required Single dose Infrequent side effects

24 Parenteral iron preparations Trade name Max dose Infusion time SAE per million infusions LWM iron dextranCosmofer20mg / kg Test dose 4 hrs 3.3 Iron sucroseVenofer500 mg 30 mins 0.6 Iron gluconateFerrlecit125 mg 30 mins 0.9 Iron carboxymaltose Ferrinject1000mg 15 mins ? Iron isomaltoside 1000 Monofer20mg / kg 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

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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 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 IBDVaricella vaccine Hepatitis B Pneumococcal polysaccharide vaccine Influenza (trivalent inactivated) Human papilloma virus AnnuallyInfluenza (trivalent, inactivated) BoosterPneumococcal polysaccharide vaccine (3–5 years) DiscretionaryTravel 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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