CKS Clinical Solutions - Iron deficiency anaemia

The case: A 40-year-old woman has some routine blood tests. Her haemoglobin level returns at 10g/dl with a microcytosis so you ask her to attend the surgery for a further assessment. What history should I take?

FBCs will need to be repeated
FBCs will need to be repeated

Ask about diet and drug history. Enquire about any overt bleeding or any illness which might suggest underlying GI bleeding (such as altered bowel habit).

Ask about travel to the tropics (increased risk of hookworm). Take a menstrual history and ask about family history of iron deficiency anaemia. If the anaemia is severe, ask about complications (e.g. angina, dysrhythmias).

What should I look for?
Examine the abdomen and perform a rectal examination, if clinically appropriate. Review the cardiovascular system and chest for signs of heart failure. If there is heavy menstrual bleeding, consider a pelvic examination.

How should I investigate?
Serum ferritin level can confirm the diagnosis, but this is not reliable in pregnant women. It is usually unnecessary to further investigate otherwise healthy young people, menstruating young women with no history of GI symptoms or family history of colorectal cancer, and pregnant women. For other patients, consider testing urine for blood, screening for coeliac disease and referral for upper and lower GI investigations. Test stool for parasites if there is a travel history.

When should I refer?
Refer urgently (within two weeks):

  • Men and women of any age with dyspepsia.
  • Men of any age with a haemoglobin level of 11g/dl or below.
  • Women who are not menstruating, with a haemoglobin level of 10g/dl or below.

Other patients with unexplained iron deficiency anaemia may still require referral (urgency depends on the haemoglobin level and clinical findings).

How should I manage iron deficiency anaemia?
Manage the underlying cause. Treat with ferrous sulphate (200mg two or three times a day), or ferrous fumarate or gluconate if ferrous sulphate is not tolerated. If diet is a cause (or contributing factor), advise a balanced intake of iron-rich foods (e.g. meat, apricots and dark green vegetables such as spinach) and consider referral to a dietitian.

What monitoring is needed?
Check FBC and clinical effect at two to four weeks. If there is a response, check at two to four months. Once all indices are normal continue iron treatment for three months then monitor every three months for one year.

Evidence
Assessment and management recommendations are based on a best practice review,1 guidelines on the management from the British Society of Gastroenterology,2 and a patient pathway on management of anaemia.3 Referral guidance is based on advice from NICE.4,5 The balanced diet of iron-rich foods is based on expert opinion.6

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP.

See www.cks.nhs.uk

References

1.Smellie WS, Forth J, Bareford D et al. J Clin Pathol 2006; 59(8): 781-9.

2. British Society of Gastroenterology. Guidelines for management of iron deficiency anaemia. 2005. www.bsg.org.uk

3. NHS Scotland. General medicine: anaemia - patient pathway. 2005. www.pathways.scot.nhs.uk

4. NICE. Referral advice: a guide to appropriate referral from general to specialist services. 2001.

5. NICE. Referral for suspected cancer. CG 27. 2005.

6. Heath AL, Fairweather-Tait SJ. Best Prac Res Clin Haematol. 2002; 15(2): 225-41.

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