Iron deficiency anaemia

Key messages

Iron deficiency anaemia is defined as a low haemoglobin in the presence of either

Low ferritin (best diagnostic marker)
Low serum iron in the presence of transferrin >3.0

The prevalence of iron deficiency anaemia amongst adult males and non-menstruating females in the developed world is approximately 2-5%
Iron deficiency anaemia can arise as a consequence of

Loss of iron (menstrual blood loss, GI blood loss, renal tract blood loss)
Malabsorption (previous gastric surgery, Coeliac disease)
Poor dietary iron intake (poor diet, lifestyle choices or cultural beliefs)
May be contributing factors:

Menstrual blood loss is the commonest cause overall
Testing for Coeliac disease (anti tTG antibodies) is worthwhile

NOTE THAT IRON AND TRANSFERRIN SHOULD BE DONE ON A FASTING SAMPLE

Who to refer, who not to refer, how to refer

Iron deficiency pathway

Refer all males and non-menstruating females for appropriate investigations (see below)

Yield for significant pathology varies considerably between iron deficiency and IDA even in patients aged over 50.

	ID	IDA
Age > 50	1.3%	6%
Age > 65	2.3%	9%

CRC risk in IDA with negative QFIT is very low <1% (Tayside,Fife and Lothian data)

Individuals with IDA should be referred for appropriate GI investigations if sufficiently fit to undergo them
Localising symptoms should direct investigation to upper GI endoscopy or colon test
Patients without localising symptoms should be referred for a colon test

Appropriate investigation will be at the discretion of the secondary care team and will depend on a patient’s age and general fitness

CT colonography will be offered to patients age >70 and less fit patients or those who cannot tolerate colonoscopy*
Minimal prep CT (no purgative laxative preparation) will be reserved for the most frail patients where any investigation at all is appropriate*

*It is useful to have up to date U&E’s for frail patients or those >80 years

Who not to refer:

GI investigations are not appropriate in other types of anaemia unless there are clear GI symptoms to be investigated

Menstruating females should not undergo GI investigation in the absence of GI symptoms or a family history of colon cancer

Testing for Coeliac disease is appropriate in these patients

How to refer:

To refer for upper GI endoscopy:

Borders General Hospital -> Endoscopy -> Endoscopy B

To refer for colon test:

Borders General Hospital -> Borders colon service

(See Borders Colon Service page for further information)

Primary care management

Patients can be started on oral iron (ferrous sulphate, ferrous fumarate, or ferrous gluconate) one tablet once per day. This can be started prior to investigations. If this is not tolerated, then reducing to one tablet on alternative days can be considered. Initial treatment can be continued for 3 months.

Oral iron maintenance is now recommended to be one tablet every other day instead of every day.

For patients unable to tolerate oral iron that still require it intravenous iron can be arranged by GPs via the infusion suite. This is not a first line treatment and oral iron should be trialled initially.

Resources and links

Scenario: Management | Management | Anaemia - iron deficiency | CKS | NICE

Local service contact details

bor.gastroenterology@borders.scot.nhs.uk