Iron Deficiency Anemia

Presentation on Anemia, its classification and iron deficiency anemia in brief.

1. Iron Deficiency Anemia Dr. Subhash Thakur Clinical Oncologist MD (PGIMER, Chandigarh)

2. Content Introduction to Anemia Clinical Features Classification Iron Deficiency Anemia Introduction Pathophysiology Clinical Features Epidemiology – world wide and Nepal Iron deficiency in pregnancy Prevention Management Conclusion

3. Anemia An : without and Emia : Blood Normal Values Hb: male : 14-18 gm/dl, female: 12-15 gm/dl, Children : 11-16 gm/dl and pregnancy : 11 to 12 gm/dl Hematocrit: >30 % MCV: 80-100 fl

4. Clinical Features Clinical Features depend on severity not on etiology Normal hemoglobin to hematocrit ratio : 1:3

5. Hematocrit level and symptoms Death : Myocardial infarction (Ischemia) Hematocrit Symptoms 25-30 Tired, fatigue after exertion 20-25 Shortness of breath <20 Confused, light headed

6. Classification : Based on MCV High (Macrocytic) B12 and folate deficiency Liver disease, alcohol, drugs Normal (Normocytic) Blood loss Hemolysis Low (Microcytic) Iron deficiency anemia Anemia of chronic disease Sideroblastic anemia Thalassemia

7. Macrocytic Vs Megaloblastic Macrocytic : large cell whereas Megaloblatic is hyper segmented neutrophils (more lobes in nucleus) B12/folate deficiency Reticulocyte count is low in macrocytic and microcystic anemia whereas it is increased in normocytic

8. Microcytic Anemia 34 years old female, occasionally fatigued otherwise healthy, no medicine use history, examinations : normal Hb : 10 gm/dl, Hct : 32 %, MCV : 72 fl Iron Deficiency Sideroblastic Anemia Anemia of Chroni Disease Thalassemia

9. Iron Deficiency Anemia RDA : 1 mg/day (requirement is low because body recycles hemoglobin) Demand is increased to 2 to 3 mg/day in menstruating lady Pregnancy : 5 mg /day Maximum absorption of iron : 4 mg/day, so in pregnancy Iron deficiency is bound to happen, so Iron supplementation is must.

10. Shellfish Spinach Liver Pumpkin seeds Fruits Apple Banana Pomegrante mulberries Foods rich in Iron

11. Absorption , transportation and Storage Absorbed in duodenum in ferrous form (Fe2+) Free iron (Fe3+) is oxidized by acid in stomach to Fe2+ for absorption Myoglobin and hemoglobin are broken down by lysosomal enzymes to ferrous form

12. Ferrous iron binds with Apo ferritin and passes through the basolateral membrane to get in blood stream In Blood stream it binds with transferrin (Beta globulin) and transported to Liver for storage from where it is again transported to Bone marrow for Hemoglobin Synthesis

13. Pathophysiology Iron Deficiency Iron Deficient Erythropoiesis IDA (microcytic Anemia) Hemoglobin : Heme + Globin

14. Causes of Iron Deficiency Blood loss Menstrual Cycles GI bleed Dietary deficiency Poor absorption GI surgeries Chronic PPI use

15. High Risk Population: Who require more iron : Children and infants, pregnancy and lactating mothers, Chronic pain killer users, aged population

16. Evaluation: CBC followed by PBS Microcytic Hypochromic Low MCV and Low MCHC High Transferrin High RDW Iron Profile Low ferrous Low ferritin High TIBC

17. Clinical Features Symptoms depend on severity not on the etiology Fatigue, tiredness, shortness of breath, confusion, light headedness Koilonychias

18. Epidemiology Africa > America Countries with little meat consumption and intestinal parasites : hookworm Nepal: Overall prevalence: 65.6%

19. Iron Deficiency in Pregnancy Increased demand : Mother, fetus, increased risk in twin/multiple pregnancy Decreased intake Altered digestive process

20. Impact on infant Increased incidence of preterm delivery LBW baby Oral iron in pregnancy : reduction in the incidence of anemia Food based approach is not enough must be supplemented

21. Management Aim of treatment: To restore Hemoglobin level and RBC indices to normal and replenish iron stores, if not achievable, further evaluation should be done Dietary approach Oral Supplementation Parental

22. Dietary Approach

23. Oral Supplementation 250 mg BD along with ascorbic acid 250 – 500 mg BD 325 mg tds : 180 mg : elemental iron : 10 mg Should be taken 1 hour before meal or 2 hours after meal

24. Parenteral: Iron dextran : 50 mg of elemental iron : deep IM or IV A/E : fever, arthralgia, backache, hypersensitivity Supplementation should be done for at least 3 months after correction has been achieved to replenish the store Caution : Iron for long term : Iron Overload : Liver, Heart, Pancrease . Treatment : Desferoxumine , not phlebotomy

25. Side effects of Iron supplementation Oral : black stool and constipation Parenteral : hypersensitivity, fever, arthralgia, backache

26. Prevention: Nepal Government Policy https://mohp.gov.np/downloads/National%20anemia%20control%20Strategy.pdf

27. Infants Breast feeding : best absorbable Cow’s milk : iron deficient

28. Revision If a person does not improve with oral FeSO4 ? Ans : supplement with vitamin C, acid helps to absorb iron from duodenum. Acid oxidizes ferric to ferrous form

29. 2. Which of these cause decreased Oral Iron absorption ? a. orange juice b. grape fruit juice c. PPI d. pregnancy

30. 3. Which of these is Anemia of Chronic Disease (ACD)? Iron level Normal : 45-160 TIBC : 220-440 Ferritin : 20-320 Iron level TIBC Ferritin 34 450 12 230 275 180 32 440 140 D. 40 210 300

31. 4. 63 years old female, anemic, drinks socially 6 nights a week, no symptoms, MCV : 70, WBC count : normal, Platelets : 636000 What is the most likely cause of thrombocytosis? Essential thrombocytosis Iron Deficiency Anemia Alcoholism CML Sideroblastic Anemia ACD

32. 5. Which is most likely macrocytic ? Anemia of Chronic Disease Renal Failure Hypothyroidism One gene deleted alpha thalassemia