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Current Management of Iron Deficiency Anemia in Inflammatory Bowel Diseases: A Practical Guide

Drugs volume 73, pages 1761–1770 (2013)Cite this article

Abstract

Anemia and iron deficiency anemia are very common in inflammatory bowel disease (IBD). In most cases, anemia is a consequence of mixed pathogenesis; inflammation and iron deficiency being the most important factors. Iron status should be evaluated carefully, as ferritin is unreliable in the presence of inflammation. It is always necessary to control disease activity; however, supplementation is usually required to fully correct iron deficiencies. Oral iron, intravenous iron, erythropoietin, and blood transfusions can be used in different clinical scenarios. Oral iron may be used in mild cases if the disease has no clinical activity. Intravenous iron should be preferred where oral iron is poorly tolerated or where it has failed in moderate to severe anemia, and in combination with erythropoietin. Iron sucrose is very safe and effective, but not very convenient, as the total needed dose must be divided into several infusions. Ferric carboxymaltose is much more convenient, and has been shown to be more effective than iron sucrose in a large randomized trial. Iron isomaltose shows theoretical promise, but very limited data are available from IBD populations. Blood transfusion can be necessary, especially in acute life-threatening situations, but the trigger for indication should be in the low range. With the correct use of available resources, anemia and iron deficiency should be well controlled in practically all IBD patients.

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Acknowledgments

The authors acknowledge Professor Miguel Muñoz and Drs José Antonio García-Erce and Santiago García for their help and support. Fernando Gomollón has received consulting fees from Pharmacosmos. Javier P. Gisbert has no relevant issues to declare. No funding was obtained to support the writing of this manuscript.

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Affiliations

  1. IBD UNIT, Digestive Diseases Service, Hospital Clínico Universitario “Lozano Blesa”, Instituto de Investigación Sanitaria de Aragón (IIS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Zaragoza, Spain

    Fernando Gomollón

  2. IBD UNIT, Digestive Diseases Service, Hospital Universitario “La Princesa”, Instituto de Investigación Sanitaria Princesa (IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain

    Javier P. Gisbert

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  1. Fernando Gomollón
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  2. Javier P. Gisbert
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Correspondence to Fernando Gomollón.

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F. Gomollón, J. P. Gisbert contributed equally to the manuscript.

Appendix

Appendix

A synoptic guide for iron

• Anemia and iron deficiency are very common in IBD.

• Full knowledge of iron status often involves several parameters (Table 2), and includes assessing the activity of the disease. If the disease is active, ferritin values are reliable when low, and unreliable when normal or high.

• Before treatment, a complete evaluation of other common potential causes of anemia must be carried out, IBD activity being the most important.

• Oral iron may be used if the disease is inactive, anemia is mild (hemoglobin levels >100.0 g/L), and where oral iron is well tolerated.

• There is no reason for oral doses higher than 100 mg of elemental iron per day.

• Many experts prefer the use of intravenous iron in all IBD patients.

• Intravenous iron should be used if:

○ IBD is active

○ the patient is intolerant to oral iron

○ anemia is moderate or severe (hemoglobin <100/105 g/L)

○ erythropoietin agents are being used

○ quick response is needed (e.g. surgery planned in short term)

• Intravenous iron preparations can be chosen depending on local availability, patient convenience, and published experience

○ Iron sucrose is safe, but not convenient (a mean of six infusions are needed)

○ ferric carboxymaltose is very effective and convenient, and extensively used, being the current standard in many sites

○ iron isomaltose shows theoretical promise, but published clinical experience is currently very limited in IBD

○ LMWID could be useful, but direct experience in IBD is scarce, and infusion times are longer

• Erythropoietin can be needed in a limited number of patients (<10%) with anemia to overcome functional iron deficiency. Intravenous iron should be added.

• Blood transfusion should be used only rarely (e.g. in acute life-threatening bleeding) and the trigger for transfusion should be in the low range (70 g/dl) in most cases

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Gomollón, F., Gisbert, J.P. Current Management of Iron Deficiency Anemia in Inflammatory Bowel Diseases: A Practical Guide. Drugs 73, 1761–1770 (2013). https://doi.org/10.1007/s40265-013-0131-2

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Keywords

  • Inflammatory Bowel Disease
  • Iron Deficiency
  • Erythropoietin
  • Iron Deficiency Anemia
  • Inflammatory Bowel Disease Patient