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.

Investigate your patients for iron deficiency

Many patients present to us with complaints of exertional dyspnea or tachycardia. Such patients may undergo extensive cardiovascular assessment, indicating an underlying sinister pathology for their symptoms. While this evaluation is justified, sometimes the underlying cause may not be so dangerous.

Iron deficiency, even before a full-fledged anemia develops may be the cause of such symptoms, which have been shown to improve on iron supplementation.

Iron deficiency (depleted iron stores in the body) and anemia are often perceived as interchangeable terms. While iron deficiency is the most common cause of anemia, but the two are different.

Deficiency of iron without anemia is much more prevalent than is detected. A person may have iron deficiency even if the hemoglobin is normal. The majority are unaware of their iron deficient state

Iron has a crucial role in oxidative metabolism within the mitochondria and production of hemoglobin and myoglobin (BMJ Open. 2018 Apr 5;8(4):e019240). Anemia due to iron deficiency impairs oxygen-carrying and tissue oxidative capacity, resulting in a diminished peak oxygen consumption (pVo2) and ability to endure submaximal exertion. Even in the absence of anemia, iron deficiency can attenuate exercise performance (J Am Coll Cardiol. 2008;51(2):103-12).

The FERRIC-HF trial, published in the Journal of the American College of Cardiology in 2008, which examined the effect of intravenous iron sucrose on exercise tolerance in anemic and nonanemic patients with symptomatic chronic heart failure and iron deficiency showed that IV iron supplementation improved exercise capacity and symptoms in patients with CHF and evidence of abnormal iron metabolism. Benefits were more evident in anemic patients.

If the patient has exertional breathlessness or symptoms such as fatigue, palpitations, headache or has a history of frequent absenteeism, also look for iron deficiency as a cause. Iron study, which measures serum iron, ferritin, transferrin, transferrin saturation, total iron-binding capacity should be done. Low serum ferritin is indicative of iron deficiency. Ferritin levels can be elevated by inflammatory processes and can mask iron deficiency (BMJ. 2017;357:j3175).

Iron supplementation, if iron deficiency found, improves functional capacity in these iron-deficient individuals even before anemia is corrected.

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Dr KK Answers: Should we screen for B12 levels?

The American Academy of Neurology recommends screening for B12 deficiency and hypothyroidism in patients with dementia.

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.