Iron deficiency anaemia (IDA) remains prevalent in Australia and worldwide, especially among high-risk groups.
IDA may be effectively diagnosed in most cases by full blood examination and serum ferritin level. Serum iron levels should not be used to diagnose iron deficiency.
Although iron deficiency may be due to physiological demands in growing children, adolescents and pregnant women, the underlying cause(s) should be sought.
Patients without a clear physiological explanation for iron deficiency (especially men and postmenopausal women) should be evaluated by gastroscopy/colonoscopy to exclude a source of gastrointestinal bleeding, particularly a malignant lesion.
Patients with IDA should be assessed for coeliac disease.
Oral iron therapy, in appropriate doses and for a sufficient duration, is an effective first-line strategy for most patients.
In selected patients for whom intravenous (IV) iron therapy is indicated, current formulations can be safely administered in outpatient treatment centres and are relatively inexpensive.
Red cell transfusion is inappropriate therapy for IDA unless an immediate increase in oxygen delivery is required, such as when the patient is experiencing end-organ compromise (eg, angina pectoris or cardiac failure), or IDA is complicated by serious, acute ongoing bleeding.
Consensus methods for administration of available IV iron products are needed to improve the utilisation of these formulations in Australia and reduce inappropriate transfusion.
New-generation IV products, supported by high-quality evidence of safety and efficacy, may facilitate rapid administration of higher doses of iron, and may make it easier to integrate IV iron replacement into routine care.
- 1. West AR, Oates PS. Mechanisms of heme iron absorption: current questions and controversies. World J Gastroenterol 2008; 14: 4101-4110.
- 2. Ganz T. Hepcidin — a regulator of intestinal iron absorption and iron recycling by macrophages. Best Pract Res Clin Haematol 2005; 18: 171-182.
- 3. Bothwell TH. Iron requirements in pregnancy and strategies to meet them. Am J Clin Nutr 2000; 72 (1 Suppl): 257S-264S.
- 4. Goddard AF, James MW, McIntyre AS, Scott BB. Guidelines for the management of iron deficiency anaemia. British Society of Gastroenterology, 2005. http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/sbn/iron_def.pdf (accessed Sep 2010).
- 5. Peeling P, Dawson B, Goodman C, et al. Athletic induced iron deficiency: new insights into the role of inflammation, cytokines and hormones. Eur J Appl Physiol 2008; 103: 381-391.
- 6. Sachdev H, Gera T, Nestel P. Effect of iron supplementation on mental and motor development in children: systematic review of randomised controlled trials. Public Health Nutr 2005; 8: 117-132.
- 7. Murray-Kolb LE, Beard JL. Iron treatment normalizes cognitive functioning in young women. Am J Clin Nutr 2007; 85: 778-787.
- 8. Allen LH. Anemia and iron deficiency: effects on pregnancy outcome. Am J Clin Nutr 2000; 71 (5 Suppl): 1280S-1284S.
- 9. Brownlie T, Utermohlen V, Hinton PS, et al. Marginal iron deficiency without anemia impairs aerobic adaptation among previously untrained women. Am J Clin Nutr 2002; 75: 734-742.
- 10. Anker SD, Comin Colet J, Filippatos G, et al. Ferric carboxymaltose in patients with heart failure and iron deficiency. N Engl J Med 2009; 361: 2436-2448.
- 11. Oti-Boateng P, Seshadri R, Petrick S, et al. Iron status and dietary iron intake of 6–24-month-old children in Adelaide. J Paediatr Child Health 1998; 34: 250-253.
- 12. Karr MA, Mira M, Alperstein G, et al. Iron deficiency in Australian-born children of Arabic background in central Sydney. Med J Aust 2001; 174: 165-168. <MJA full text>
- 13. Karr M, Alperstein G, Causer J, et al. Iron status and anaemia in preschool children in Sydney. Aust N Z J Public Health 1996; 20: 618-622.
- 14. Rangan A, Aitkin I, Blight G, et al. Factors affecting iron status in 15–30 year old female students. Asia Pac J Clin Nutr 1997; 6: 291-295.
- 15. Zhou SJ, Gibson RA, Crowther CA, et al. Effect of iron supplementation during pregnancy on the intelligence quotient and behavior of children at 4 y of age: long-term follow-up of a randomized controlled trial. Am J Clin Nutr 2006; 83: 1112-1117.
- 16. Hopkins RM, Gracey MS, Hobbs RP, et al. The prevalence of hookworm infection, iron deficiency and anaemia in an Aboriginal community in north-west Australia. Med J Aust 1997; 166: 241-244.
- 17. Guralnik JM, Eisenstaedt RS, Ferrucci L, et al. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood 2004; 104: 2263-2268.
- 18. Badami KG, Taylor K. Iron status and risk-profiling for deficiency in New Zealand blood donors. N Z Med J 2008; 121 (1274): 50-60.
- 19. World Health Organization. United Nations Children’s Fund. United Nations University. Iron deficiency anaemia: assessment, prevention, and control. A guide for programme managers. Geneva: WHO, 2001. http://www.who.int/nutrition/publications/en/ida_assessment_prevention_control.pdf (accessed Sep 2010).
- 20. Grant CC, Wall CR, Brewster D, et al. Policy statement on iron deficiency in pre-school-aged children. J Paediatr Child Health 2007; 43: 513-521.
- 21. Royal Australian and New Zealand College of Obsteticians and Gynaecologists. College Statement: vitamin and mineral supplements in pregnancy. RANZCOG, 2008. http://www.ranzcog.edu.au/publications/statements/C-obs25.pdf (accessed Sep 2010).
- 22. Guyatt GH, Oxman AD, Ali M, et al. Laboratory diagnosis of iron-deficiency anemia: an overview. J Gen Intern Med 1992; 7: 145-153.
- 23. Guyatt GH, Patterson C, Ali M, et al. Diagnosis of iron-deficiency anemia in the elderly. Am J Med 1990; 88: 205-209.
- 24. Hansen TM, Hansen NE. Serum ferritin as indicator of iron responsive anaemia in patients with rheumatoid arthritis. Ann Rheum Dis 1986; 45: 596-602.
- 25. Besarab A, Amin N, Ahsan M, et al. Optimization of epoetin therapy with intravenous iron therapy in hemodialysis patients. J Am Soc Nephrol 2000; 11: 530-538.
- 26. Jones CH, Richardson D, Ayers S, et al. Percentage hypochromic red cells and the response to intravenous iron therapy in anaemic haemodialysis patients. Nephrol Dial Transplant 1998; 13: 2873-2876.
- 27. Mast AE, Blinder MA, Dietzen DJ. Reticulocyte hemoglobin content. Am J Hematol 2008; 83: 307-310.
- 28. Suominen P, Punnonen K, Rajamaki A, Irjala, K. Serum transferrin receptor and transferrin receptor-ferritin index identify healthy subjects with subclinical iron deficits. Blood 1998; 92: 2934-2939.
- 29. Corazza GR, Valentini RA, Andreani ML, et al. Subclinical coeliac disease is a frequent cause of iron-deficiency anaemia. Scand J Gastroenterol 1995; 30: 153-156.
- 30. Beutler E. Disorders of iron metabolism. In: Lichtman MA, Williams WJ, Beutler E, et al, editors. Williams hematology. 7th ed. New York: McGraw-Hill Medical, 2006: 511-553.
- 31. Department of General Medicine, Royal Children’s Hospital. Oral iron preparations — iron supplementation. Melbourne: Department of General Medicine, Royal Children’s Hospital, 2009. http://www.rch.org.au/genmed/clinical.cfm?doc_id=7883 (accessed Sep 2010).
- 32. Zhou SJ, Gibson RA, Crowther CA, et al. Should we lower the dose of iron when treating anaemia in pregnancy? A randomized dose-response trial. Eur J Clin Nutr 2009; 63: 183-190.
- 33. Zumberg MS, Kahn MJ. Acquired anemias: iron deficiency, cobalamin deficiency, and autoimmune hemolytic anemia. In: Crowther MA, Ginsberg J, Schunemann HJ, et al, editors. Evidence based hematology. Malden MA: Blackwell Publishing, 2008: 197-205.
- 34. Solomons NW, Schumann K. Intramuscular administration of iron dextran is inappropriate for treatment of moderate pregnancy anemia, both in intervention research on underprivileged women and in routine prenatal care provided by public health services. Am J Clin Nutr 2004; 79: 1-3.
- 35. Hamstra RD, Block MH, Schocket AL. Intravenous iron dextran in clinical medicine. JAMA 1980; 243: 1726-1731.
- 36. Newnham E, Ahmad I, Thornton A, et al. Safety of iron polymaltose given as a total dose iron infusion. Intern Med J 2006; 36: 672-674.
- 37. Haines ML, Gibson PR. Delayed adverse reactions to total-dose intravenous iron polymaltose. Intern Med J 2009; 39: 252-255.
- 38. NSW Therepeutic Advisory Group. Iron polymaltose infusions discussion paper: rapid response to iron polymaltose infusions email discussion. NSWtag, 2008. http://www.ciap.health.nsw.gov.au/nswtag/publications/otherdocs/IronPolymaltosediscussionpaper1208.pdf (accessed Sep 2010).
- 39. Chertow GM, Mason PD, Vaage-Nilsen O, et al. Update on adverse drug events associated with parenteral iron. Nephrol Dial Transplant 2006; 21: 378-382.
- 40. Medicines and Healthcare Products Regulatory Agency. Ferinject 50mg iron/ml solution for injection/infusion. Public assessment report — decentralised procedure. MHPRA, 2007. http://www.mhra.gov.uk/home/groups/l-unit1/documents/websiteresources/con014025.pdf (accessed Sep 2010).
- 41. Grey DE, Finlayson J. Red cell transfusion for iron-deficiency anaemia: a retrospective audit at a tertiary hospital. Vox Sang 2008; 94: 138-142.
Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You will be notified by email within five working days should your response be accepted.