Anaemia management in semi urban set up in India: Just check Hb if low look for rise in Hb after 2 weeks of alternate day oral Iron before investigating further

Anaemia management in semi urban set up in India: Just check Hb if low look for rise in Hb after 2 weeks of alternate day oral Iron  before investigating further

Dr KK Aggarwal and Dr Maj Prachi Garg

As per the National Family Health Survey (NFHS) - IV (20015-16) India’s, 54.2 percent women (15-49 years) and 59.5 percent children (6-59 months) in rural area of the country are anaemic.

The most common cause of anaemia is iron deficiency, caused by inadequate dietary iron intake or absorption, increased needs for iron during pregnancy or growth periods, and increased iron losses as a result of menstruation and helminth (intestinal worms) infestation.

On this Sunday we checked Hb of 100 women in a camp organised at Mera Clinic Kotla Mubarakpur in Delhi and found over 90% had Hb of less than 12.

We gave albendazole to also and started them on oral iron.

We all know that regardless of the presence of symptoms, all patients with iron deficiency anemia and most patients with iron deficiency without anemia should be treated.

It is also true that the cause of iron deficiency also must be identified and addressed, especially in adults with new onset iron deficiency. In a camp set up, most people come for free treatment, sending them for investigations may not be feasible. So, the best strategy is to start with oral iron and get Hb repeated after two weeks, and if there is no rise of Hb, investigate them for other causes of anaemia.

We only treat patients with severe, severely symptomatic (with symptoms of myocardial ischemia), or life-threatening anemia with red blood cell (RBC) transfusion.

In a rural or semi urban set up, in non-pregnancy state, we do not offer IV iron unless the patient has inflammatory bowel disease, gastric surgery, or chronic kidney disease.

We in a rural set up treat patients who have uncomplicated iron deficiency anemia with oral iron due to the ease of administration.

For the most part, all oral iron preparations are equally effective.

For individuals treated with oral iron, we prefer the dose be taken every other day rather than every day.

his is based on evidence in individuals with iron deficiency that demonstrates improved absorption and reduced gastrointestinal side effects. Some individuals may reasonably choose every-day dosing if they find that it improves tolerability or ease of use.

Effective treatment of iron deficiency results in resolution of symptoms, a modest reticulocytosis (peaking in 7 to 10 days), and normalization of the hemoglobin level in six to eight weeks.

Typical response

An effective regimen for the treatment of uncomplicated iron deficiency with oral iron preparations should lead to the following responses:

If pica for ice is present, it disappears almost as soon as oral iron therapy is begun, well before there are any observable hematologic changes.

The patient will note an improved feeling of well-being within the first few days of treatment.

The Hb concentration will rise slowly, usually beginning after approximately one to two weeks of treatment and will rise approximately 2 g/dL over the ensuing three weeks. The hemoglobin deficit should be halved by approximately one month, and the hemoglobin level should return to normal by six to eight weeks.

Typically, papillation of the tongue is decreased in patients with iron deficiency and can be used as a gauge of duration of symptoms. Classically, loss of papillae begins at the tip and lateral borders and moves posteriorly and centrally. Following iron repletion, a rapid correction (weeks to months) is observed.

For patients receiving oral iron, we often re-evaluate the patient two weeks after starting. We check the haemoglobin.

Our regimen

The recommended daily dose for the treatment of iron deficiency in adults is 150 to 200 mg of elemental iron daily. A 325 mg ferrous sulphate tablet contains 65 mg of elemental iron per tablet; three tablets per day will provide 195 mg of elemental iron, of which approximately 25 mg is absorbed and used in production of heme and other molecules.

We prefer alternate-day dosing (taking the iron every other day rather than every day) for better iron absorption than daily dosing.

We advise our patients to take their dose every other day. We follow Monday, Wednesday, and Friday approach.

We give 1 to 3 tablets [65 to 200 mg]) based on patient preference and tolerance.

Rule out other causes of before initiating ESAs in cancer patients

The American Society of Clinical Oncology (ASCO) and the American Society of Hematology (ASH) have updated their clinical guideline for the use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. The guideline also advises blood transfusion as a treatment option in these patients.

Some key recommendations are:

·         ESAs may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and hemoglobin (Hb) is < 10 g/dL.

·         Do not offer ESAs for chemotherapy-associated anemia to patient in whom cancer treatment is curative in intent.

·         ESAs should not be considered for nonchemotherapy-associated anemia except for selected patients with myelodysplastic syndromes (those with lower risk myelodysplastic syndromes and a serum erythropoietin level ≤ 500 IU/L).

·         Before considering an ESA, observe the hematologic response to cancer treatment in patients with myeloma, non-Hodgkin lymphoma, or chronic lymphocytic leukemia.

·         First rule out other causes of anemia or an underlying hematopoietic malignancy. 

·         Epoetin beta and alfa, darbepoetin and biosimilar epoetin alfa are comparable in effectiveness and safety.

·         During ESA treatment, Hb may be increased to the lowest level required to avoid transfusions.

·         Discontinue ESAs if no response is evident within 6 to 8 weeks and re-evaluate the patient.

·         Iron replacement may be used to improve Hb response and reduce RBC transfusions for patients receiving ESA with or without iron deficiency.

(Source: Journal of Clinical Oncology. Published online April 10, 2019)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

A1c is an unreliable diagnostic test for diabetes

Using the hemoglobin A1c to diagnose diabetes tends to underestimate the prevalence of the disease, suggests a study presented at ENDO 2019, the Endocrine Society’s annual meeting in New Orleans, Louisiana.

In the study, 9,000 adults without a diabetes diagnosis were randomized to an A1c test and an oral glucose tolerance test (OGTT). Comparison of the results showed that using A1c as a diagnostic test missed about 73% cases of diabetes that were detected by OGTT. Race and ethnicity were found to have a significant impact on the accuracy of the test. A1c was more likely to detect abnormal glucose levels in non-Hispanic whites than in non-Hispanic blacks or Hispanics.

As per the authors of the study, A1c, when used solely to define diabetes is a highly unreliable test and significantly underestimates the prevalence of diabetes. A1c should be used along with OGTT for improved accuracy of detection.

The American Diabetes Association recommends measuring HbA1c to diagnose prediabetes and diabetes due to its “greater convenience (fasting not required), greater preanalytical stability and less day-to-day perturbations during stress and illness.” HbA1c value of ≥6.5% has been established as the diagnostic figure associated with diabetes.

However, A1c has lower sensitivity to diagnose diabetes. A1c can give false results in some people.

·         People of African, Mediterranean, or Southeast Asian descent, or people with family members with sickle cell anemia or a thalassemia are particularly at risk of interference. People in these groups may have a less common type of hemoglobin, known as a hemoglobin variant that can interfere with some A1c tests.

·         A falsely low A1c result may be seen in people with anemia, heavy bleeding.

·         A falsely high A1c result is seen in individuals who are very low in iron, e.g., those with iron deficiency anemia.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

#AskDrKK: Can patients with low Hb fly?

#DrKKAnswers:
1. Patients with hemoglobin below 8.5 g/dL generally should be given supplemental oxygen, unless the anemia is known to be well compensated.
2. Anemic patients are at risk for lightheadedness and loss of consciousness during flight, even with minimal exertion, eg, walking to the lavatory.
3. The relative hypoxia in the cabin poses a particular risk to patients with sickle cell anemia. Such patients should use supplemental oxygen and be kept well hydrated.
4. Those with sickle cell trait are not considered at risk for flights at normal altitudes under usual conditions.

Emedinews: Dr K K Answers- What should be ideal Hb of a patient with CKD

Hemoglobin levels above 11 g/dL in patients with chronic kidney disease and dialysis patients have been associated with death, cardiovascular risk, and stroke.

The US FDA recommends that patients with chronic kidney diseae receive Erythropoietin-stimulating agent therapy only when Hb is below 10 g/dL and patients on dialysis should maintain their hemoglobin in the 10-11 g/dL range.

Dr KK Answers: Why my child eats ice?

Pagophagia, or pica for ice is specific for the iron deficiency state. It may be present in patients who are not anemic and responds rapidly to treatment with iron, often before any increase is noted in the hemoglobin concentration. Pica means perverted appetite for non food substances such as clay or dirt (geophagia), paper products, or starch (amylophagia). 

Dr KK Answers: How to handle iron tablet induced gastric symptoms?

Abdominal discomfort, nausea/vomiting, diarrhea/constipation suffered by patients on oral iron is directly related to the amount of elemental iron ingested.

1.    One should switch such patients on low elemental iron content tablets.

2.    One tablet of iron bis-glycinate contains 27 mg of elemental iron

3.    One  325 mg tablet of ferrous gluconate contains 36 mg of elemental iron.

4.    ferrous sulfate elixir provides 44 mg of elemental iron per 5 mL.

Dr KK Answers: Which iron salt should one choose in anemia?

Iron is best absorbed as the ferrous (Fe2+) salt in a mildly acidic medium. It is better to add 250 mg vitamin C at the time of iron administration to enhance the degree of iron absorption. The cheapest salt is iron sulfate (325 mg of iron salt with 65 mg is elemental iron)

Dr KK Answers: Can I take iron tablet while on antibiotics?

Certain antibiotics (eg, quinolones, tetracycline) can inhibit the absorption of iron.

Dr KK Answers: Can I take iron tablet with antacid?

Antacids can inhibit the absorption of iron salts. Iron should be given two hours before, or four hours after, ingestion of antacids.

Dr KK Answers: Should I take iron on an empty stomach?

Iron salts should not be given with food because phosphates, phytates, and tannates in food bind the iron and impair its absorption. A number of factors can inhibit the absorption of iron salts including cereals, dietary fiber, tea, coffee, eggs, or milk.

Dr KK Answers: Should I take enteric or sustained release tablets of iron?

Iron is not absorbed in the stomach and is absorbed best from the small intestine (duodenum and proximal jejunum). Enteric coated or sustained release capsules, which release iron further down in the intestinal tract, are much less efficient sources of iron. 

Dr KK Answers: Why my child eats ice?

 Pagophagia, or pica for ice is specific for the iron deficiency state. It may be present in patients who are not anemic and responds rapidly to treatment with iron, often before any increase is noted in the hemoglobin concentration. Pica means perverted appetite for non food substances such as clay or dirt (geophagia), paper products, or starch (amylophagia). 

Dr KK Answers: What is oral iron challenge test?

In sprue, atrophic gastritis, H pylori infection, gastrectomy and gastric bypass procedures iron is not absorbed from diet or the pills.

An oral iron tolerance test is done for detecting such patients.

1.    Measure fasting serum iron level

2.    Measure a second serum iron level one to four hours following oral ingestion of one 325 mg tablet of iron sulfate (iron content 65 mg) along with water.

3.     An increase in serum iron of at least 100 microg/dL indicates that oral iron absorption is adequate. 

Dr KK Answers: What is therapeutic iron therapy trial?

A presumptive diagnosis of iron deficiency anemia is made if there is a positive response to a trial of oral iron therapy. A positive response means is a modest reticulocytosis beginning in five to seven days, followed by an increase in hemoglobin of about 2 to 4 g/dL every three weeks.

Dr KK Answers: Can my restless leg be due to iron deficiency?

Iron deficiency is one of the causes of restless legs syndrome which presents as marked discomfort in the legs that occurs only at rest and is immediately relieved by movement.

One should measure serum ferritin levels and if low give a trial of oral iron therapy. Oral iron may still be effective in some with normal ferritin levels. 

Dr KK Answers: Why I get red urine after consuming beets?

It can happen if you have iron deficiency anemia. The condition is called Beeturia. This is due to increased intestinal absorption and subsequent excretion of the reddish pigment betalaine (betanin) present in beets. Betalaine is a redox indicator. It is decolorized by ferric ions. When adequate amounts of iron are not available for decolorization of this pigment, beeturia will occur.

Source: Am J Dis Child 1969; 117:424

Dr KK Answers: Can Hb rise in athletics?

Dilutional anemia can occur secondary to an increased plasma volume, gastrointestinal bleeding, intravascular hemolysis (march hemoglobinuria), iron deficiency, polycythemia. All can occur as a consequence of strenuous sports, or the use of performance-enhancing agents, such as androgens and erythropoietin. 

Dr KK Answers: Can smokers have high Hb levels?

Patients who smoke or have significant exposure to secondary smoke or other sources of carbon monoxide may have hematocrits higher than normal  occasionally reaching polycythemic levels.

Dr KK Answers: Can a person be anemic with normal Hb levels?

Patients admitted to the hospital in a volume depleted state may not show abnormally low HGB/HCT values on initial testing. An underlying anemia may become apparent only after the volume depletion has been corrected.