Management of iron-deficiency anemia following acute gastrointestinal hemorrhage: A narrative analysis and review

Low Rates of Diagnosis and Treatment of Iron Deficiency Anemia After an Acute Severe Gastrointestinal Hemorrhage

BACKGROUND

Few studies report about management of iron deficiency anemia after a severe, acute gastrointestinal bleed. Most include good risk patients with upper gastrointestinal bleeds and report only laboratory improvements but not clinical outcomes.

AIMS

To assess management of iron deficiency anemia and clinical outcomes of patients after a severe, acute gastrointestinal bleed from either upper or lower sources in an unselected group of patients.

METHODS

Retrospective analysis of adult patients hospitalized with severe gastrointestinal bleeding in two referral centers. They had endoscopic diagnoses of lesions including non-variceal upper, variceal, and lower sites (diverticulosis or other colon sources). Analyses were of rates of iron studies ordered and iron treatments up to 4 months post-discharge. Composite clinical outcomes were also assessed and analyzed.

RESULTS

For 337 patients studied, iron studies were ordered in only 50%. When tested, iron deficiency was diagnosed in 75% of anemias. Intravenous iron or oral iron was prescribed in only 7.1% and 26.7% of patients, respectively. By 4 months, 94% of patients treated with intravenous iron and 80% treated with oral iron achieved ≥ 2 g/dL increase in hemoglobin level. Patients with high rates of severe co-morbidities and severe anemia had poor clinical outcomes although most were not treated for IDA.

CONCLUSIONS

Despite significant anemia after a severe gastrointestinal bleed from common diagnoses, iron studies were not routinely ordered. Iron deficiency anemia was infrequently recognized or treated with iron therapies. Patients with severe co-morbidities and anemia after an acute gastrointestinal bleed had poor clinical outcomes.

Low Rates of Diagnosis and Treatment of Iron Deficiency Anemia After an Acute Severe Gastrointestinal Hemorrhage

Background

Few studies report about management of iron deficiency anemia after a severe, acute gastrointestinal bleed. Most include good risk patients with upper gastrointestinal bleeds and report only laboratory improvements but not clinical outcomes.

Aims

To assess management of iron deficiency anemia and clinical outcomes of patients after a severe, acute gastrointestinal bleed from either upper or lower sources in an unselected group of patients.

Methods

Retrospective analysis of adult patients hospitalized with severe gastrointestinal bleeding in two referral centers. They had endoscopic diagnoses of lesions including non-variceal upper, variceal, and lower sites (diverticulosis or other colon sources). Analyses were of rates of iron studies ordered and iron treatments up to 4 months post discharge. Composite clinical outcomes were also assessed and analyzed.

Results

For 337 patients studied, iron studies were ordered in only 50%. When tested, iron deficiency was diagnosed in 75% of anemias. Intravenous iron or oral iron was prescribed in only 7.1% and 26.7% of patients respectively. By 4 months, 94% of patients treated with intravenous iron and 80% treated with oral iron achieved ≥ 2 g/dL increase in hemoglobin level. Patients with high rates of severe comorbidities and severe anemia had poorer clinical outcomes than others with severe anemia and less comorbidity.

Conclusions

Despite significant anemia after a severe gastrointestinal bleed from common diagnoses, iron studies were not routinely ordered. Iron deficiency anemia was infrequently recognized or treated with iron therapies. Patients with severe co-morbidities and anemia after an acute gastrointestinal bleed had poor clinical outcomes.

Adverse events in patients with cardiovascular disease taking proton pump inhibitors

INTRODUCTION

Proton pump inhibitors (PPIs) rank among the most frequently prescribed medications to treat acid-related diseases. Mounting concerns surround the potential for serious adverse events, including cardiovascular events, associated with their prolonged use/misuse.

AREAS COVERED

This comprehensive review explores cardiovascular adverse events linked to PPI use among high-risk cardiovascular patients. A structured search was conducted on PubMed.

EXPERT OPINION

Many patients with cardiovascular disease who require antiplatelet treatment will require long-term PPI treatment. Interpreting the published data is not straightforward. First, because there is no plausible mechanistic explanation for PPIs to induce cardiovascular events apart from the potential interaction with the metabolism of thienopyridines. Although several observational studies have shown an increased cardiovascular risk and mortality in patients taking long-term PPIs, most available clinical trials and meta-analyses of available studies do not. However, the absence of firm evidence of this link does not necessarily imply that this association does not exist, and other hypothesis must be explored. Anemia is a common event in patients who take antiplatelet therapy and PPIs, and it is a factor associated with cardiovascular events and death. Anemia in these patients is often attributed to erosive lesions of the small intestine, where PPI may play a key role by modifying the microbiota.

Letter: Post-endoscopic management after upper gastrointestinal bleeding-Replenishment of iron loss

This article is linked to Shung et al paper. To view this article, visit https://doi.org/10.1111/apt.17949

Circulating microRNAs and hepcidin as predictors of iron homeostasis and anemia among school children: a biochemical and cross-sectional survey analysis

BACKGROUND

MicroRNAs (miRNAs) can control several biological processes. Thus, the existence of these molecules plays a significant role in regulating human iron metabolism or homeostasis.

PURPOSE

The study aimed to determine the role of circulating microRNAs and hepcidin in controlling iron homeostasis and evaluating possible anemia among school children.

METHODS

The study was based on a biochemical and cross-sectional survey study that included three hundred fifty school children aged 12-18 years old. RT-PCR and immunoassay analysis were accomplished to estimate iron concentration, Hgb, serum ferritin (SF), soluble transferrin receptor (sTfR), total body iron stores (TIBs), total oxidative stress (TOS), total antioxidant capacity (TAC), α-1-acid glycoprotein (AGP), high sensitive C-reactive protein (hs-CRP), and miRNAs; miR-146a, miR-129b, and miR-122 in 350 school adolescents.

RESULTS

Iron disorders were cross-sectionally predicted in 28.54% of the study population; they were classified into 14.26% with ID, 5.7% with IDA, and 8.6% with iron overload. The overall proportion of iron depletion was significantly higher in girls (20.0%) than in boys (8.6%). MicroRNAs; miR-146a, miR-125b, and miR-122 were significantly upregulated with lower hepcidin expression in adolescence with ID and IDA compared to iron-overloaded subjects, whereas downregulation of these miRNAs was linked with higher hepcidin. Also, a significant correlation was recorded between miRNAs, hepcidin levels, AGP, hs-CRP, TAC, and other iron-related indicators.

CONCLUSION

Molecular microRNAs such as miR-146a, miR-125b, and miR-122 were shown to provide an additional means of controlling or regulating cellular iron uptake or metabolism either via the oxidative stress pathway or regulation of hepcidin expression via activating genes encoding Hfe and Hjv activators, which promote iron regulation. Thus, circulating miRNAs as molecular markers and serum hepcidin could provide an additional means of controlling or regulating cellular iron and be associated as valuable markers in diagnosing and treating cases with different iron deficiencies.

Appropriateness of inpatient intravenous iron therapy in a Swiss tertiary care hospital

INTRODUCTION

Intravenous (IV) iron replacement is an established treatment for iron deficiency and is recommended in various medical guidelines, but cheaper oral iron formulations remain first-line therapy in several instances. Data on adherence to current prescription standards are lacking in Switzerland.

METHODS

Retrospective single center quality control study evaluating the appropriateness of IV iron replacement in 400 inpatients during 2019 and 2021 at a Swiss tertiary care hospital. Appropriateness of IV iron was assessed by expert chart review according to national and international guidelines.

RESULTS

IV iron prescriptions were assessed as inappropriate in 147 (37%) of cases (indication lacking in 13%, oral route preferred in 24%). Inappropriate prescribing was more common (p < .001) in surgical wards (66%) compared to medical units (48%) and the gynecologic ward (19%). Iron studies were lacking in 29% of inappropriate IV administrations. Insufficient replacement dosages were chosen in 38% of patients with appropriate prescription.

CONCLUSION

Based on current guidelines, inappropriate in-hospital prescription of IV iron was frequently observed. Considerable differences exist between hospital units, which are consistent with conflicting recommendations of professional societies. We recommend increased attention toward the prescription quality to avoid unnecessary, expensive, and potentially harmful use of IV iron.