Today we’re going to talk about Iron deficiency anemia, specifically going over some treatment pearls with you. I had a patient who came in with the hemoglobin of 5.6 and I thought this would be a good learning case to share with you guys.
So, very quickly let’s talk about my patient, then we’ll go over the treatment pearls when dealing with other patients with anemia, iron deficiency anemia specifically.
So, my patient came in with a chief complaint of vaginal bleeding, fatigue, palpitations, dyspnea on exertion, and weakness. She’s been feeling like this for several months. She came in over the past week because it started to worsen. She was placed on birth control six months prior, started having some spotting, and slowly started to have worsened vaginal bleeding daily.
She is now to the point where she is changing her pads 10 times a day. 10 times a day for vaginal bleeding is a lot of bleeding. She’s losing a lot of blood. She is not on any type of vitamins; she is not taking any type of iron. So for that reason, 5.6, heavy vaginal bleeding, I recommended that she go to the ER for transfusion. She refused.
She does not have insurance, she could not afford to go to the ER, so she opted out of that recommendation. So, the only other choice was to treat her in house. I started her on estrogen, high dose estrogen works very well for dysfunctional uterine bleeding, however keep in mind, I didn’t know the cause of the bleeding at that point, and she was not going to be referred out for ultra sound.
You kind of have to tailor your treatment plans to the patient, right? So, started her on high dose estrogen, started her on oral iron therapy three times a day, combined it with vitamin C, we’ll go over why in a little bit, and I told her to come back two days later. She came back after two days and said the vaginal bleeding has resolved. She actually started to feel a little bit better with the iron.
I told her to come back the following day, which was yesterday. I saw her and she said that her vaginal bleeding worsened and she was kind of spiraling downhill. Her symptoms came back, and came back worse.
You look at this patient, she’s pale, she was actually jaundice at this point, she just looked ill. Right? You have that feeling when patients just don’t look good. So I told her “you know what? I don’t care, you have to go to the ER at this point, you need a transfusion.” So, she agreed and went to the ER.
So hopefully everything turns out alright. We did do an ultrasound yesterday as well, and there was a lot of uterine pathology, more than likely she’s going to need a hysterectomy. High dose estrogen is probably not going to cut it at this point and they probably are going to have to take out the entire uterus to deal with the vaginal bleeding.
So, let’s go over some treatment pearls with oral iron therapy first. This is definitely first line treatment. Ferrous sulfate is by far the most commonly prescribed iron therapy. It takes about six weeks for hemoglobin to go back to normal. After about two weeks of iron therapy, you’re going to start to have some kind of improvement.
So, the patients are actually going to start to feel a little bit better after two weeks. It takes six months to actually replenish these iron stores as well. Treat patients for six months. Yes, their hemoglobin might return back to baseline after six weeks, but there iron stores, total iron stores, are probably still depleted.
So, treat these patients for six months. This is going to be reflected in ferritin, also remember ferritin is an acute phase reactant, right? Meaning it can be falsely elevated due to other things like stress and infection. For the most part, when speaking about iron deficiency, ferritin is going to be one of your most specific indicators of iron deficiency and it’s going to represent your total body stores.
Alright guys, so some rules. Whenever you give iron, this is going to be absorbed in the proximal jejunum and the duodenum. So, for that reason avoid enteric coated or sustained released tablets. Why? By the time these medications are released, you’ve passed that point of absorption or you’re actually now secreting it, in whole, into the stool because it just takes so long for it to be released.
Always give patients iron on an empty stomach; this is going to increase absorption. Be aware that it might increase GI side effects as well. Avoid giving antacids, calcium or antibiotics; this is especially true with H2 blockers. You need to separate these medications by two to four hours.
Now, vitamin C, iron is best absorbed in an acidic medium. Giving vitamin C, which is ascorbic acid, will increase iron absorption. You can also give patients orange juice and this again will also increase absorption.
The max daily dosing that you can do with iron is going to be 200mg of elemental iron. Each tablet of Ferris sulfate 325mgs contains 65mgs of elemental iron. For that reason, three times a day is max dosing. Three times a day will give you 195mgs of elemental iron. You don’t need to remember this math, the main takeaway, the max dosing is three times a day, any more than that, you’re not absorbing anything; it’s going straight to your stool.
When do we transfuse these patients? So a general rule of thumb is: anybody with a hemoglobin under 6 , even if they’re stable, they should be transfused. Anybody with a hemoglobin over 10 should never be transfused. Now, anywhere from 6-10 depends on their comorbidities.
Do they have heart failure? Are they currently infracting? How quickly did they get to this level is very important, because if their body has reached this level in six months, like my patient, she’s had time to compensate, right? She’s had time to adjust to this low oxygen state. So, she’s able to handle it much better than a patient who was at hemoglobin of 13 and dropped down to 9 in one day. They probably need to be transfused, even though they have hemoglobin of nine, right?
So, how do patients die from severe anemia? Myocardial infarction. If oxygen isn’t circulating to the heart, this leads to ischemia and eventually leads to myocardial infarction. So, for that reason, you’re going to transfuse patients under six even if they’re stable.
Remember, treat the patient not the numbers! The hemoglobin isn’t as important as how quickly they got there, what their symptoms are, and how they look. Always treat the patient.