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welcome . بسم الله الرحمن الرحيم. WHE2008. Anemia (When Iron Deficiency is the Cause). By: Dr. ABDULLAH T. AL-MOHAMADI DEMONESTRATOR King Abdulaziz University Hospital Jeddah, K. S. A. WHE2008. Today’s Agenda. ● Definition of Anemia ● Magnitude of the problem and its impact

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  1. welcome

  2. بسم الله الرحمن الرحيم

  3. WHE2008 Anemia (When Iron Deficiency is the Cause) By: Dr. ABDULLAH T. AL-MOHAMADI DEMONESTRATOR King Abdulaziz University Hospital Jeddah, K. S. A.

  4. WHE2008 Today’s Agenda ● Definition of Anemia ● Magnitude of the problem and its impact ● Prevalence ● Functions of iron ● Normal iron cycle ● Causes of iron deficiency anemia ● Factors that modify iron absorption ● Symptoms ● Signs ● Stages of iron deficiency ● Diagnosis ● Prevention ● Treatment ● Treatment failure ● Recommendations

  5. WHE2008 Anemia is defined as hemoglobin concentration lower than the established cut off defined by WHO • Less than 11g/dl; for pregnant women and for children 6 months – 5 years of age. • Less than 12g/dl; for non pregnant women. • Less than 13g/dl; for adult males.

  6. WHE2008 Most Common Nutritional Disorder in the World • Has negative effects on work capacity and physical labor. • Diminishes motor, mental and growth development in infants and children. • Might cause low birth weight and preterm delivery or even maternal and fetal death *Haas and Brownlie, 2001*

  7. WHE2008 Magnitude of the Problem • It is common in developing countries. • Prevalence was observed in the United States among certain population such as toddlers and females of childbearing age.(●) (Table -1-) • Iron deficiency anemia has a prevalence of 2-5% among adult men and post-menopausal women in the developed word.* (●)looker et al, Prevalence of iron deficiency in the United States. JAMA, 1997. (*) WHO.Iron deficiency anemia. Assessment, prevention and control. A Guide for Program Managers Geneva. 2001.

  8. WHE2008 Prevalence of Iron Deficiency-United States-National Health and Nutrition

  9. WHE2008 World Health Organization (WHO) Estimates that most preschool children and pregnant women in developing countries are iron deficient.* (Table 2) (*) WHO report, Iron deficiency anemia. Assessment, Prevention and Control. A Guide for Program Managers. Geneva. 2001.

  10. Table -2- Updated Regional and Global Prevalence (%) and Numbers Affected by Anemia(2001)

  11. WHE2008 Magnitude of the Problem: cont. • The prevalence of anemia in developing countries is three to four times higher than that for developed countries. • Prevalence of anemia in the Gulf region ranged from 15-48% in women childbearing age mostly attributed to iron deficiency(●)

  12. WHE2008 Magnitude of the Problem: cont. • In Saudi Arabia the overall country prevalence of anemia was 30-56%(●) • Cross sectional study, conducted in Riyadh among school girls showed that IDA prevalence was 40.5% among female adolescents (16-18) years old.* (●)Verster A, Pols J. Anemia in Mediterranean region “1995” (*) Al-Shehris.Health Profile of Saudi adoloscent Schoolgirls. “1996 “ (*) Joharah, M. Al-Quaiz. Iron deficiency anemia. A study of Risk factors. Saudi Med J 2001.

  13. WHE 2008 WHO/UNICEF jointly adopted nutritional goals, aiming to control iron deficiency by the turn of the century. (●) WHO, UNICEF, INACG. Guidelines for use of iron supplements to prevent and treat iron deficiency anemia, 1998

  14. WHE2008 Recent report from WHO indicates that the prevalence of anemia has not changed much over the years, (It is a persisting public health problem).

  15. WHE2008 Iron and Functions • Iron, is one of the most common elements constituting about 5% of the earth crust. • Essential for all living organisms. • It has several vital functions in the body .

  16. WHE2008 Iron and Functions: cont. • Storage and carrier of oxygen to tissue by red blood cell hemoglobin or to muscles by myoglobin • Some important enzymes contain iron like that catalyze the redox reaction required for the generation of energy eg. Cytochrome.

  17. WHE2008 Fig (2) Hemoglobin Heme

  18. WHE2008 Fig (2) Normal Iron Cycle Duodenum Dietary iron (average, 1 - 2 mg Utilization Utilization per day) Plasma (TIBC) transferrin (3 mg) Bone Muscle marrow (myoglobin) (300 mg) Circulating (300 mg) erythrocytes Storage (hemoglobin) iron (Ferritin) (1,800 mg) Sloughed mucosal cells Desquamation/Menstruation Other blood loss (average, 1 - 2 mg per day) Reticuloendothelial Liver macrophages (1,000 mg) Iron loss (600 mg)

  19. WHE2008 Causes of Iron Deficiency Anemia • Blood loss Menorrhagia is one of the most frequent causes of iron deficiency and should always be suspected as the cause in women during reproductive life. (*)Query Specific points in the menstrual history (*) The use of intra-uterine devices (IUCD).

  20. WHE2008 Daily iron losses and requirements (mg) Daily Loss Requirement Total Loss for Growth (=Requirement) Urine, skin, Faeces, etc. menses Infant (0-4 months) 0.5 0.5 (5-12months) 0.5 0.5 1.0 Child 0.5 0.5 1.0 Adolescent male 0.9 0.9 1.8 Adolescent female 0.9 1.0 0.5 2.4 Menstruating female 0.9 1.9 2.8 Adult male 0.9 0.9 Post menopausal female 0.9 0.9

  21. WHE2008 Causes of iron deficiency anemia: cont • Losses can increase with colorectal cancer, polyps, diverticular disease, excessive use of certain medication, Hook worm infestation and frequent blood donation. (●) Common cause of referral to gastroenterologist. (●) Blood loss from the (GI) tract is the commonest cause of iron deficiency anemia in adult men and post-menopausal women • Most common cause of Iron Deficiency Anemia, in America and North America

  22. WHE2008 Causes of Iron Deficiency Anemia : cont • high physiological requirement such as in infancy, early childhood, puberty and Pregnancy: • Blood in the body expands until it is about 50% or more • Most women start pregnancy without sufficient iron store • Increase demand for iron particularly in the second and third trimesters

  23. WHE2008 Pregnancy: cont. ● Higher risk with morning sickness ● Two or more pregnancies close together ● Pregnancy with more than one baby ● Iron poor diet or if prior pregnancy menstrual flow was heavy.

  24. WHE2008 Causes of Iron Deficiency Anemia cont ■Diet ● Rarely is the sole cause of iron deficiency. ● Vegetarians are more likely to develop iron deficiency anemia. ● Various food can influence the absorption of dietary iron. Vit. C can increase the absorbtion of iron. Tea, coffee and cocoa drinking especially with food reduce the absorbtion of dietary iron.

  25. WHE2008 Causes of Iron Deficiency Anemia: cont. ● Calcium intake can inhibit iron absorption. A cross sectional study among girls and young women in 6 European countries showed that dietary calcium intake had a consistent inverse association with iron store.* * Van de Vijver LpL et al. Calcium intake is weakly but consistently negatively associated with iron status in girls and women in six Eusropean countries. J Nut 1999.

  26. WHE2008 Causes of Iron Deficiency Anemia: cont. Malabsorbtion ■Hypo-or achlorohydria, H. Pylori colonisation ■ Coeliac disease ■ Gastrectomy, Gut resection and Gastric bypass surgeries and others.

  27. WHE2008 Factors that Modify Iron Absorption

  28. WHE2008 ● Iron deficiency develops after gastric bypass for several reasons: (●) Intolerance for red meat (●) Diminished gastric acid secretion (●) Exclusion of the duodenum from the alimentary tract

  29. WHE2008 ■ In a case control study of risk factors for IDA among Saudi women of childbearing age (87 patients and 203 controls) ● Poor dietary habits ● Menorrhagia ● History of ingestion of NSAID or antacids were the most important risk factors. J M. Al—Quaiz-Iron deficiency anemia, A Study of risk factors Saudi Med J. 2001

  30. WHE2008 Symptoms ■Seldom appear before Hb <10g/dl. ■ Tiredness, palpitation, lack of stamina, shortness of breath, dizziness, headache, irritability, depression and excessive hair loss. ■ soreness and burning of the tongue and a sensation that the tongue feels swollen. ■ Vertigo, tinnitus, tendency to faint, anginal pain, gastrointestinal discomfort, loss of appetite or perversion of the appetite (pica)

  31. WHE2008 Cont. Pica ● Occurs variably in patients with iron deficiency ● Precise pathophysiology of the syndrome is unknown ● Patients consume unusual items eg. laundry starch, ice, soil clay ● Clay and starch can bind iron in the GIT, exacerbating the deficiency.

  32. WHE2008 Physical Examination ■Pallor ■ Dryness or roughness of the skin, or it may be more transparent and thinner than normal. ■ Brittle, soft and flattened or spoon shaped koilonychia ■ Lips are often dry and cracked and the surface may become uneven. ■ Painful, moist cracks at the angles of the mouth occurs in about 15%.

  33. WHE2008 Cont. ■ 50% of patients suffer smooth, glossy, reddening of the tongue vesicles or erosions develop. ■ The hair may be brittle, splitting at the ends with marked thinning. ■ Cold intolerance develops in one fifth of patients ■ 5 – 20% of patients with long standing iron deficiency anemia develop dysphagia.

  34. WHE2008 Stages of Iron Deficiency ●prelatent iron deficiencyoccurs when stores are depleted without a change in hematocrit or serum iron levels. This stage of iron deficiency is rarely detected. ● latent iron deficiency occurs when the serum iron drops and the TIBC increases without a change in the hematocrit. This stage is occasionally detected by a routine check of the transferrin saturation. ● frank iron deficiency anemia is associated with erythrocyte microcytosis and hypochromia. Iron deficiency attracts medical attention most commonly at this stage.

  35. WHE2008 Diagnosis of Iron Deficiency very vague ■ symptoms such as fatigue and tiredness may be attributed to overwork or disregarded completely. ● Complete blood count~Hb level * documents severity of microcytic hypochromic indices ( MCV, MCH, MCHC) and red cell distribution width. ● Platelets may be normal. Increased or reduced in rare cases. ● The WBC count is usually within reference range.

  36. Fig (1) Iron Deficiency Anemia Anemia Normal blood

  37. WHE2008 Diagnosis of Iron Deficiency: cont. ● Assessment of body iron profile (serum iron, total iron-binding capacity (TIBC) and ferritin) low SF is diagnostic of iron deficiency. ● The serum transferrin receptor assay is a relatively new approach to measuring iron status at the cellular level.

  38. WHE2008 Cont. • Search for the underlying cause. • Upper and lower GI investigations should be considered in all post-menopausal female and all male patients , unless there is a history of significant overt non-GI blood loss (Grade B evidence). • Celiac disease serology if positive, should be confirmed by small bowel biopsy. (●) BSG Guidelines in Gastroentrology for the Management of iron deficiency anemia, May 2005.

  39. WHE2008 Prevention of Iron Deficiency • Evidence are accumulating , strongly suggest a relationship between iron deficiency and brain development. IQ of school children and attention deficit disorder. • Functional defects affecting learning and behavior cannot be reversed by giving iron later on.

  40. WHE2008 ● WHO strategies. (1) Food education. (2) Iron supplementation ~giving iron tablets to certain target group such as pregnant women and pre-school children. (3) Iron fortification of certain foods.

  41. WHE2008 Several Factors Determine theFeasibility and Effectiveness of Different Strategies (1) Health infrastructure. (2) Economy. (3) Access to iron fortification. (4) Food education.

  42. WHE2008 Treatment of Iron Deficiency (1) Blood transfusion should be reserved for patients with or at risk of cardiovascular instability. (2) Food education (3) Treatment of the underlying cause. (4) Correction of the deficiency by therapy with inorganic iron. Keep iron supplements highly capped and away from children’s reach.

  43. WHE2008 Treatment of Iron Deficiency: cont. Types of inorganic iron: (1) Ferrous sulphate (2) Ferrous gluconate (3) Ferrous fumarate

  44. WHE2008 Treatment of Iron Deficiency: cont. 200 mg ferrous sulphate – 63 mg iron 300 mg ferrous gluconate or ferrous fumarate - 35 mg iron Simultaneous intake of ascorbic acid will enhance the iron absorption. • 2-3 times /day , 3-6 months to correct the deficit.

  45. WHE2008 Treatment of Iron Deficiency: cont. Side effects  related to amount of iron epigastric pain and nausea diarrhea, constipation rarely skin eruptions

  46. WHE2008 Parentral Therapy - unnecessary • lack of compliance because of side effects • malabsorbtion • late pregnancy • when hemorrhage is likely to continue

  47. Parentral Therapy:cont Intravenous preparation , Iron dextran (Imferon) Intramascular preparation , Iron sorbitol (jectofer) Sodium ferric gluconate (ferrlecit) sucrose (venofer)

  48. WHE2008 Parentral Therapy: cont. Side effects (1) systemic anaphylaxix (0.6-0.7%) (2) local inflammation, phlebitis

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