Establish cause of blood loss and prevent its recurrence or the lack of absorption/intake – please see:
In cases of confirmed iron deficiency anaemia, treat with once daily iron supplementation as this is effective and better tolerated. Continue until the haemoglobin normalises and then for an additional 3 months to replenish iron stores. Ferritin levels should be >50 before discontinuation of iron supplementation.
If the patient experiences side effects (often nausea or bowel disturbance), reduce the frequency to alternate day iron supplementation or change the oral iron preparation: please see the East Region Formulary for alternative iron formulations. GI side effects relate to dose.
Patients should be given information about iron rich foods and diet discussed.
Long term PPI use should be discussed as this can cause iron deficiency due to lack of absorption.
Tea and coffee should not be consumed along with iron supplements as it prevents absorption.
Women with heavy menstrual bleeding causing recurrent iron deficiency should be offered tranexamic acid 1g TDS PO on the heaviest days of flow or hormonal interventions unless contraindicated. Please see the RefHelp page on heavy menstrual bleeding for further detail on management.
There are now a plethora of low dose oral iron supplements available from supermarkets and pharmacies. Liquid water fortified with iron, oral sprays and liquid preparations can be helpful in people who experience GI symptoms as an alternative to IV iron. These may need to be taken for longer periods of time to fully replace iron stores, but oral iron can improve haemoglobin as effectively as IV iron with good compliance.
INTRAVENOUS IRON
If the patient is absolutely unable to tolerate any oral iron preparation and they are anaemic (low Hb) they can be referred for consideration of intravenous iron (see below).
If under a parent specialty for bleeding symptoms, or with a clear organ system cause for iron deficiency, referral should be directed to the appropriate specialty, and not to haematology. Iron deficiency is common and no longer seen as primarily a condition requiring a haematology specialist. Intravenous iron is now on the East Lothian Formulary.
IV iron infusions are associated with:
- osteomalacia and rickets in some people as per the MHRA warning in the BNF
- anaphylaxis and other systemic symptoms can occur with IV iron administration even when tolerated previously
- permanent skin discolouration can occur if IV iron extravasates.
These risks should be discussed with patients prior to referral.
Many patients with historical oral iron intolerance may have received IV iron in the past. Such patients should be offered the lower dose oral iron replacement detailed above before re-referral and should be similarly counselled regarding risks of IV iron, especially as the bone side effects are more commonly seen with people receiving repeat infusions.
Who to refer:
For intravenous iron:
- Iron deficiency anaemia where the patient is completely intolerant of all oral iron preparations and requires intravenous iron treatment – please refer to the involved specialist (and not haematology), who can arrange an infusion in the Medical Day Case Unit.
Who not to refer:
For intravenous iron, do not refer:
- Those who have not trialled the lower dose iron regimes outlined above
- Anyone who is not anaemic
How to refer:
Patients needing treatment with intravenous iron should be referred to the specialist investigating their symptoms.
