Iron Deficiency Anemia😍

Mineral Iron

Sources

• Heme:
• Animal source (20 - 40% bioavailability).

• Non-Heme:
• Plant source (6 - 9% bioavailability):
• Pumpkin seeds (Rich).
• Pista.
• Dates.
• Green leafy vegetables.
• Poor man’s source: Jaggery
• Note: Iron in jaggery due to iron vessel used for production.

• Pregnancy:
• Iron cannot be fully supplemented by diet alone
• Supplementation required regardless of Hb or socioeconomic status

• Mass prophylaxis:
• Use Tablet ferrous sulphate
• (Us Ate)
• Withhold in:
• Acute illness (fever, pneumonia, diarrhea)
• Known thalassemia major
• History of repeated blood transfusion

• Always continue iron for 3 months after Hb normalizes
• To replenish iron stores

WHO Anemia Definition (Hemoglobin Levels):

• Best for epidemiological surveys

• Insensitive for early nutrient depletion

• Levels:
• Healthy Adult Male: <13 g/dL
• Healthy Adult Female: <12 g/dL
• Pregnant Woman: <11 g/dL
• CKD Patient: <10 g/dL
• Children 6 months—5 years: Hb <11 g/dl
• Children 6-14 years: Hb <12 g/dl

Causes

• Dietary, blood loss (trauma, PUD, colon cancer, menorrhagia)

• Hookworm infection

Approach to anemia in children:

Iron Deficiency Anemia

• Most common cause of nutritional disorders in the world

• Most common cause of anemia in the world

• Vitamin C helps in the absorption of iron

• Associated with celiac disease

Iron Metabolism (for IDA):

• Absorption: Duodenum.

• Dietary Fe3+ → Fe2+ (by Cytochrome B Reductase) for absorption.

• Fe2+ into duodenal cells via DMT1 (Divalent Metal Transporter).

• Fe2+ → Fe3+ (by Hephaestin and Ceruloplasmin) inside cell.

• Fe3+ out of duodenal cells via Ferroportin.

• Transport: Transferrin bound Fe3+ (Normal Saturation: 33%).

• Storage: Ferritin.

• Regulated by Hepcidin.

Absorption

• Ferric iron (Ingested) → Ferrous iron (Absorbed).
• FerrUs → comes to us

• Activated by: Vitamin C

• Inhibited by: Phytates, tannin, oxalates, fiber, calcium.

• "I'm Iron. My religion was 3."
• This refers to Fe³⁺ 

• "I need to go to a country, but I can only do so by crossing another country which told me 'Do CHange' your religion."
• Do CHange → Duodenal Cytochrome B (Duodenal Cyto B)
• Duodenal Cytochrome B reduces Fe³⁺ to Fe²⁺.

• I gave into 'demand’
• demand → DMT1 (Divalent Metal Transporter 1)
• DMT1 transports the non-heme Fe²⁺ (ferrous iron) into the enterocyte.

• "I changed to religion 2 and entered."
• This represents Fe²⁺ (ferrous iron), the form that enters the cell via DMT1.

• "And then escaped by a ferri."
• ferri → Ferroportin 1
• Ferroportin 1 transports iron out of the enterocyte, across the basolateral membrane.

• “Sid tried to kill me when I was on Ferri
• Hepcidin inhibits Ferroportin

• "Hamza/Hafsa helped me change my religion back to 3."
• Hamza/Hafsa → Hephaestin
• Hephaestin oxidizes Fe²⁺ back to Fe³⁺ at the basolateral membrane, before it enters circulation.

Disorders

• Formula: (MCV / RBC count) x 100.

• Interpretation:
• <13: Thalassemia minor
• Mnemonic: Tha Lessemia → < 13
• >13: Iron Deficiency Anemia

Oral Iron Therapy (First Line)

• Ferrous sulphate (200 mg):
• Contains 60 mg elemental iron ~10% absorption.
• Absorption increases to ~20% in deficiency.
• Only 6 mg absorbed from a normal dose.

• Ferrous Fumarate

• ferrous gluconate

• Side effect: black stool

• Tabs or drops
• Drops → deep in mouth
• As they cause skin pigmentation.

• Earliest response - Reticulocytosis.

• Adequate response → Hb ↑ by 0.5 g/dl/week

• Factors affecting:
• Ascorbic acid : Increase Absorption
• Phytates, Tannate and oxalates : Decrease Absorption

• Iron deficiency anemia:
• Always continue iron for 3 months after Hb normalizes
• To replenish iron stores

Parenteral Iron therapy

• Ferrous Sucrose (200 mg)

• Ferric Carboxy Maltose
• 1 gm single dose IV

• Iron Isomaltose
• 1 gm single dose IV

Other Preparations of injectable iron are:

• Iron Dextran – Can be given IV as well as IM
• Mnemonic: Dextran → dual route

• Iron Sorbital citrate (Used IM only)
• Mnemonic: Sorbitol → Sirf IM

• IM iron is given by Z-tract technique to avoid pigmentation.

Anemia in Pregnancy

• M/c indirect cause of maternal mortality in India.

• Causes :
• Physiological Anemia
• Hb cut off is raised for defining anemia in pregnancy.
• M/c cause of anemia in pregnancy.
• Normocytic normochromal anemia.
• Hb : Never falls below 11 g/dL.
• Pathological Anemia
• M/c cause : Iron Deficiency Anemia (IDA).
• Microcytic hypochromic anemia.
• Hb : <11 g/dL.

• WHO Classification : 7 - 10 - 11
• Mild : 10-10.9 g/dL.
• Moderate : 7-9.9 g/dL.
• Severe : <7 g/dL.

• Best Screening test for anemia in Pregnancy
• S. ferritin > MCHC

Iron requirements

• Total iron requirement during pregnancy - 1000 mg
• Fetus and placenta -300 mg
• Rest for mother

• Fe - trimester wise
• 1st : 1-2 mg/day
• 2nd: 4-6 mg/day
• 3rd: 6-8 mg/day
• 2nd half of pregnancy : 6-8 mg/day

• Note :
• ICMR Very severe anemia : Hb <4 g/dL.
• Thalassemia : Rx with iron is C/I.
• Nestroft test.
• IDA : Rx with iron supplementation.

ANEMIA MUKT BHARAT PROGRAM

• 6 x 6 x 6 Initiatives

Interventions :

1. IFA pill : Weekly

2. Deworming : Albendazole for hookworm infection
• 200 mg (1/2 tab) for 1-2 yrs
• 400 mg (1 tab) for >2 yrs
• Biannually (Twice a year) :
• (National deworming days)
• 10th February &
• 10th August
• Not against ascariasis

3. Delayed cord clamping : Prevention of neonatal anemia

4. Digital hemoglobinometer.

5. Mandatory iron & folic acid fortified foods

6. Non-nutritional causes of anemia

• Pregnant woman IFA
• From 4th month of pregnancy till 6 months post-delivery

Mnemonic

• Pink → Primary kids (5–9 yrs)

• Blue → Boys & girls (Adolescents)

• Red → Reproductive (Pregnant + Lactating)

Supplementation in Pregnancy

• Deworming: Once in second trimester.

IFA Pill

• Red color pill.

• Fe : 60 mg + Folic acid : 500 mcg (To prevent megaloblastic anemia).

• Dose to
• Prevent anemia : 1 tablet/day 
• Rx anemia : 2 tablets/day.

• Recommended after 12 weeks

• 1 tablet/day for at least 180 days in pregnancy

MANAGEMENT

Parenteral iron :

• C/I : 1st trimester.

• Rate of Hb ↑ :  0.7 g/dL/week after 3rd week.

Dose : Ganzoni formula.

• 2.4 x Pre-pregnancy weight x Hb deficit (target Hb - Patients Hb) + 500 mg

• Mnemonic Iron man te set Gansoni

• Note:
• Target Hb can be 11 or 14
• If target = 11
• Need maintenance till 180 days after delivery
• Oral Iron is given
• If target is 14
• Do not need maintenance

• Minimum time gap b/w oral & parenteral iron : 
• 3 weeks (Oral iron tablets C/I with parenteral therapy).

Oral iron therapy :

• Rate of Hb↑ : Same as parenteral

• For loading as well as maintenance therapy
• If target Hb = 11 g/dL

• Maintenance dose : 
• 1 pill/day continued throughout pregnancy up to 180 days after delivery.

Treatment Algorithm :

Blood transfusion at any GA if

• Hb <5g%

• Signs of heart failure

1st trimester

• No parenteral iron therapy
1. 2 IFA tab per day OR
• 60 mg elemental Fe + 0.5 mg FA
2. Blood transfusion if
1. Unstable vitals.
2. Signs of heart failure
3. Thalassemia.
4. Hb <5 g/dL at any gestational age.

2nd and 3rd trimester

Special Considerations

• Thalassemia & Sickle Cell Disease: 
• Folic acid only

• Calcium Recommendation (Pregnant & Non-Pregnant Females): 
• 1000 mg