Ms. T is a 38-year-old woman who presents with a 6-month history of heavy menstrual bleeding and fatigue. Her lab results show low hemoglobin, ferritin, iron, MCV and MCH levels consistent with iron deficiency anemia. Her risk factors include female gender, past pregnancies, long-term NSAID use, and intermenstrual bleeding. She is started on iron supplements to replenish her iron stores, treat her anemia, and resolve her symptoms.
2. PATIENT INTRODUCTION
Ms. T is a 38 year old white woman who presents to her
Nurse Practitioner complaining of 6 month history of
intermenstrual bleeding and menorrhagia accompanied with
extreme fatigue and weakness. Her month periods now
included 8-10 days of bleeding and cramping.
Medical history: G2 P2, uses NSAIDS regularly for left knee
pain from previous sport injury as teen.
Family history: non contributory
4. DIFFERENTIAL DIAGNOSES
Depression
Hypothyroidism
GI bleed
Cancer (Chronic disease anemia)
Chronic Myeloid Leukemia
Beta Thalassemia minor
Poor diet (malnutrition)
5. HEMOGRAM OF IRON DEFICIENCY
ANEMIA AND DDX FROM OTHER
ANEMIAS
IDA ACD VBD
Ferritin
︎⇩ ⇧ normal
Iron
⇩ ⇩ normal
MCV/ MCH
⇩ Usually
normal to
decreased
⇧
Iron deficiency anemia (IDA)
Anemia of Chronic Disease (ACD)
Vit B12 deficiency (VBD)
(Schrier & Camaschella, 2017)
6. PATHOPHYSIOLOGY OF THE
DISEASE
Iron is a crucial element for hemoglobin production, its
necessity is especially high in kids and pregnant women due
high demand. Iron deficiency is the most common cause for
anemia in general population, anemia becomes evident when
Iron stores in a form of Ferritin are depleted. Since the biggest
source of Iron for building new Hb recycled from old RBC, even
a small amount of chronic bleeding can lead to anemia.
(Schrier, 2017)
7. THE NORMAL IRON CYCLE
Iron absorbed from the small
intestine or released from storage
or available from catabolism of
old RBC
Then iron attached to a
protein transferrin and
transported to bone marrow
for Hb synthesis
Excess Iron stored by the
liver in form of Ferritin
As RBC age, they get
destroyed by macrophages in
the spleen and iron gets
recycled into plasma
(McCane & Huether, 2014, p.964)
8. TREATMENT GOALS
Investigate the cause of anemia and loss of Iron stores
Patient education regarding her new diagnoses, treatment options
and prognoses.
Correct anemia and Iron stores with supplements
Watch for treatment compliance
Diet counseling
9. PATIENT SPECIFIC TREATMENT
Diet counseling
Investigate the cause of prolonged intermenstrual bleeding, stop the use of
NSAIDS if possible and rule out GI bleed .
Educate the patient how to use Iron supplements and about its side
effects.
Advise patient to keep Iron supplements away from children (overdose is
toxic)
Start supplementing with Iron supplements in conjunction with vitamin C.
10. INITIATING THERAPY
Can start from 180 mg elemental Iron a day and
regulate the dose based on patients tolerance and
severity of anemia. It is recommended to start with a
lower dose to ease up on side effects and slowly go
up.
Order CBC and Ferritin, and see the patient again in 2-
4 weeks
Continue treatment for 3-6 month. Supplementing
beyond 6 month is not recommended
11. AVAILABLE IRON PREPARATIONS
There is no preference to a specific agent, however sustained
release products may not be as effective as regular product.
Iron salt Formulation
(elemental iron)
Adult dose Side
effects
Cost per
month
Ferrous sulfate Tab 300mg (60mg) 1tab Q3D +++ 2-3$
Sustained release Tab
160mg(50mg)
1-4 tab OD + 25$
Suspension 75mg/ml
(15mg/ml)
4ml Q3D ++ 100$
Syrup 30mg/ml
(6mg/ml)
10ml Q3D ++ 3-5$
(BCGuidelines, 2015, Appendix B)
12. AVAILABLE IRON PREPARATIONS
CONT.
Iron Salt Formulation
(elemental Iron)
Adult dose Side
effects
Cost per
month
(Pharmacare
coverage)
Ferrous
Gluconate
Tab 300mg
(35mg)
1-3 tab 2-3
times a day
++ 3-5$
Ferrous
Fumarate
Tab 300mg
(90mg)
1 tab Q2D ++ 2-20$
Suspension
300mg/5ml
(20mg/ml)
3 ml Q3D ++ 35$
Polysacchari
de
Iron
Capsules 150mg
(150mg)
1 caps OD + 24$
(BCGuidelines, 2015, Appendix B)
13. SIDE EFFECTS
Iron supplements associated with many side effects,
therefore clinician should watch for compliance.
Side effects include:
Nausea
Vomiting
Dyspepsia
Constipation/ Diarrhea
Dark stools
Bloating
(BCGuidelines, 2015, Appendix B)
14. DRUG-DRUG AND FOOD-DRUG
INTERACTIONS
Iron absorbed best in acid environment, therefore any food or
medication that can increase gastric PH will interfere with proper
absorption.
Iron can interfere with absorption of other drugs, best given alone.
Food interaction: Cereals, dietary fiber, tea, coffee, eggs and milk
may decrease absorption
15. PATIENT SPECIFIC RISK FACTORS
Ms T. is at risk for anemia for several factors:
Female of child baring age
Was pregnant twice
Long intermenstrual bleeding
Long term use of NSAIDS
16. EPIDEMIOLOGY
Overall Iron deficiency is the most common reason for anemia, it
affects over 12 percent of the population, and more prevailing in third
world countries due to poor diet (Schrier, 2017).
Who is at risk?
Infants
Children
Women
Elderly
People with certain conditions
17. EPIDEMIOLOGY CONT.
Causes for
iron
deficiency
Poor
absorption
Inadequate
intake and
high
demand
Blood
loss
o Chronic bleeding
o Heavy period
o Frequent blood
donor
o Celiac disease
o Gastric surgery
o Gastric ulcer
o Gastric
parasites
o Poor diet
o Vegetarian diet
o Pregnancy/lactati
on
o Growth sprout
(Schrier,2017)
18. REFERENCE
Benz, E., 2017. Clinical Manifestations and Diagnosis of the Thalassemias.
UptoDate. Retrieved from https://www.uptodate.com/contents/clinical-
manifestations-and-diagnosis-of-the-
thalassemias?source=search_result&search=beta%20thalassemia%20minor&sel
ectedTitle=1~14
British Columbia Guidelines, 2015. Iron Deficiency – Investigation and
Management. Retrieved from
http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-
guidelines/iron-deficiency
Dietitians of Canada, 2016. Food sources of Iron. Retrieved from
http://www.dietitians.ca/Your-Health/Nutrition-A-Z/Minerals/Food-Sources-of-
Iron.aspx
Ross, D., 2017. Diagnosis of and Screening for Hypothyroidism in Non Pregnant
Adults. Uptodate. Retrieved from https://www.uptodate.com/contents/diagnosis-
of-and-screening-for-hypothyroidism-in-nonpregnant-
adults?source=search_result&search=hypothyroidism&selectedTitle=1~150
LifeLabs, 2017. Reference Range. Retrieved from
http://www.lifelabs.com/healthcare-providers/Pages/Reference-Ranges.aspx
McCance, K., & Huether, S.,2014, p.964. The Hematologic System.
Pathophysiology: the Biologic Basis for Disease in Adults and Children.
19. REFERENCE CONT.
Schrier, S., 2017. Causes and Diagnosis of Iron Deficiency and Iron
Deficiency Anemia in Adults. UptoDate. Retrieved from
https://www.uptodate.com/contents/causes-and-diagnosis-of-iron-
deficiency-and-iron-deficiency-anemia-in-
adults?source=search_result&search=iron%20deficiency%20anemia
&selectedTitle=1~150
Schrier, S., Camaschella, C., 2017. Anemia of Chronic
Disease/Inflammation. UptoDate. Retrieved from
https://www.uptodate.com/contents/anemia-of-chronic-disease-
inflammation?source=search_result&search=anemia%20of%20chroni
c&selectedTitle=1~150
Van Etten, R., 2017. Clinical Manifestations and Diagnosis of Chronic
Myeloid Leukemia. UptoDate. Retrieved from
https://www.uptodate.com/contents/clinical-manifestations-and-
diagnosis-of-chronic-myeloid-
leukemia?source=search_result&search=chronic%20myeloid%20leuk
emia&selectedTitle=1~150
Editor's Notes
Main points of this history is: Ms T. being a white woman, long term heavy menstrual bleeding and long term NSAIDS use.
From her physical exam we can see that she is tachycardic, lab results indicate that she is anemic with microcytic and hypochromic RBC. We can also see that her Ferritin and Iron are low meaning her Iron storages are depleted (British Columbia Guidelines, 2015).
Depression - Ms. T’s symptoms of extreme fatigue, weakness can raise a question about her mental status, while we can not exclude this diagnoses, by looking at her lab results those symptoms initially can be result of her anemia.
Hypothyroidism – also can present with fatigue and weakness, however in this case I would expect Ms. T’s to be bradycardic with macrocytic RBC (Ross,2017) .
GI bleed – due to her long-term NSAIDS use, I would be suspicious of Iron deficiency anemia second to GI bleed, to investigate we can order “Hemoccult stool test”.
Cancer or chronic disease anemia – usually presents with normochromic and normocytic anemia (Schrier & Camaschella, 2017)
Chronic Leukemia – some of the sympoms of Leukemia can be fatigue and weakness due to low RBC and anemia, however in this case Ms. T’s WBC count is normal (Van Etten, 2017)
Beta Thalassemia minor– is a genetic condition that affects people with Mediterranean origin (Italian, Greek), microcytic and hypochromic RBC are typical to people with this condition, however they don’t have clinical picture of anemia and their Ferritin is normal, RBW test will be beneficial for diagnosis (Benz,2017).
Often Iron deficiency can exist without any symptoms until anemia develops, however patient can complain on other non-specific symptoms, for example, hair loss, fatigue and cold intolerance (BCGuidlines, 2016).
Only 10% of Iron is absorbed from food. The uptake mechanism of Iron in the body regulated by hepatic peptide hepcidin. High level of hepcidin signals the body to decrease Iron absorption from the gut, inflammation can stimulate production of hepcidin and interfere with normal Iron cycle (McCane & Huether, 2014).
due to effects of Iron on the stomach
Foods containing Iron include: Non heme iron – Oatmeal, lentils, edamame, spinach. Heme Iron - red meat, liver. See the reference source for complete list. (Dietitians of Canada, 2016)
Iron is best absorbed on empty stomach, however it is poorly tolerated this way, one of the strategies to help with adherence to treatment is to give daily dose in small portions and advise the patient to take it with meals. Best taken with citric fruits or orange juice, and dark green veg. Patient should not take Iron in combination with multi-vitamins. (BCGuidlines, 2015)
Cont. next slide
Liquid preparations can cause teeth staining, advise patient to use straw.
For example “ Antacids, anything containing aluminum, magnesium, calcium, zinc, proton pump receptor antagonist” (BcGuidelines, 2015, appendix B).
Iron should be given two hour before or after with meds like “bisphosphonates, tetracycline abx, quinolone abx, levodopa, methyldopa, levothyroxine and penicillamine.” (BCGuidelines, 2015, appendix B).
Every subsequent pregnancy increases the risk of IDA.
