INFLAMMATORY BOWEL DISEASE: ANAEMIA
Managing Iron Deficiency Anaemia (IDA) in Inflammatory bowel disease (IBD)
A third of patients with active IBD
may have a haemoglobin of less than 12g/dl
due to the triad of malabsorption, blood loss and inflammation.
IDA can delay recovery from flare-ups
and contribute to the general fatigue
Other consequences may include:
pallor, delayed healing, hair loss, tongue soreness or pica.
Ferritin is an acute-phase protein
so levels of under 100 µg/l may reflect iron-deficiency in the presence of inflammation.
Consider other causes of iron-deficiency in patients with IBD:
colorectal carcinoma,
menorrhagia,
dietary deficiencies
or malabsorption,
be mindful of associated conditions such as coeliac disease.
Dietary Iron
Patients are normally advised to increase the intake of
green leafy vegetables, fruit, and iron-enriched cereals and bread,
but patients with IBD may restrict their intake of such foods
to avoid triggering diarrhoea, bloating or abdominal pain.
Oral iron supplements
ferrous (divalent Fe2+ salts)
or ferric (trivalent Fe3+ salts)
coupled with sugar complexes.
Ferrous sulphate 200 mg
or ferrous gluconate 210 mg twice a day
are the usual initial recommendations.
Ferrous fumerate 210mg twice a day may also be used.
Iron Absorption
Vitamin C increases absorption of oral iron,
but
Iron absorption is reduced by
a high intake of phytate (found in wholegrain cereals),
polyphenols (tea and coffee),
calcium,
or medication that raises the gastric pH (antacids and proton pump inhibitors).
HB monitoring
The Hb concentration should rise by about 2g/100 mL (20 g/litre) over 3–4 weeks.
The Hb concentration should be checked after 2-4 weeks of treatment
and then monthly until the Hb is normal
and the underlying cause has been treated effectively.
Treatment should be continued for a further 3 months to replenish the iron stores
and the Hb levels rechecked should symptoms recur.
Dose-related adverse effects
from taking an iron supplement are common
and include
constipation,
diarrhoea,
epigastric pain,
nausea.
Many of these symptoms already occur for patients with IBD,
and any treatment that may exacerbate these is often not readily tolerated.
Stool discolouration can be concerning for patients
who may have suffered melaena from ileal or proximal colonic bleeding.
Iron preparations can be taken after food to reduce gastro-intestinal side-effects.
Constipation should be treated with laxatives before considering alternatives to oral ferrous iron.
If an iron supplement is still not tolerated,
then
either reduce the dose or try an alternative preparation ferrous iron preparation.
If these are not tolerated,
then oral ferric iron (ferric maltol) may be considered
(depending upon local prescribing policies)
before considering the use of parenteral (intravenous) iron.
Parenteral iron administration
traditionally has been reserved for patients with intolerance or inadequate response to oral iron, and for patients in whom a rapid increase in iron stores is desired e.g. before major surgery.
However, the injections are not suitable for primary care settings,
can be painful, are expensive,
and carry the risk of anaphylactic reactions.
A third of patients with active IBD
may have a haemoglobin of less than 12g/dl
due to the triad of malabsorption, blood loss and inflammation.
IDA can delay recovery from flare-ups
and contribute to the general fatigue
Other consequences may include:
pallor, delayed healing, hair loss, tongue soreness or pica.
Ferritin is an acute-phase protein
so levels of under 100 µg/l may reflect iron-deficiency in the presence of inflammation.
Consider other causes of iron-deficiency in patients with IBD:
colorectal carcinoma,
menorrhagia,
dietary deficiencies
or malabsorption,
be mindful of associated conditions such as coeliac disease.
Dietary Iron
Patients are normally advised to increase the intake of
green leafy vegetables, fruit, and iron-enriched cereals and bread,
but patients with IBD may restrict their intake of such foods
to avoid triggering diarrhoea, bloating or abdominal pain.
Oral iron supplements
ferrous (divalent Fe2+ salts)
or ferric (trivalent Fe3+ salts)
coupled with sugar complexes.
Ferrous sulphate 200 mg
or ferrous gluconate 210 mg twice a day
are the usual initial recommendations.
Ferrous fumerate 210mg twice a day may also be used.
Iron Absorption
Vitamin C increases absorption of oral iron,
but
Iron absorption is reduced by
a high intake of phytate (found in wholegrain cereals),
polyphenols (tea and coffee),
calcium,
or medication that raises the gastric pH (antacids and proton pump inhibitors).
HB monitoring
The Hb concentration should rise by about 2g/100 mL (20 g/litre) over 3–4 weeks.
The Hb concentration should be checked after 2-4 weeks of treatment
and then monthly until the Hb is normal
and the underlying cause has been treated effectively.
Treatment should be continued for a further 3 months to replenish the iron stores
and the Hb levels rechecked should symptoms recur.
Dose-related adverse effects
from taking an iron supplement are common
and include
constipation,
diarrhoea,
epigastric pain,
nausea.
Many of these symptoms already occur for patients with IBD,
and any treatment that may exacerbate these is often not readily tolerated.
Stool discolouration can be concerning for patients
who may have suffered melaena from ileal or proximal colonic bleeding.
Iron preparations can be taken after food to reduce gastro-intestinal side-effects.
Constipation should be treated with laxatives before considering alternatives to oral ferrous iron.
If an iron supplement is still not tolerated,
then
either reduce the dose or try an alternative preparation ferrous iron preparation.
If these are not tolerated,
then oral ferric iron (ferric maltol) may be considered
(depending upon local prescribing policies)
before considering the use of parenteral (intravenous) iron.
Parenteral iron administration
traditionally has been reserved for patients with intolerance or inadequate response to oral iron, and for patients in whom a rapid increase in iron stores is desired e.g. before major surgery.
However, the injections are not suitable for primary care settings,
can be painful, are expensive,
and carry the risk of anaphylactic reactions.