Mistakes in the management of iron deficiency anaemia: a narrative review

Figures & data

Table 1. Haemoglobin cut-off values to diagnose anaemia [1].

Group	Haemoglobin g/L
Men (Age > 15)	130
Non-pregnant women	120
Pregnant women	110

Table 2. Haemoglobin cut-off values according to severity of anaemia [1].

Group	Haemoglobin g/l in non-anaemia	Haemoglobin g/l in mild anaemia	Haemoglobin g/l in moderate anaemia	Haemoglobin g/l in severe anaemia
Men (Age > 15)	≥130	110–129	80–109	<80
Non-Pregnant women	≥120	110–119	80–109	<80
Pregnant women	≥110	100–109	70–99	<70

Table 3. Non-gastrointestinal and gastrointestinal causes of iron deficiency anaemia.

Non-gastrointestinal causes	Gastrointestinal causes
Menstruation	Aspirin/ NSAID use
Blood donation	Malignancy:Oesophageal/gastric/small bowel/ampullary/ colonic
Haematuria	Helminthic infections
Epistaxis	Benign gastric ulceration
	Esophagitis
	Angiodysplasia
	Gastric antral vascular ectasia

Table 4. Comparison of guidelines and limited resource setting practice.

Category	British Society of Gastroenterology (BSG) [10]	American Gastroenterological Association (AGA) [11]
Diagnosis	Serum ferritin:	Serum ferritin:
	<15 ng/mL = IDA  <45 ng/mL = GI tests If false positive = Transferrin saturation	<45 ng/mL = iron deficiency
Clinical assessment	Urinalysis or urine microscopy Coeliac serology if appropriate Bidirectional endoscopy in men and postmenopausal women with newly diagnosed IDA. Reserves colonoscopy (LGIE) in addition to UGIE in premenopausal women for patients with risk factors for colon malignancy	Bidirectional endoscopy all asymptomatic men and postmenopausal women Bidirectional endoscopy over IRT in asymptomatic pre-menopausal women IDA Helicobacter pylori & celiac tests in patients with IDA without other identifiable aetiology (no routine gastric biopsies)
Special assessment	CT colonography if not suitable for colonoscopy	–
Negative endoscopy	Try IRT	Try IRT
	If recurrent IDA / no response to IRT = capsule endoscopy	If failure with a trial of IRT = capsule endoscopy
	Alternatives: CT/MR enterography	Also, non-invasive testing for Helicobacter pylori and treat
Management	Don’t defer IRT pending testing	Don’t defer IRT pending testing
Treatment	Start: 1 iron tablet/day	Start: 150–200 mg iron/day
	Adjust if not tolerated to 1 iron tablet/ every other day or IV iron	If no response – assess non-adherence, malabsorption or ongoing blood loss exceeding iron intake
	If symptomatic IDA: Consider limited blood transfusion
		Consider IV iron if needed (impaired absorption due to prior gastric surgery, with inflammatory bowel disease or chronic kidney disease, or in whom blood loss exceeds the ability to replete iron orally)
Monitoring	First 4 weeks for a Hb response to oral IRT	First 4 weeks for a Hb response to oral IRT
	Continue treatment 3 months post – Hb normalisation
Follow up	Monitor blood count every 6 months to detect recurrent IDA	–

IDA – iron deficiency anaemia; IRT – iron replacement therapy; UGIE – upper gastrointestinal endoscopy; LGIE – lower gastrointestinal endoscopy.

World Health Organisation. Haemoglobin concentration for the diagnosis of anaemia and assessment of severity. World Health Organisation. 2022. [online] Available from: https://www.who.int/vmnis/indicators/haemoglobin.pdf  [accessed 16 March 2022].

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