HOW I DO – Anemia – PART – 22

HOW I DO – Anemia – PART – 22

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question: In last part, we covered some very important points re anemia 1. Iron deficiency is only HALF the diagnosis. Other half is to find what led to iron deficiency – nutritional, blood loss, absorption issue. 2. Especially important not to miss an early GI cancer – after age 40-50. And sometimes even younger. 3. Stool for occult blood is abnormal in only 30% cases of GI cancer. Hence upper and lower GI endoscopy is mandatory after age 40-50 if new iron deficiency. Piles is common but may not be the only source. 4. If there is even a single episode of GI bleed, it must be investigated thoroughly. Second episode may not happen and cancer can spread. Or second episode can be fatal. 5. Multiple non cancer GI causes also can be diagnosed by endoscopy. 6. Not to forget heavy menses, bleeding disorder if heavy menses from young age; not to miss signs of cervical or endometrial cancer.

What about absorption issues leading to iron deficiency?

Answer: Ofcourse we need to keep these in mind. Fortunately, true absorption disorders are uncommon. Celiac disease should be tested for if suspected. Adults may also have worms. We frequently give three days of albendazole even to adults with iron deficiency. In spite of extensive testing, however, there are adults who seem to have poor absorption of iron from diet. They need oral iron supplement and sometimes intravenous iron. I suspect that most of these patients however are not giving true diet history, and may have more menstrual loss than they report. Since most of these patients are women. Such history is rare in adult males.

Que: Ok so now we know all about evaluation of iron deficiency anemia and cause of iron deficiency. What next?

Ans: How do I treat iron deficiency.

1. Nutrition. I advise and give a list of foods rich in iron to most patients. For nutritional anemia, I do a much more detailed counselling to stress importance of healthy diet. That iron supplements will not supply all other minerals and many other components of a healthy diet e.g. even fiber. Iron supplements are a temporary measure, and far more inferior in quality than diet per se. For students, people with traveling jobs etc traditional diet list may not work. They need more practical tips as well, as per their situation.
2. Oral iron. Ideal per textbooks is iron sulfate. And many patients may tolerate it, but in practice, most of us don’t take chance and instead advise iron fumarate, ascorbate or gluconate. This is a reasonable compromise of efficacy and tolerance, to ensure compliance. Without compliance, ideal iron salt will also not work. Same way, ideal is empty stomach. But higher intolerance rate. Hence I advise upfront that, if you can tolerate take empty stomach. If not tolerating, immediately switch to after meal. For those who may not understand or follow even this, I advise post meal from day one. There are many different iron products available, with possibly hundreds of brand names in India. Many in combination with other vitamins, some with vitamin C to increase absorption. Most important is to ensure that you use one of the common salts as above, and with reasonable iron content, and something where compliance is possible. Intolerance, very high cost may lead to lack of compliance. Clear instructions about what side effects to expect, and what to do in such a case is important. So that, patients return for further advice, rather than just stopping drug and not taking any iron.
3. For nutritional or heave menstrual periods (until treated successfully), I advise very long courses like one year or so. And followed by maintenance i.e. keep taking iron tablet every weekend or once a week or so. To prevent early relapse. Monitor ferritin once or twice a year. And target near 100. If that is achieved, relapse is rare. Mostly these patients remain far below ferritin level of 100. Concern for iron overload in these patients is highly over stressed. That is rare. Undertreatment is far far more common. Most patients feel better in 2-3 months and stop oral iron. We advise upfront re need to build storage of iron as well i.e. improve ferritin level to prevent early relapse. Not to stop iron when you feel much better or when Hb is normal. At least six months of oral iron after Hb has reached normal range. And then maintenance. Since dietary habits are much harder to change long term, in spite of repeated counselling. Similarly heavy menstrual periods is a complex issue and not solved easily in many patients. Hence maintenance is important. Maintenance is not a concept mentioned in textbooks to my knowledge. Something I advise based on experience.
4. Iron injections. In spite of all good efforts by patients and doctors, there are many patients who don’t succeed with diet, oral iron. They need iron injections. Intramuscular iron is rarely used now in our practice. It is painful, stains skin, higher risk of injection abscess, and smaller dose per injection. IV iron on the other hand, especially FCM (ferric carboxy maltose) allows much larger doses at one time, are very well tolerated, and have rare anaphylaxis. We don’t use iron sucrose now, the most commonly used iron injection earlier. Iron sucrose had much higher rate of reactions, especially if you try to give more than 200 mg at one time. FCM on the other hand can be given as 1 g at one time, and that too in only 30 minutes. We normally repeat once a week for total 3 g for severe iron deficiency. Reactions are rare. In such cases, another IV iron preparation is Ferric derisomaltose, also available in India. It also has less risk of hypophosphatemia compared with FCM.

April 12^th 2026 Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 9998084001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com   www.shyamhemoncclinic.com