Iron Deficiency Anaemia

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

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: • 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 James EJGH 2005

11. ID without anaemia US Prospective cohort study • 9024 participants aged 25-74 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 • 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 48-24 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 efficaciouswith 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 Van Roon Am J Gastro 2007 Van Rheenen BMJ 2010

22. Capsule endoscopy

23. Parenteral iron

24. Parenteral iron preparations

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 (7.6 -18% 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 1999 - 2009. • 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 European evidence-based Consensus on the prevention, diagnosis and management of opportunistic infections in IBD. J Crohn’s Colitis 2009;3:47–91