What are the guideline sources, guidelines and references for Iron deficiency anemia ?
Guideline sources The following summarized guidelines for the evaluation and management of iron deficiency anemia (IDA) are prepared by our editorial team based on guidelines from the European Society of Gastrointestinal Endoscopy (ESGE 2023), the American College of Obstetricians and Gynecologists (ACOG 2021), the British Society of Gastroenterology (BSG 2021; 2011), the American Gastroenterological Association (AGA 2020), the U.S. Preventive Services Task Force (USPSTF 2015), the European Crohn's and Colitis Organisation (ECCO 2015), the Royal College of Obstetricians and Gynaecologists (RCOG 2015), and the American Association of Family Physicians (AAFP 2013). 1 2 3 4 5 6 7 8 9 10 11 11 11 12 13 14 15 Definition IDA is a form of anemia that results from inadequate iron supply for erythropoiesis, and is defined as a Hgb two standard deviations below normal with evidence of low body iron stores. 11 Epidemiology https://web.pathway.md/diseases/rec4rfHrceqkwzFWP 1/8 6/24/23, 2:34 PM Iron deficiency anemia Pathway IDA can be caused by increased iron demand (pregnancy, infancy), insufficient iron intake, decreased iron absorption (IBD, gastrectomy), chronic blood loss (menorrhagia, systemic bleeding, hookworm infection), drugs (NSAIDs, glucocorticoids), genetics (iron-refractory IDA), and iron- restricted erythropoiesis (CKD). 11 Pathophysiology In the United States, the prevalence of iron deficiency ranges from 4.5-18.0%., while the prevalence of IDA is estimated at 2.9%. 12 Disease course IDA typically presents with hypochromic, microcytic erythrocytes. Clinical manifestations are related to the severity of the anemia, and may additionally include restless leg syndrome, decreased quality of life, and increased maternal and newborn mortality. 11 Prognosis and risk of recurrence Iron deficiency is an independent predictor of cardiovascular events in patients with coronary artery disease. Iron deficiency is a risk factor for all-cause mortality in patients with CKD. IDA is also associated with morbidity and mortality in pregnant women. 13 14 15 Guidelines 1. Screening and diagnosis Etiology: recognize that IDA is common following resection or bypass surgery involving the stomach and/or small bowel, including bariatric surgery. A Show 4 more Indications for screening (children): insufficient evidence to assess the balance of benefits and harms of screening for IDA in children ages 6 to 24 months. I Indications for screening, pregnancy: As per RCOG 2015 guidelines, obtain screening for anemia in pregnant patients at 28 weeks of gestation. Obtain an additional CBC at 20-24 weeks in patients with multiple pregnancies. B As per USPSTF 2015 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for IDA in pregnant females to prevent adverse maternal health and birth outcomes. I As per AAFP 2013 guidelines, obtain screening for IDA in all pregnant females. B Diagnostic criteria: As per BSG 2021 guidelines: Define anemia as a Hgb concentration below the LLN for the relevant population and laboratory performing the test. B https://web.pathway.md/diseases/rec4rfHrceqkwzFWP 2/8 6/24/23, 2:34 PM Iron deficiency anemia Pathway Recognize that a good response to iron therapy (Hgb rise 10 g/L within a 2-week timeframe) in anemic patients is highly suggestive of absolute iron deficiency, even if the results of iron studies are equivocal. B As per AGA 2020 guidelines, use a cutoff of 45 ng/mL when using ferritin to diagnose iron deficiency in patients with anemia. A 2. Classification and risk stratification Cancer risk assessment: use age, sex, Hgb concentration and mean cell volume as independent predictors of risk of gastrointestinal cancer in patients with IDA, as part of a holistic risk assessment. A 3. Diagnostic investigations General principles: evaluate all levels of anemia in the presence of iron deficiency. B History and physical examination: Elicit a detailed history, as it may provide important clues as to the causes of IDA in individual cases. B Consider postponing DRE until after colonoscopy in the absence of rectal symptoms (such as rectorrhagia and tenesmus), as it is rarely contributory. Complete blood count: obtain red cell indices as they provide a sensitive indication of iron deficiency in the absence of chronic disease or Hgbopathy. A Hemoglobin electrophoresis: obtain Hgb electrophoresis to avoid unnecessary gastrointestinal investigations in patients of appropriate ethnic background with microcytosis and hypochromia. B Iron studies: As per BSG 2021 guidelines, obtain iron studies to confirm iron deficiency before proceeding to other investigations. B Show 2 more As per AAFP 2013 guidelines, measure serum ferritin as the best initial test to diagnose iron deficiency. B Urinalysis and microscopy: obtain urinalysis or urine microscopy in the initial evaluation of patients with confirmed IDA. B Fecal immunochemical testing: insufficient evidence to support the use of FITing for risk stratification of patients with IDA. I Screening for celiac disease: As per BSG 2021 guidelines: Obtain screening for celiac disease in the initial evaluation of patients with confirmed IDA. B https://web.pathway.md/diseases/rec4rfHrceqkwzFWP 3/8 6/24/23, 2:34 PM Iron deficiency anemia Pathway Obtain screening for celiac disease routinely with serologic testing, or on small bowel biopsy at the time of upper gastrointestinal endoscopy. A As per AGA 2020 guidelines, consider initial serologic testing, followed by small bowel biopsy only if positive, in asymptomatic adult patients with IDA and plausible celiac disease. C As per AAFP 2013 guidelines, consider testing for celiac disease in all patients with IDA. C Screening for Helicobacter pylori infection: consider obtaining noninvasive testing for H. pylori, followed by treatment if positive, in patients with IDA without other identifiable etiology after upper and lower gastrointestinal endoscopy. C Upper and lower gastrointestinal investigations: Perform upper and lower gastrointestinal endoscopy in the initial evaluation of appropriate patients with confirmed IDA. B Show 3 more Perform upper and lower gastrointestinal endoscopy in asymptomatic male and postmenopausal female patients with iron-deficiency anemia. B Consider upper and lower gastrointestinal endoscopy in asymptomatic premenopausal female patients with IDA. C Small bowel investigations: As per ESGE 2023 guidelines, obtain small bowel evaluation in patients with IDA only after eliciting a complete medical history and performing EGD with duodenal and gastric biopsies and ileocolonoscopy. B Perform small bowel capsule endoscopy as a first-line examination when small bowel evaluation is indicated. A Do not perform routine second-look endoscopy before small bowel capsule endoscopy. B As per BSG 2021 guidelines, obtain further investigation of the small bowel and renal tract to exclude other causes in patients with negative bidirectional endoscopy of acceptable quality and either an inadequate response to iron replacement therapy or recurrent IDA. B Show 4 more 4. Diagnostic procedures Gastric biopsy: do not perform a routine gastric biopsy to diagnose atrophic gastritis in patients with IDA. D Small bowel biopsy: perform small bowel biopsy at the time of upper gastrointestinal endoscopy for the screening of celiac disease in patients with IDA. A 5. Medical management Iron supplementation: As per BSG 2021 guidelines, do not defer iron replacement therapy while awaiting investigations for IDA unless colonoscopy is imminent. D https://web.pathway.md/diseases/rec4rfHrceqkwzFWP 4/8 6/24/23, 2:34 PM Iron deficiency anemia Pathway Show 2 more As per AGA 2020 guidelines, consider a trial of initial iron supplementation rather than performing video capsule endoscopy in uncomplicated asymptomatic patients with IDA and negative upper and lower gastrointestinal endoscopy. C Helicobacter pylori eradication: As per AGA 2020 guidelines, administer treatment for H. pylori, if positive, in patients with IDA. B As per BSG 2011 guidelines, initiate eradication therapy for H. pylori, if present, in patients with recurrent IDA and normal upper gastrointestinal endoscopy. B 6. Therapeutic procedures Red blood cell transfusion: Consider administering limited transfusion of packed red cells in patients with symptomatic IDA. Continue iron replacement therapy after transfusion. B Consider administering limited transfusion of packed red cells in patients with symptomatic IDA. Continue iron replacement therapy after transfusion. B 7. Specific circumstances Pregnant patients, screening: As per RCOG 2015 guidelines, obtain screening for anemia in pregnant patients at 28 weeks of gestation. Obtain an additional CBC at 20-24 weeks in patients with multiple pregnancies. B As per USPSTF 2015 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for IDA in pregnant females to prevent adverse maternal health and birth outcomes. I As per AAFP 2013 guidelines, obtain screening for IDA in all pregnant females. B Pregnant patients (diagnosis): diagnose anemia in pregnancy in the presence of Hgb < 110 g/L in the first trimester, < 105 g/L in the second and third trimesters, and < 100 g/L postpartum. B Pregnant patients, prevention: as per USPSTF 2015 guidelines, insufficient evidence to assess the balance of benefits and harms of routine iron supplementation during pregnancy for the prevention of adverse maternal health and birth outcomes. I Pregnant patients, iron supplementation: as per RCOG 2015 guidelines, consider initiating a trial of oral iron supplementation as first-line therapy in patients with normocytic or microcytic anemia. Obtain further testing if there is no demonstrable rise in Hgb at 2 weeks and compliance has been assured. C Show 3 more Young patients (female): recognize that IDA is common in young females, and major contributory factors include menstrual losses, pregnancy and poor dietary intake. A https://web.pathway.md/diseases/rec4rfHrceqkwzFWP 5/8 6/24/23, 2:34 PM Iron deficiency anemia Pathway Show 2 more Young patients (male): use the same investigational algorithm in young male patients with confirmed IDA as for older patients, recognizing that it is uncommon in young males. B Patients with inflammatory bowel disease (screening): Obtain screening for anemia in all patients with IBD. Recognize that the major forms of anemia in IBD are IDA, anemia of chronic disease, and anemia of mixed origin. B Obtain CBC, serum ferritin, and CRP for laboratory screening of anemia. Obtain measurements every 6-12 months in patients in remission or with mild disease, and at least every 3 months in outpatients with active disease. B Patients with inflammatory bowel disease (diagnosis): use the WHO definition of anemia for patients with IBD. B Show 4 more Patients with inflammatory bowel disease (evaluation): obtain anemia workup (including at least RBC indices such as red cell distribution width and MCV, reticulocyte count, differential blood cell count, serum ferritin, transferrin saturation, and CRP concentration) if the Hgb is below normal. Include the following in a more extensive workup: serum concentrations of vitamin B12, folic acid, haptoglobin, the percentage of hypochromic red cells, reticulocyte Hgb, LDH, soluble transferrin receptor, creatinine, and urea. B Show 2 more Patients with inflammatory bowel disease (iron supplementation): initiate iron supplementation in all patients with IBD and IDA. A Show 4 more Patients with inflammatory bowel disease (RBC transfusion): consider administering RBC transfusion in patients with anemia with Hgb levels < 7 g/dL, or > 7 g/dL if symptoms or particular risk factors are present, followed by subsequent IV iron supplementation. C Patients with inflammatory bowel disease (monitoring of recurrence): Monitor patients with IBD for recurrent iron deficiency every 3 months for at least a year after correction, and 6-12 months thereafter. B Consider suspecting persistent intestinal disease activity in cases of recurrent anemia, even if there is clinical remission and inflammatory parameters (such as CRP) are normal. C Patients with inflammatory bowel disease (management of recurrence): Recognize that IBD-associated iron deficiency and anemia recur frequently and fast, even after treatment with IV iron, while the recurrence of iron deficiency is lower in patients with higher post-treatment ferritin levels. B Initiate re-treatment with IV iron as soon as serum ferritin drops < 100 g/L or Hgb < 12-13 g/dL (according to gender) after successful treatment of IDA with IV iron. B Patients with comorbidities: Recognize that: functional iron deficiency is a common contributory factor to the anemia associated with advanced CKD https://web.pathway.md/diseases/rec4rfHrceqkwzFWP 6/8 6/24/23, 2:34 PM Iron deficiency anemia Pathway IDA is a common manifestation of IBD, particularly when the disease is active iron deficiency is common in chronic HF and is often multifactorial. A Show 4 more 8. Follow-up and surveillance Follow-up: Monitor patients in the first 4 weeks for Hgb response to oral iron and continue treatment for a period of around 3 months after normalization of Hgb level to ensure adequate repletion of the marrow iron stores. B Consider obtaining periodic blood count monitoring in non-anemic patients with iron deficiency. C Management of recurrent disease: recognize that Hgb levels normalize with iron replacement therapy in most patients with IDA, but it recurs in a minority of patients on long-term follow-up. B Show 2 more 9. Quality improvement Care pathways: all service providers should have clear points of referral and management pathways in patients with IDA. B Show 2 more References 1. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins Obstetrics. Anemia in Pregnancy: ACOG Practice Bulletin, Number 233. Obstet Gynecol. 2021 Aug 1;138 2):e55-e64. Open 2. Short MW, Domagalski JE. Iron deficiency anemia: evaluation and management. Am Fam Physician. 2013 Jan 15;87 2 98 104. Open 3. Goddard AF, James MW, McIntyre AS et al. Guidelines for the management of iron deficiency anaemia. Gut. 2011 Oct;60 10 1309 16. Open 4. Jonathon Snook, Neeraj Bhala, Ian L P Beales et al. British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults. Gut. 2021 Nov;70 11 2030 2051. Open 5. Cynthia W Ko, Shazia M Siddique, Amit Patel et al. AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia. Gastroenterology. 2020 Sep;159 3 1085 1094. Open 6. Siu AL, Bibbins-Domingo K, Grossman D et al. Screening for Iron Deficiency Anemia and Iron Supplementation in Pregnant Women to Improve Maternal Health and Birth Outcomes: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2015 Oct 6;163 7 529 36. Open https://web.pathway.md/diseases/rec4rfHrceqkwzFWP 7/8 6/24/23, 2:34 PM Iron deficiency anemia Pathway 7. Axel U Dignass, Christoph Gasche, Dominik Bettenworth et al. European consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases. J Crohns Colitis. 2015 Mar;9 3 211 22. Open 8. Royal College of Obstetricians and Gynaecologists. Blood Transfusion in Obstetrics. RCOG. 2015 May. Open 9. Albert L Siu, US Preventive Services Task Force. Screening for Iron Deficiency Anemia in Young Children: USPSTF Recommendation Statement. Pediatrics. 2015 Oct;136 4 746 52. Open 10. Marco Pennazio, Emanuele Rondonotti, Edward J Despott et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy ESGE Guideline Update 2022. Endoscopy. 2023 Jan;55 1 58 95. Open 11. Camaschella C. Iron-deficiency anemia. N Engl J Med. 2015 May 7;372 19 1832 43. Open 12. Lopez A, Cacoub P, Macdougall IC et al. Iron deficiency anaemia. Lancet. 2016 Feb 27;387 10021 907 16. Open 13. Zeller T, Waldeyer C, Ojeda F et al. Adverse Outcome Prediction of Iron Deficiency in Patients with Acute Coronary Syndrome. Biomolecules. 2018 Jul 20;8 3 . pii: E60. Open 14. Cho ME, Hansen JL, Peters CB et al. An increased mortality risk is associated with abnormal iron status in diabetic and non-diabetic Veterans with predialysis chronic kidney disease. Kidney Int. 2019 Sep;96 3 750 760. Open 15. Khaskheli MN, Baloch S, Sheeba A et al. Iron deficiency anaemia is still a major killer of pregnant women. Pak J Med Sci. 2016 May-Jun;32 3 630 4. Open 16. Thomas DW, Hinchliffe RF, Briggs C et al. Guideline for the laboratory diagnosis of functional iron deficiency. Br J Haematol. 2013 Jun;161 5 639 48. Open 17. Clara Camaschella. Iron deficiency: new insights into diagnosis and treatment. Hematology Am Soc Hematol Educ Program. 2015;2015 8 13. Open 18. Julie Parrott, Laura Frank, Rebecca Rabena et al. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients. Surg Obes Relat Dis. 2017 May;13 5 727 741. Open https://web.pathway.md/diseases/rec4rfHrceqkwzFWP 8/8