Health-related quality of life in patients with iron deficiency anemia: impact of treatment with intravenous iron

A Multicenter Single-Arm Study of Switching to Ferric Citrate Hydrate for Iron Deficiency Anemia in Patients Intolerant to Oral Iron: RIO-SWITCH

INTRODUCTION

Treatment interruptions due to adverse drug reactions (ADRs) are common in iron deficiency anemia (IDA). We evaluated medication completion rates and quality of life (QoL) changes in patients with IDA after starting ferric citrate hydrate (FCH) treatment.

METHODS

This multicenter, open-label, uncontrolled, single-arm comparative study included 30 Japanese female patients with IDA who experienced nausea and/or vomiting (N/V) with previous oral iron preparations. Patients received FCH 500 mg orally daily (< 1000 mg/day). Those with hemoglobin levels ≥ 11.0 g/dl completed the study at week 4; others continued until week 8. The primary endpoint was medication completion rate. Secondary endpoints included medication compliance rate, treatment satisfaction scores, and QoL scores and changes.

RESULTS

Thirty patients initiated and completed treatment; 24 reached ≥ 11.0 g/dl hemoglobin at week 4 and ended treatment, while 6 continued until week 8. The medication compliance rate was 93.92% ± 8.11% (mean ± standard deviation [SD]), and the completion rate was 100.0% (95% confidence interval 88.4-100.0%). Questionnaire findings revealed that the most severe nausea score decreased from 5.7 ± 2.4 to 1.7 ± 2.1 (mean ± SD), N/V incidence decreased from 100.0 to 63.3%, and patients reporting that N/V did not interfere with daily life increased from 6.7 to 52.6% following the switch to FCH. Twenty-four patients (80.0%) reported a satisfactory experience with FCH versus their previous oral iron preparation. Scores for all eight subscales of the Short-Form 36-Item Health Survey v2 improved, with significant increases in six. Nine ADR events occurred in six patients (20.0%), including nausea in three (10.0%); none were serious or resulted in treatment discontinuation.

CONCLUSION

FCH treatment exhibited a satisfactory medication completion rate in patients with IDA. Switching to FCH reduced N/V incidence and improved N/V and QoL severity compared with previous oral iron preparations.

TRIAL REGISTRATION

jRCTs031210634. Registration date: March 01, 2022.

Cost-Effectiveness of Ferritin Screening Thresholds for Iron Deficiency in Reproductive-Age Women

Iron deficiency (ID) is a top five leading cause of disability-adjusted life-years in women of reproductive age around the world. Despite its enormous health burden, no screening guidelines exist for the detection and treatment of ID in women of reproductive age. We sought to determine the cost-effectiveness of screening versus no screening for ID in women of reproductive age in the United States. A lifetime simulation of women of reproductive age was conducted using a Markov cohort model under three strategies: (1) no screening, (2) screening at a ferritin threshold of 15 μg/L, and (3) screening at a ferritin threshold of 25 μg/L, from the US health system perspective, and at a willingness-to-pay threshold of $100 000/quality-adjusted life year (QALY). Epidemiologically informed ID prevalence estimates sourced from the National Health and Nutrition Examination Survey were employed for model parameterization. The primary outcome was the incremental cost-effectiveness ratio (ICER, in $/QALY). Base-case results for the three strategies accrued $209 700, $210 200, and $210 200 discounted lifetime costs and 23.6, 24.0, and 24.4 discounted lifetime QALYs, respectively. Screening at a ferritin threshold of 25 μg/L was the cost-effective intervention with an ICER of $680/QALY (95% credible interval $350-$750/QALY). In dual base-case analyses examining intravenous rather than oral iron repletion for treatment, screening at a ferritin threshold of 25 μg/L remained the cost-effective intervention with an ICER of $2300/QALY (95% CI $1800-$3800/QALY). In probabilistic sensitivity analyses, screening at a ferritin threshold of 25 μg/L was the cost-effective intervention in 100% of 10 000 second order Monte Carlo iterations.

Understanding and Managing Infusion Reactions and Hypophosphataemia With Intravenous Iron-A Nurses' Consensus Paper

AIM

To provide evidence-based guidance on practical aspects and potential safety concerns (infusion reactions and hypophosphataemia) related to the use of intravenous iron from a nursing perspective.

DESIGN

A modified Delphi consensus method.

METHODS

Literature searches were conducted and used to support the development of 16 consensus statements. Six nurses with expertise in the field of gastroenterology and experience with the administration of intravenous iron participated in a modified Delphi process to develop a final set of statements.

RESULTS

Overall, 16 statements achieved consensus and covered the practicalities of administration, infusion reactions and hypophosphataemia. Patient preparation is a key step in the administration of intravenous iron, but information should be communicated carefully to prevent undue anxiety. Highlighting the nurse's confidence in the management of any reactions may help to reduce anxiety. The patient should be observed during the first 5-10 min of an infusion to allow prompt management of immediate infusion reactions, although severe hypersensitivity reactions are rare. Nurses should be vigilant for symptoms of hypophosphataemia (such as fatigue, weakness and muscle/bone pain), which can develop following treatment with ferric carboxymaltose, saccharated ferric oxide and iron polymaltose. Serum phosphate levels should be measured in patients receiving ferric carboxymaltose who are at risk of low phosphate.

IMPACT

Infusion reactions and hypophosphataemia with intravenous iron are documented in the literature, but existing publications do not approach these topics from a nursing perspective. This consensus paper highlights the importance of patient preparation, monitoring and prompt management when administering intravenous iron to ensure patient safety. Considering that nurses have a central role in the administration of intravenous iron, the availability of evidence-based guidance is essential for both nurse confidence and patient safety.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was involved in the consensus process.

Intravenous iron in chronic kidney disease without anaemia but iron deficiency: A scoping review

Iron deficiency (ID) is a prevalent complication of chronic kidney disease (CKD), often managed reactively when associated with anaemia. This scoping review evaluates the evidence supporting intravenous (IV) iron therapy in non-anaemic individuals with CKD and ID, focusing on safety, efficacy, and emerging therapeutic implications. Current diagnostic markers, including serum ferritin, transferrin saturation, and reticulocyte haemoglobin content, are reviewed alongside their limitations in the context of inflammation and variability. The pathophysiology of ID in CKD is explored, highlighting the roles of hepcidin, hypoxia-inducible factor pathways, and uraemic toxins. Comparative studies reveal that IV iron offers a more rapid correction of iron stores, improved compliance, and fewer gastrointestinal side effects compared to oral iron. Evidence from trials such as "iron and heart" and "iron and muscle" suggests potential benefits of IV iron on functional capacity and fatigue, though findings were statistically non-significant. Insights from heart failure trials support the safety and efficacy of IV iron in improving quality of life and reducing hospitalizations, with newer formulations like ferric derisomaltose demonstrating favourable safety profiles. This review underscores the need for standardized screening protocols for ID in CKD, even in the absence of anaemia, to facilitate earlier intervention. Future research should prioritise robust outcome measures, larger sample sizes, and person-specific treatment strategies to optimise dosing and administration frequency. Tailored approaches to IV iron therapy have the potential to significantly improve functional outcomes, quality of life, and long-term health in people with CKD.

High prevalence of undiagnosed iron deficiency in endometriosis patients: A cross-sectional study

OBJECTIVE

The primary objective was to evaluate the prevalence of undiagnosed iron deficiency in patients with endometriosis.

METHODS

We performed a multi-center, cross-sectional study at two tertiary care hospitals. We included 251 non-pregnant women (18-50 years old) presenting with a clinical or surgical diagnosis of symptomatic endometriosis. Patients who consented to the study underwent screening bloodwork (including complete blood count, ferritin, and transferrin saturation) and completed the study survey assessing demographics, medical and surgical history, and validated questionnaires to assess iron deficiency and endometriosis symptoms.

RESULTS

The prevalence of iron deficiency in our endometriosis cohort was 53.4% (134/251), and the prevalence of iron deficiency anemia was 13.5% (34/251). Patients with iron deficiency were more likely to have heavy menstrual bleeding (HMB) compared with patients without iron deficiency (66/133, 49.6% vs. 40/115, 34.8%, p = 0.022). Nonetheless, 58% (142/251) of our study population did not endorse HMB. Despite absence of HMB, 47% (67/142) of these patients were iron-deficient. Transferrin saturation was diagnostic for iron deficiency in 63 of 176 patients (35.7%) who had a normal ferritin (≥30 ng/mL). Patients with iron deficiency had a significantly lower adjusted median Functional Assessment of Chronic Illness Therapy Fatigue Subscale score compared with those without iron deficiency (26.3. vs. 29.8, p = 0.025).

CONCLUSION

This study highlights the high prevalence of iron deficiency, which remains undiagnosed in over half of patients with endometriosis presenting to a gynecologist. Future research should focus on assessing the effectiveness of iron therapy in improving symptoms and overall well-being in this population.

The humanistic burden of immunoglobulin A nephropathy on patients and care-partners in the United States

PURPOSE

This cross-sectional survey study quantified the humanistic burden of immunoglobulin A nephropathy (IgAN), in terms of physical and mental health-related quality of life (HRQoL) and work productivity, among adults with primary IgAN and their care-partners.

METHODS

HRQoL was assessed (01/31/22 - 05/31/23) with validated tools including the KDQoL-36 (with SF-12), GAD-7 (anxiety), PHQ-9 (depression), and WPAI: SHP (work productivity). Participant characteristics and total/domain scores were summarized; selected outcomes were compared to an external, kidney disease-free cohort.

RESULTS

117 adults with IgAN and their care-partner pairs, and one adult without a care-partner, were included. The mean ages of patients and care-partners were 38.0 (SD: 8.6) and 40.2 (11.8) years, respectively; 55.9% and 43.6% were female. Mean physical and mental SF-12 scores for patients were 46.7 (SD: 8.0) and 41.9 (9.2), respectively, and 50.7 (7.3) and 43.7 (10.24) for care-partners. Both SF-12 components for patients, and the mental component for care-givers, were significantly worse compared to the US general population. Among patients, 27.1% had moderate/severe anxiety and 49.2% reported at least moderate depression. Compared to external controls, patients experienced significantly higher severity of anxiety (6.6 vs. 5.4) and depression (8.1 vs. 6.6; both p < 0.0001). Among care-partners, 13.7% experienced moderate anxiety and 37.8% experienced moderate/moderately-severe depression. Among employed individuals, both groups reported IgAN-related absenteeism (8.8-9.4%), presenteeism (25.1-25.9%), and overall work impairment (30.4-30.5%).

CONCLUSION

US adults with IgAN and their care partners experience impairments to mental and physical HRQoL and heightened levels of depression and anxiety, underscoring the need for effective IgAN therapies and care-partner support.

Iron Deficiency Anemia in Children During and After PICU Stay: Single-Center Retrospective Cohort, 2021-2022

OBJECTIVES

The primary objective was to determine iron deficiency (ID) anemia (IDA) monitoring practices in children during PICU stay. A secondary objective was to determine the current follow-up practices for IDA after PICU discharge.

DESIGN

Retrospective observational study of 2 years (2021-2022).

SETTING

Single-center academic PICU in the United States.

SUBJECTS

All patients younger than 18 years and excluded patients who died in the PICU or within 6 months of PICU discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Anemia was defined by a hemoglobin concentration of less than 11 g/dL. ID was defined by either a ferritin of less than 30 ng/mL or a transferrin saturation (TSAT) of less than or equal to 20%. Suspicion for functional iron deficiency (SID) was defined by ferritin greater than or equal to 30 ng/mL and TSAT less than or equal to 20%, given the hyperferritinemic effect of inflammation. We documented serum iron, total iron binding capacity, TSAT, ferritin, and hemoglobin at PICU admission and discharge and 3 and 6 months after discharge. Overall, 913 of 1275 met the inclusion criteria, and 492 patients had a hemoglobin of less than 11 g/dL. Only 93 of 492 (18.9%) had iron studies at any time during the PICU stay. Among the 93 patients with iron studies, 20 patients (22%) were lost to follow-up. Of the remaining 73 patients, 67 of 73 had a hemoglobin checked at 3 months, of which 37 of 67 (55%) were still anemic. At 6 months, there were 64 of 73 patients who had a hemoglobin checked, of which 32 of 64 (50%) were still anemic. At 3 months, 39 of 73 (53%) had iron studies performed; of these, 13 of 39 had ID, 12 of 39 had SID, and 14 of 39 had neither ID nor SID. At 6 months, 35 of 73 (48%) had iron studies; of these, ten of 35 had ID, 11 of 35 had SID, and 14 of 35 had neither ID nor SID.

CONCLUSIONS

Detection of ID and follow-up after PICU stay remain inadequate. We recommend that future studies assess the value of screening all critically ill patients for ID at the time of discharge and followed up, as necessary.

Injury-Associated Anemia in Orthopaedic Trauma: A Comprehensive Review

» Anemia is a common comorbidity in orthopaedic trauma patients with important clinical consequences, significantly negatively affecting a patient's course following orthopaedic trauma.» Anemia remains relatively understudied in the orthopaedic trauma population with a large amount of current literature focused solely on geriatric hip fracture patients.» Greater investigation into alternatives to blood transfusions such as iron therapy or cell salvaging for treatment of anemia in the orthopaedic trauma population is needed.

Absolute and functional iron deficiency: Biomarkers, impact on immune system, and therapy

Iron is essential for numerous physiological processes and its deficiency often leads to anemia. Iron deficiency (ID) is a global problem, primarily affecting reproductive-age women and children, especially in developing countries. Diagnosis uses classical biomarkers like ferritin or transferrin saturation. Recent advancements include using soluble transferrin receptor (sTfR) or hepcidin for improved detection and classification of absolute and functional iron deficiencies, though mostly used in research. ID without anemia may present symptoms like asthenia and fatigue, even without relevant clinical consequences. ID impacts not only red-blood cells but also immune system cells, highlighting its importance in global health and immune-related comorbidities. Managing ID, requires addressing its cause and selecting appropriate iron supplementation. Various improved oral and intravenous products are available, but further research is needed to refine treatment strategies. This review updates on absolute and functional iron deficiencies, their relationships with the immune system and advancements in diagnosis and therapies.

Randomized Controlled Trial of Intravenous Ferric Carboxymaltose vs Oral Iron to Treat Iron Deficiency Anemia After Variceal Bleed in Patients With Cirrhosis

INTRODUCTION

Limited evidence exists on the optimal strategy to correct iron deficiency anemia after variceal bleeding (VB) in cirrhosis. This trial compared the efficacy and safety of intravenous ferric carboxymaltose (IV-FCM) with those of oral iron therapy in this cohort.

METHODS

In this open-label, single-center, randomized controlled trial, eligible patients with hemoglobin <10 g/dL and iron deficiency (ferritin <100 ng/mL) after VB received either IV-FCM (1,500-2,000 mg) divided into 2 doses (n = 48) or oral carbonyl iron (100 mg elemental iron/day) (n = 44) for 3 months. The primary outcome was change in hemoglobin at 3 months. Secondary outcomes included improvement in anemia (last hemoglobin >12 g/dL), normalization of iron stores (ferritin >100 ng/mL), liver-related adverse events, adverse drug reactions, and changes in quality of life (CLDQOL questionnaire).

RESULTS

Baseline characteristics, including median Child-Turcotte-Pugh score 7 (interquartile range [IQR] 6-9), Model for End-Stage Liver Disease score 12 (IQR 10-17), blood hemoglobin (8.25 ± 1.06 g/dL), and ferritin (30.00 ng/mL [15.00-66.50]), were comparable in both arms. The median increase in hemoglobin at 3 months in the IV and oral arms was 3.65 g/dL (IQR 2.55-5.25) and 1.10 g/dL (IQR 0.05-2.90 g/dL) ( P < 0.001), respectively. Iron stores normalized in 84.6% and 21% of the IV and oral arms, respectively ( P < 0.001). Anemia improved in 50% and 21.9% in the IV and oral arms, respectively ( P < 0.009). Patients in the IV arm showed a significant improvement in all domains of CLDQOL. Liver-related adverse events were comparable in both arms. Transient mild/moderate hypophosphatemia developed in 43% of patients receiving IV-FCM.

DISCUSSION

Intravenous iron replacement is efficacious and safe to treat iron deficiency anemia after VB in patients with cirrhosis.

Anemia in patients with cartilage hair hypoplasia: a narrative review and recommendations

Cartilage hair hypoplasia (CHH) can lead to the development of anemia as a possible complication of this rare genetic disease. Despite various publications on anemia in CHH patients, a comprehensive review on this topic has not been conducted. This article reviews publications on anemia in CHH patients published from 1981 to 2022. Most authors have reported macrocytic anemia and blood transfusion as a common treatment approach in this patient group. Recommended guidelines for managing anemia in CHH patients include iron chelation therapy for those requiring multiple blood transfusions, regular assessment of anemia symptoms, red blood cell parameters, and immune system function. Future studies should evaluate the erythroid system in a larger cohort of CHH patients, considering key factors such as concurrent illnesses, age, height, and weight.

Intravenous iron and iron deficiency anemia in patients with gastrointestinal cancer: A systematic review

BACKGROUND

Iron deficiency anemia (IDA) is a prevalent hematological complication associated with gastrointestinal (GI) cancers due to an increased loss of iron and decreased iron absorption. The purpose of this systematic review is to evaluate the use of parenteral iron to treat IDA in patients with GI cancer.

METHODS

PubMed, Cochrane, EMBASE, CINHAL and Scopus were searched from January 1, 2010 to September 29, 2023 with no language restrictions. We excluded editorials, case reports, abstracts, conference papers, and poster presentations. Studies were included if they discussed IDA, GI neoplasms, use of iron supplementation (with or without erythropoietin-stimulating agents [ESAs]), defined anemia and had an adult patient population. We assessed the efficacy of parenteral iron in comparison to other iron supplementation methods when treating IDA in patients with GI cancer. The Cochrane Risk of Bias Tool 2 (RoB 2) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) assessment tools were used to assess the quality of the included studies. Moreover, the Cochrane Effective Practice and Organization data collection form was used to collect pertinent study information.

RESULTS

Our search yielded 3,969 studies across all databases. Twenty-one studies were included (6 randomized control trials; 15 non-randomized studies). Of the 15 studies evaluating hemoglobin (Hb) response, seven studies found an increase in Hb levels when patients were treated with IV iron. The 14 studies evaluating red blood cell (RBC) transfusion rates found conflicting differences in RBC transfusion needs when treated with IV iron. Studies analyzing health related outcomes typically found an increase in quality of life and decreased post-operative complications.

DISCUSSION

This review demonstrates improved outcomes of IDA in patients with GI cancer treated with IV iron instead of other iron supplementation methods. Timely diagnosis and appropriate IDA management can greatly improve quality of life in this patient population, especially if myelosuppressive chemotherapy is required.

Association between depression, anemia and physical activity using isotemporal substitution analysis

BACKGROUND

Depression is a leading cause of disability and mortality, with estimated number of deaths exceeding 2.2 million worldwide. We examined depression in relation to anemia and physical activity, both of which have an impact on depression mechanisms.

METHODS

This cross-sectional study used data from the Korean National Health and Nutrition Examination Survey, including 18,622 participants. Depression was measured by The Patient Health Questionnaire-9, and physical activity was assessed by the Global Physical Activity Questionnaire. Anemia was defined by World Health Organization criteria for blood hemoglobin levels. Isotemporal substitution model for physical activity was used to assess the effect of replacing sedentary behavior to each intensity level of physical activity. Logistic regression was applied to estimate the association on depression.

RESULTS

Replacing sedentary behavior with moderate or vigorous physical activity was associated with a lower risk of depression in the anemic (OR: 0.875, 95% CI: 0.782-0.978) and non-anemic groups (OR: 0.943, 95% CI: 0.919-0.967). Depression risk was significantly reduced by replacing walking with moderate to vigorous physical activity in both anemic (OR: 0.877, 95% CI: 0.784-0.982) and non-anemic groups (OR: 0.951, 95% CI: 0.927-0.976).

CONCLUSIONS

Moderate to vigorous physical activity had a protective association against depression in both anemic and non-anemic groups. Anemic patients are recommended to perform physical activity for any duration acceptable to them to prevent depression.

Real-world experience of intravenous iron sucrose supplementation and dynamics of soluble transferrin receptor and hepcidin in a Spanish cohort of absolute iron deficient patients

The study evaluated the safety and effectiveness of the generic intravenous (IV) iron treatment (Feriv®), in a Spanish cohort with absolute iron deficiency (ID) (serum ferritin <50 ng/ml, with or without anaemia) (n = 122; 91% women; median age of 44 years [IQR: 33.7-54]). Iron-related biomarkers were measured before treatment (baseline), 2 weeks after beginning the protocol (intermediate control, IC) and between 7 and 10 days after treatment completion (final time-point). Primary efficacy endpoints were ferritin levels ≥ 50 ng/ml, anaemia restoration or an increase in haemoglobin (Hb) of at least one point in patients without baseline anaemia. After treatment, iron-related biomarkers improved, including ferritin, Hb, sideremia, transferrin, transferrin saturation index, soluble transferrin receptor (sTfR), and hepcidin. Baseline ferritin concentration (13.5 ng/ml [IQR: 8-24.2]) increased at the IC and continued rising at the final time-point, reaching a median ferritin of 222 ng/ml and 97.3% of patients ≥ 50 ng/ml. At the final time-point, anaemia prevalence decreased from 26.2% to 5%, while the 34.1% without baseline anaemia showed an increase in Hb of at least one point. Headache was the only drug-adverse event recorded in 2.3% of patients. At a late time-point (27.5 median weeks after ending therapy [IQR: 22-40]), evaluated in a subgroup of 66 patients, 18% had ferritin levels < 50 ng/ml. Multivariate analysis showed that low baseline ferritin and high sTfR/hepcidin ratio tended to be independently associated with ID recurrence. Feriv® is a safe, effective first-line treatment for absolute ID, with improvement of serum ferritin and Hb. ID recurrence was associated with the baseline degree of iron stores depletion, indicated by serum ferritin, and sTfR/hepcidin ratio.

Patient reported outcome measures and cardiovascular outcomes following high dose modern intravenous iron in non-dialysis dependent chronic kidney disease: secondary analysis of ExplorIRON-CKD

Intravenous iron is commonly used to treat iron deficiency anemia in non-dialysis chronic kidney disease (ND-CKD). There is a paucity of information on the potential impact of intravenous iron on patient reported outcome measures, functional status and markers of cardiovascular health. As part of the secondary analysis of this double-blind exploratory randomized controlled trial focusing on patients with iron deficiency (+ /- anemia) and ND-CKD (serum ferritin < 200 µg/L or transferrin saturation ≤ 20% and serum ferritin 200-299 µg/L; CKD stages: 3a-5), 26 patients were randomized in a 1:1 ratio to receive ferric derisomaltose or ferric carboxymaltose. Participants received 1000 mg at baseline and 500-1000 mg at one month to achieve iron repletion. Quality of life and fatigue status were assessed using the Short-Form (36) questionnaire and the fatigue severity scale. Functional status was evaluated using the Duke Activity Status Index and the 1-min-sit-to-stand test. Cardiac markers such as NT-proBNP, Troponin T and pulse wave velocity were monitored. Intravenous iron was associated with similar improvements in most domains of the Short-Form (36) questionnaire, fatigue status, and 1-min-sit-to-stand ability increased significantly by the end of the trial in both groups (p < 0.001). Markers of cardiac function remained stable, with no arterial stiffness impact. Longer term studies are required to further evaluate the impact of intravenous iron on quality of life and cardiac safety in patients with ND-CKD.

Disutilities Associated with Intravenous Iron Infusions: Results from a Time Trade-off Survey and Diminishing Marginal Utility Model for Treatment Attributes in China

Purpose

Treatment process attributes can affect health state utilities associated with therapy. For intravenous iron, used to treat iron deficiency and iron deficiency anemia, research into process attributes is still lacking. This study estimated utilities associated with process attributes for intravenous iron infusions.

Methods

An online survey including seven health state vignettes and time trade-off tasks was administered to participants, who were not patients living with iron deficiency or iron deficiency anemia, from a Chinese online panel. Vignettes used an identical description of iron deficiency and iron deficiency anemia but differed in the annual number of infusions, infusion duration, and infusion-associated risk of hypophosphatemic osteomalacia. Disutilities and their rate of change as the number of infusions increased were examined using a power model.

Results

The survey was completed by 1091 participants. The highest utilities were observed for one annual infusion of 15-30 minutes or 30-60 minutes, without risk of hypophosphatemic osteomalacia (0.754 and 0.746, respectively). In comparison, more infusions and infusions with a risk of hypophosphatemic osteomalacia were associated with lower utilities. Utility continued to decrease, but at a diminishing rate, as the annual number of infusions increased, with utility decrements of 0.006 and 0.002, respectively, when going from zero to one and from four to five infusions per year. All marginal disutilities were small (values <0.01).

Conclusion

This study suggested that treatment attributes of intravenous iron infusions affect health state utilities. Using intravenous iron formulations that allow for fewer and shorter infusions without the risk of hypophosphatemic osteomalacia can reduce the number of visits required and increase patients' quality of life.

Ferric derisomaltose and tranexamic acid, combined or alone, for reducing blood transfusion in patients with hip fracture (the HiFIT trial): a multicentre, 2 × 2 factorial, randomised, double-blind, controlled trial

BACKGROUND

Anaemia and blood transfusion are associated with poor outcomes after hip fracture. We evaluated the efficacy of intravenous iron and tranexamic acid in reducing blood transfusions after hip fracture surgery.

METHODS

In this double-blind, randomised, 2 × 2 factorial trial, we recruited adults hospitalised for hip fractures in 12 medical centres in France who had preoperative haemoglobin concentrations between 9·5 and 13·0 g/dL. We randomly allocated participants (1:1:1:1), via a secure web-based service, to ferric derisomaltose (20 mg/kg intravenously) and tranexamic acid (1 g bolus followed by 1 g over 8 h intravenously at inclusion and 3 g topically during surgery), iron plus placebo (normal saline), tranexamic acid plus placebo, or double placebo. Unmasked nurses administered study drugs; participants and other clinical and research staff remained masked to treatment allocation. The primary outcome was the percentage of patients transfused during hospitalisation (or by day 30). The primary analysis included all randomised patients. This study is registered on ClinicalTrials.gov (NCT02972294) and is closed to new participants.

FINDINGS

Of 413 patients (51-104 years old, median [IQR] 86 [78-91], 312 [76%] women, 101 [24%] men), 104 received iron plus tranexamic acid, 103 iron plus placebo, 103 tranexamic acid plus placebo, and 103 double placebo between March 31, 2017 and June 18, 2021 (study stopped early for efficacy after the planned interim analysis done on the first 390 patients included on May 25, 2021). Data for the primary outcome were available for all participants. Among patients on double placebo, 31 (30%) were transfused versus 16 (15%) on both drugs (relative risk 0·51 [98·3% CI 0·27-0·97]; p=0·012). 27 (26%) participants on iron (0·81 [0·50-1·29]; p=0·28) and 28 (27%) on tranexamic acid (0·85 [0·54-1·33]; p=0·39) were transfused. 487 adverse events were reported with similar event rates among the groups; among prespecified safety endpoints, severe postoperative anaemia (haemoglobin <8 g/dL) was more frequent in the double placebo group. Main common adverse event were sepsis, pneumonia, and urinary infection, with similar rates among all groups.

INTERPRETATION

In patients hospitalised for hip fracture surgery with a haemoglobin concentration 9·5-13·0 g/dL, preoperative infusion of ferric derisomaltose plus tranexamic acid reduced the risk of blood transfusion by 50%. Our results suggest that combining treatments from two different pillars improves patient blood-management programmes. Either treatment alone did not reduce transfusion rates, but we might not have had the power to detect it.

FUNDING

French Ministry of Health, HiFIT trial.

Role of single-dose intravenous iron therapy for the treatment of anaemia after orthopaedic trauma: protocol for a pilot randomised controlled trial

INTRODUCTION

Orthopaedic trauma and fracture care commonly cause perioperative anaemia and associated functional iron deficiency due to a systemic inflammatory state. Modern, strict transfusion thresholds leave many patients anaemic; managing this perioperative anaemia is an opportunity to impact outcomes in orthopaedic trauma surgery. The primary outcome of this pilot study is feasibility for a large randomised controlled trial (RCT) to evaluate intravenous iron therapy (IVIT) to improve patient well-being following orthopaedic injury. Measurements will include rate of participant enrolment, screening failure, follow-up, missing data, adverse events and protocol deviation.

METHODS AND ANALYSIS

This single-centre, pilot, double-blind RCT investigates the use of IVIT for acute blood loss anaemia in traumatically injured orthopaedic patients. Patients are randomised to receive either a single dose infusion of low-molecular weight iron dextran (1000 mg) or placebo (normal saline) postoperatively during their hospital stay for trauma management. Eligible subjects include adult patients admitted for lower extremity or pelvis operative fracture care with a haemoglobin of 7-11 g/dL within 7 days postoperatively during inpatient care. Exclusion criteria include history of intolerance to intravenous iron supplementation, active haemorrhage requiring ongoing blood product resuscitation, multiple planned procedures, pre-existing haematologic disorders or chronic inflammatory states, iron overload on screening or vulnerable populations. We follow patients for 3 months to measure the effect of iron supplementation on clinical outcomes (resolution of anaemia and functional iron deficiency), patient-reported outcomes (fatigue, physical function, depression and quality of life) and translational measures of immune cell function.

ETHICS AND DISSEMINATION

This study has ethics approval (Oregon Health & Science University Institutional Review Board, STUDY00022441). We will disseminate the findings through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05292001; ClinicalTrials.gov.

Intravenous errc carboxymaltos vesus oral ferrous sulfate replament in elderly patients after acute non-variceal gastrointestinal bleeding (): protocol of a multicentre, open-label, randomised controlled trial

INTRODUCTION

Acute gastrointestinal bleeding (GIB) is a life-threatening emergency with a critical economic burden. As a result of bleeding, anaemia often requires intravenous or oral iron supplementation. Elderly patients are even more prone to untoward outcomes after hospital discharge if iron supplementation is inefficient. There is a gap in current guidelines on which supplementation route clinicians should choose. We aim to investigate the effect of one dose of intravenous iron therapy versus 3-month oral iron administration on anaemia in an elderly population.

METHODS AND ANALYSIS

The FIERCE study is an open-label, randomised controlled, two-armed trial. At least 48 hours after the acute non-variceal GIB treatment, patients will be recruited in participating centres. A random sequence generator will allocate the participants to group A (intravenous ferric carboxymaltose, 1000 mg) or group B (oral ferrous sulfate (FS), ca. 200 mg every day) with an allocation ratio of 1:1 on the day of the planned discharge from the hospital. Randomisation will be stratified for participating centres and the need for transfusion within the same hospitalisation before recruitment to the trial. Quality of life assessment, functional measurement and laboratory tests will be performed at baseline, 1 and 3 months±7 days after enrolment to the trial. The primary endpoint is a composite endpoint, including all-cause mortality, anaemia-associated unplanned emergency visit and anaemia-associated unplanned hospital admission within 3 months of enrolment in the trial.

ETHICS AND DISSEMINATION

The study has been approved by the relevant organisation, the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (46395-5/2021/EÜIG). We will disseminate our results to the medical community and will publish our results in peer-reviewed journals.

TRIAL REGISTRATION

The trial has been registered at ClinicalTrials.gov (NCT05060731).

Profile and characteristics of the adequacy of blood transfusions in Trauma Intensive Care. A cross sectional multicenter study

Introduction

Major trauma is one of the major health care problems facing modern society, trauma systems require careful planning to achieve an ideal level of coverage for the population. The Patient Blood Management Program is an integrated and global strategy to provide patient care that aims to assess and address, when possible, the etiology of blood abnormalities rather than transfuse without treating the underlying cause. We aimed to describe the factors that are associated with the clinical decision to transfuse polytraumatized patients admitted to the Intensive Care Unit (ICU).

Method

We performed a cross sectional multicenter study of patients admitted to ICUs for trauma in 14 Spanish hospitals from September 2020 to December 2021.

Results

A total of 69 patients were treated in the emergency room due to polytrauma, 46% of them were considered serious in the initial triage. Thirty were caused by a fall from considerable height (43.47%), followed by 39 patients admitted due to trac accidents (56.52%). The location of the trauma was mainly cranioencephalic, followed by thoracic trauma. Of the 69 patients, 25 received a blood transfusion during their ICU stay (36.23%).

Discussion

No significant differences were observed between transfused and non-transfused patients, except for the severity scales, where transfused patients have a higher score on all the scales assessed in the ICU except for the Revised Trauma Score. As we can see, the incidence of kidney failure was also different between the groups analyzed, reaching 44.00% in transfused patients and 13.64% in the group of patients without blood transfusion, p = 0.005. In this sense, 92.00% of the transfusions performed were inadequate according to the criteria of Hb in blood prior to the decision to transfuse (Hb < 9). Our data support the need to consider clinical practice guidelines regarding blood transfusion and its practices.

Pegcetacoplan versus eculizumab in patients with paroxysmal nocturnal haemoglobinuria (PEGASUS): 48-week follow-up of a randomised, open-label, phase 3, active-comparator, controlled trial

BACKGROUND

In the PEGASUS trial, the complement C3 inhibitor, pegcetacoplan, showed superiority to eculizumab in improving haematological outcomes in adult patients with paroxysmal nocturnal haemoglobinuria and suboptimal response to eculizumab at 16 weeks. The aim of the open-label period was to evaluate the long-term efficacy and safety of pegcetacoplan through to 48 weeks.

METHODS

PEGASUS was a phase 3, randomised, open-label, active-comparator controlled trial conducted in 44 centres in Australia, Belgium, Canada, France, Germany, Japan, Russia, South Korea, Spain, the UK, and the USA. Eligible participants were aged 18 years or older, had paroxysmal nocturnal haemoglobinuria, and had a haemoglobin concentration of less than 10·50 g/dL after 3 months or longer of stable eculizumab treatment. After a 4-week run-in with eculizumab plus pegcetacoplan, patients were randomly assigned (1:1) by interactive response technology to pegcetacoplan (1080 mg subcutaneously twice weekly) or eculizumab (according to their regimen at enrolment) for 16 weeks and could continue to the open-label period (32 weeks of pegcetacoplan monotherapy [pegcetacoplan-to-pegcetacoplan] or 28 weeks of pegcetacoplan monotherapy [eculizumab-to-pegcetacoplan]). Randomisation was stratified by platelet count and number of previous blood transfusions. The primary endpoint was change from baseline in haemoglobin at week 16, which has previously been reported. The outcomes of the open-label period (week 16 to week 48) are reported here. At 48 weeks, efficacy (including mean haemoglobin concentration and quality of life measured on the Functional Assessment of Chronic Illness Therapy [FACIT]-Fatigue scale) was assessed in the intention-to-treat population and safety was assessed per protocol. This trial was registered with ClinicalTrials.gov, NCT03500549, and has been completed.

FINDINGS

Between June 14, 2018, and Nov 14, 2019, 80 patients were randomly assigned to receive treatment with pegcetacoplan (41 patients) or eculizumab (39 patients). Most participants were women (49 [61%]) and 31 (39%) were men; 12 (15%) were Asian, two (3%) were Black, 49 (61%) were White, and 17 (21%) were another race or did not report their race. The open-label period had 77 participants (38 pegcetacoplan-to-pegcetacoplan, 39 eculizumab-to-pegcetacoplan). Patients in the pegcetacoplan-to-pegcetacoplan group maintained high mean haemoglobin concentrations between 16 weeks (11·54 g/dL [SD 1·96]) and 48 weeks (11·30 g/dL [1·77]; p=0·14). Patients in the eculizumab-to-pegcetacoplan group had significantly greater mean haemoglobin concentrations at 48 weeks (11·57 g/dL [2·21]) versus 16 weeks (8·58 g/dL [0·96]; p<0·0001). Clinically meaningful improvements in FACIT-Fatigue scores were observed at 48 weeks, with a mean change from baseline for all patients receiving pegcetacoplan monotherapy of 9·89 points (SD 9·63), for patients in the pegcetacoplan-to-pegcetacoplan group mean 10·14 points (9·06), and for patients in the eculizumab-to-pegcetacoplan group mean 9·62 points (10·34). During the entire study period, 13 (16%) of 80 patients discontinued treatment (three [7%] of 41 through to week 16 due to breakthrough haemolysis, and ten [13%] of 77 due to severe treatment-emergent adverse events) and 18 patients (eight pegcetacoplan-to-pegcetacoplan, ten eculizumab-to-pegcetacoplan) had at least one serious treatment-emergent adverse event during the open-label period, four were considered to be related to pegcetacoplan treatment. The most common treatment-emergent adverse events (in ≥10% patients) among both pegcetacoplan-treated groups during the open-label period were injection site reactions (in 20 [26%] of 77 patients), haemolysis (15 [19%]), nasopharyngitis (12 [16%]), and diarrhoea (ten [13%]). No treatment-related deaths occurred throughout the duration of the study.

INTERPRETATION

The durability of improved haematological outcomes and favourable safety profile over 48 weeks of treatment suggests that pegcetacoplan has the potential to improve treatment benefit and alter treatment goals in patients with paroxysmal nocturnal haemoglobinuria.

FUNDING

Apellis Pharmaceuticals.

Iron homeostasis in heart transplant recipients randomized to ferric derisomaltose or placebo

INTRODUCTION

The randomized IronIC trial evaluated the effect of intravenous ferric derisomaltose on physical capacity in iron-deficient, maintenance heart transplant (HTx) recipients. Iron deficiency was defined as in heart failure with high cut-points for ferritin to compensate for inflammation. However, intravenous iron did not improve physical capacity except in patients with ferritin <30 μg/L. We aimed to explore determinants of iron status in the 102 IronIC participants to better define iron deficiency in the HTx population.

METHODS

We assessed key governors of iron homeostasis, such as hepcidin, soluble transferrin receptor (sTfR), and interleukin-6 (IL-6). We also measured growth factors and inflammatory markers with relevance for iron metabolism. The results were compared to those of 21 healthy controls.

RESULTS

Hepcidin did not differ between HTx recipients and controls, even though markers of inflammation were modestly elevated. However, HTx recipients with ferritin <30 μg/L or sTfR above the reference range had significantly reduced hepcidin levels suggestive of true iron deficiency. In these patients, intravenous iron improved peak oxygen uptake. Hepcidin correlated positively with ferritin and negatively with sTfR.

CONCLUSION

HTx recipients with iron deficiency as defined in heart failure do not have elevated hepcidin levels, although inflammatory markers are modestly increased. The high ferritin cut-offs used in heart failure may not be suitable to define iron deficiency in the HTx population. We suggest that hepcidin and sTfR should be measured to identify patients with true iron deficiency, who might benefit from treatment with intravenous iron.

Intravenous iron therapy to treat burn anaemia: A retrospective cohort study

PURPOSE

Intravenous iron is an effective treatment for anaemia in many populations but has not been evaluated in those with burn anaemia. This study aimed to evaluate the efficacy and safety of intravenous iron to manage burn anaemia.

METHODOLOGY

This was a retrospective cohort study of patients admitted to the Royal Brisbane and Women's Hospital with burns to at least 15% total body surface area (TBSA). Data collected from patient records included demographics, treatment details, and outcomes including length of stay, blood transfusions, and serum haemoglobin concentrations. Linear mixed effects regression models were used to assess the effect of treatment with intravenous iron on haemoglobin over time.

RESULTS

Sixty patients met inclusion criteria, with 11 (18%) treated using intravenous iron. Those treated with intravenous iron had higher TBSA burns (median 39% vs 18%, P = 0.0005), more operations (3 vs 1, P = 0.0012), and more blood transfusions (median 8 units vs 0 units, P = 0.0002). One patient (9%) experienced a minor adverse drug reaction from intravenous iron. When examining the change in modelled haemoglobin levels over the first 14 days following the last major operation, the change in the intravenous iron group (11.22 g/L) was 14.56 g/L greater than the change in the group not receiving intravenous iron (-3.34 g/L, P = 0.0282).

CONCLUSION

This exploratory study provides preliminary evidence of benefit and safety of intravenous iron treatment on burn anaemia recovery.

Effect of postpartum anaemia on maternal health-related quality of life: a systematic review and meta-analysis

BACKGROUND

Postpartum anaemia remains a persistent and severe public health issue in many parts of the world. Studies have reported mixed findings on the effects of anaemia during the postpartum period on maternal health-related quality of life (HRQoL). We conducted this systematic review to summarise available evidence to inform public health practitioners on whether 1) anaemia negatively impact maternal health-related quality of life and 2) whether iron supplementation in anaemic women can improve maternal HRQoL during the postpartum period.

METHODS

This review's protocol was registered online with PROSPERO (CRD42020206618). We extensively searched Embase, PubMed, Cochrane and Scopus through the HINARI website to identify studies that reported either association or effect of postpartum anaemia on fatigue, depression and mother-child interaction. We restricted our search to studies of human females published in English language from databases inception until August 2020. We followed a Cochrane guideline for reporting systematic reviews and meta-analysis to synthesise data.

RESULTS

Twenty-seven studies were included in this systematic review, with some reporting all three domains (fatigue, depression and mother-child interaction) of HRQoL. Seven observational studies with pooled dichotomous outcomes showed that iron deficient or anaemic women were 1.66 times more likely to experience symptoms of depression than non-anaemic or iron-replete women [RR = 1.66 (95% CI: 1.28; 2.16), I2 = 67.0%, P < 0.01]. In three randomized controlled trials (RCTs), pooled continuous data showed statistically significant reduction in fatigue scores in women who received iron supplementation than the control group [MD: -1.85 (95% CI: -3.04; -0.67), I2 = 65.0%, p < 0.06]. Two of the four included studies showed that anaemic mothers were less responsive and had negative feelings towards their children than non-anaemic mothers.

CONCLUSION

Evidence from this review suggests that postpartum anaemia negatively affects health-related quality of life and that iron replenishment improves both symptoms of fatigue and depression. Nevertheless, it remains unclear whether postpartum anaemia affects mother-child interaction.

Platelet reactivity and platelet count in women with iron deficiency treated with intravenous iron

Background

Iron deficiency anemia (IDA) and heavy menstrual bleeding are prevalent, interrelated issues impacting over 300 million premenopausal women worldwide. IDA is generally associated with increased platelet counts; however, the effects of IDA and its correction on platelet function in premenopausal women remain unknown.

Objectives

We sought to determine how IDA and intravenous iron affect platelet count and platelet function in premenopausal women.

Methods

Hematologic indices were assessed in a multicenter, retrospective cohort of 231 women repleted with intravenous iron. Pre- and postinfusion blood samples were then obtained from a prospective cohort of 13 women to analyze the effect of intravenous iron on hematologic parameters as well as platelet function with flow cytometry and platelet aggregation assays under physiologic shear.

Results

Following iron replacement, anemia improved, and mean platelet counts decreased by 26.5 and 16.0 K/mm3 in the retrospective and prospective cohorts, respectively. Replacement reduced baseline platelet surface P-selectin levels while enhancing platelet secretory responses to agonists, including collagen-related peptide and ADP. Platelet adhesion and aggregation on collagen under physiologic shear also significantly increased following repletion.

Conclusion

We find that intravenous iron improves anemia while restoring platelet counts and platelet secretory responses in premenopausal women with iron deficiency. Our results suggest that iron deficiency as well as iron replacement can have a range of effects on platelet production and function. Consequently, platelet reactivity profiles should be further examined in women and other groups with IDA where replacement offers a promising means to improve anemia as well as quality of life.

OUP accepted manuscript

Background

Methods

Results

Conclusion

Clinical trial registration number

Intravenous iron for the treatment of iron deficiency anemia in China: a patient-level simulation model and cost-utility analysis comparing ferric derisomaltose with iron sucrose

OBJECTIVES

Two intravenous (IV) iron formulations, ferric derisomaltose (FDI) and iron sucrose (IS), are currently available for the treatment of iron deficiency anemia (IDA) in China. Clinical studies have demonstrated that FDI has an improved efficacy and safety profile versus IS, while requiring fewer infusions to correct iron deficits. Based on these findings, the present study evaluated the costs and benefits of FDI and IS for the treatment of IDA, from a healthcare system and societal perspective in China.

METHODS

A patient-level model was developed to project time to hematological response and incidence of cardiovascular adverse events and hypersensitivity reactions (HSRs) associated with FDI and IS over 5 years. Costs included iron acquisition, administration, and adverse event/HSR treatment costs, based on published studies, fee schedules, and a physician survey. Health state utilities associated with adverse events, HSRs, and the number of infusions were obtained from the literature and a time trade-off survey.

RESULTS

From a healthcare system perspective, FDI was associated with incremental costs of RMB 1,934 (purchasing power parity USD 462) and incremental quality-adjusted life expectancy of 0.078 quality-adjusted life-years (QALYs) versus IS, yielding an incremental cost-utility ratio of RMB 24,901 (USD 5,949) in the base case scenario. From a societal perspective, FDI was associated with reduced total costs and therefore dominant versus IS.

LIMITATIONS

Limitations included the absence of clinical data specific to China and insufficient data to model persistence with treatment.

CONCLUSIONS

This was the first cost-utility analysis comparing FDI and IS for the treatment of IDA in China. Based on a patient-level model, FDI was found to improve quality of life and reduce administration and adverse events costs relative to IS. Using the 2020 Chinese gross domestic product per capita of RMB 72,447 (USD 17,307) as a cost-effectiveness threshold, FDI would be considered cost-effective in China.

Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis

Importance

Intravenous iron is recommended by many clinical guidelines based largely on its effectiveness in reducing anemia. However, the association with important safety outcomes, such as infection, remains uncertain.

Objective

To examine the risk of infection associated with intravenous iron compared with oral iron or no iron.

Data Sources

Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials (RCTs) from 1966 to January 31, 2021. Ongoing trials were sought from ClinicalTrials.gov, CENTRAL, and the World Health Organization International Clinical Trials Search Registry Platform.

Study Selection

Pairs of reviewers identified RCTs that compared intravenous iron with oral iron or no iron across all patient populations, excluding healthy volunteers. Nonrandomized studies published since January 1, 2007, were also included. A total of 312 full-text articles were assessed for eligibility.

Data Extraction and Synthesis

Data extraction and risk of bias assessments were performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) and Cochrane recommendations, and the quality of evidence was assessed using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. Two reviewers extracted data independently. A random-effects model was used to synthesize data from RCTs. A narrative synthesis was performed to characterize the reporting of infection.

Main Outcomes and Measures

The primary outcome was risk of infection. Secondary outcomes included mortality, hospital length of stay, and changes in hemoglobin and red blood cell transfusion requirements. Measures of association were reported as risk ratios (RRs) or mean differences.

Results

A total of 154 RCTs (32 920 participants) were included in the main analysis. Intravenous iron was associated with an increased risk of infection when compared with oral iron or no iron (RR, 1.17; 95% CI, 1.04-1.31; I2 = 37%; moderate certainty of evidence). Intravenous iron also was associated with an increase in hemoglobin (mean difference, 0.57 g/dL; 95% CI, 0.50-0.64 g/dL; I2 = 94%) and a reduction in the risk of requiring a red blood cell transfusion (RR, 0.93; 95% CI, 0.76-0.89; I2 = 15%) when compared with oral iron or no iron. There was no evidence of an effect on mortality or hospital length of stay.

Conclusions and Relevance

In this large systematic review and meta-analysis, intravenous iron was associated with an increased risk of infection. Well-designed studies, using standardized definitions of infection, are required to understand the balance between this risk and the potential benefits.

Iron Deficiency in Celiac Disease: Prevalence, Health Impact, and Clinical Management

Iron is an essential nutrient to life and is required for erythropoiesis, oxidative, metabolism, and enzymatic activities. It is a cofactor for mitochondrial respiratory chain enzymes, the citric acid cycle, and DNA synthesis, and it promotes the growth of immune system cells. Thus, iron deficiency (ID) leads to deleterious effects on the overall health of individuals, causing significant morbidity. Iron deficiency anemia (IDA) is the most recognized type of anemia in patients with celiac disease (CD) and may be present in over half of patients at the time of diagnosis. Folate and vitamin B12 malabsorption, nutritional deficiencies, inflammation, blood loss, development of refractory CD, and concomitant Heliobacter pylori infection are other causes of anemia in such patients. The decision to replenish iron stores and the route of administration (oral or intravenous) are controversial due, in part, to questions surrounding the optimal formulation and route of administration. This paper provides an algorithm based on the severity of symptoms; its impact on the health-related quality of life (HRQL); the tolerance and efficiency of oral iron; and other factors that predict a poor response to oral iron, such as the severity of histological damage, poor adherence to GFD, and blood loss due to mucosal lesions.

Intravenous Iron-Induced Hypophosphatemia: An Emerging Syndrome

Some, but not all, intravenous iron formulations have been recognized to induce renal phosphate wasting syndrome. Most commonly this has been reported following treatment of iron deficiency anemia (IDA) with ferric carboxymaltose (FCM). A search of PubMed identified relevant randomized controlled trials (RCTs), and case studies evaluating hypophosphatemia (HPP) resulting from intravenous iron treatment. While more recent larger comparative RCTs have confirmed that the majority of patients receiving FCM, especially those with normal renal function, may experience severe HPP, complete documentation is hampered by inconsistent reporting of serum phosphate in such trials. Similarly, while case series and RCTs have documented the persistence of HPP for several weeks or even months, the lack of studies lasting beyond 5–6 weeks has constrained full understanding of the duration of effect. Clinical trials have established that the mechanism involves the bone/metabolic axis with the elevation of intact fibroblast growth factor 23 playing the central role. Reports continue to accumulate of the clinical consequences of severe HPP which are, most commonly, bone abnormalities following repetitive dosing. Case reports and studies, however, have also shown that symptomatic hypophosphatemia can occur after a single FCM dose. The frequency of such events remains unknown, in part due to lack of awareness of hypophosphatemia coupled with the fact that the most common acute symptoms of HPP (fatigue and weakness) are the same for IDA and for many of the chronic diseases that cause IDA. Changes to US and European prescribing information for FCM should raise awareness of the potential for HPP and need to monitor patients at risk for it.

NIMO-CKD-UK: a real-world, observational study of iron isomaltoside in patients with iron deficiency anaemia and chronic kidney disease

Background

Intravenous iron is often used to treat iron deficiency anaemia in non-dialysis chronic kidney disease (ND-CKD), but the optimal dosing regimen remains unclear. We evaluated the impact of high- versus low-dose intravenous iron isomaltoside on the probability of retreatment with intravenous iron in iron-deficient ND-CKD patients.

Methods

This real-world, prospective, observational study collected data from 256 ND-CKD patients treated for anaemia in the UK. Following an initial course of iron isomaltoside, patients were followed for ≥12 months. Iron dose and the need for retreatment were determined at the investigators’ discretion. The primary study outcome was the need for retreatment at 52 weeks compared between patients who received >1000 mg of iron during Course 1 and those who received ≤1000 mg. Safety was evaluated through adverse drug reactions.

Results

The probability of retreatment at Week 52 was significantly lower in the >1000 mg iron group (n = 58) versus the ≤1000 mg group (n = 198); hazard ratio (95% confidence interval [CI]): 0.46 (0.20, 0.91); p = 0.012. Mean (95% CI) haemoglobin increased by 6.58 (4.94, 8.21) g/L in the ≤1000 mg group and by 10.59 (7.52, 13.66) g/L in the >1000 mg group (p = 0.024). Changes in other blood and iron parameters were not significantly different between the two groups. Administering >1000 mg of iron isomaltoside saved 8.6 appointments per 100 patients compared to ≤1000 mg. No serious adverse drug reactions were reported. Of the patients who received ≤1000 mg of iron in this study, 82.3% were eligible for a dose >1000 mg.

Conclusions

The >1000 mg iron isomaltoside regimen reduced the probability of retreatment, achieved a greater haemoglobin response irrespective of erythropoiesis-stimulating agent treatment, and reduced the total number of appointments required, compared to the ≤1000 mg regimen. Many of the patients who received ≤1000 mg of iron were eligible for >1000 mg, indicating that there was considerable underdosing in this study.

Trial registration

ClinicalTrials.gov NCT02546154, 10 September 2015.

Is fatigue a cue to obtain iron supplements in Odisha, India? A mixed methods investigation

OBJECTIVES

This study aims to understand if fatigue, the main symptom of anaemia, is a health concern that cues women and their referent groups to obtain iron folic acid supplements.

DESIGN

This is a mixed methods study that consisted of a cross-sectional perceptual mapping and card sorting activity along with 16 focus group discussions with women of reproductive age, mothers-in-law and men. Participants of the perceptual mapping and card sorting activity were asked to compare images of anaemia-related items and concepts. Participants in the focus group discussions were asked about their daily life, aspirations and concerns among women and perceptions of anaemia and iron supplementation in the community. The quantitative data were analysed through multidimensional scaling and analyses of variance in SPSS. The qualitative data were analysed through applied thematic analysis using NVivo.

SETTING

Bhubaneswar, Odisha, India.

PARTICIPANTS

Women of reproductive age (n=30), mothers-in-law (n=30) and married men (n=30) were randomly selected to participate in the perceptual mapping and card sorting exercise. A separate sample of each group was randomly selected for the focus group discussions (n=148).

PRIMARY AND SECONDARY OUTCOME MEASURES

We collected perceptions of dissimilarity between anaemia-related items, including fatigue and medical items; the extent to which these items were perceived as important to health or likable; and qualitative information about gender norms.

RESULTS

Cognitive maps and card sorting revealed that fatigue was conceptualised distinctly from items related to medical treatment and that perceptions around fatigue's importance to health were low. Women from the focus groups reported that fatigue is a regular part of their daily life.

CONCLUSION

Our results indicate that fatigue is currently not an adequate cue to seek treatment, perhaps due to the normalisation of fatigue as a part of women's daily life.

Impact of non-cardiovascular comorbidities on the quality of life of patients with chronic heart failure: a scoping review

PURPOSE

To determine the impact of non-cardiovascular comorbidities on the health-related quality of life (HRQoL) of patients with chronic heart failure (CHF).

METHODS

A scoping review of the scientific literature published between 2009 and 2019 was carried out. Observational studies which assessed the HRQoL of patients with CHF using validated questionnaires and its association with non-cardiovascular comorbidities were included.

RESULTS

The search identified 1904 studies, of which 21 fulfilled the inclusion criteria to be included for analysis. HRQoL was measured through specific, generic, or both types of questionnaires in 72.2%, 16.7%, and 11.1% of the studies, respectively. The most common comorbidities studied were diabetes mellitus (12 studies), mental and behavioral disorders (8 studies), anemia and/or iron deficiency (7 studies), and respiratory diseases (6 studies). Across studies, 93 possible associations between non-cardiovascular comorbidities and HRQoL were tested, of which 21.5% regarded anemia or iron deficiency, 20.4% mental and behavioral disorders, 20.4% diabetes mellitus, and 14.0% respiratory diseases. Despite the large heterogeneity across studies, all 21 showed that the presence of a non-cardiovascular comorbidity had a negative impact on the HRQoL of patients with CHF. A statistically significant impact on worse HRQoL was found in 84.2% of associations between mental and behavioral disorders and HRQoL (patients with depression had up to 200% worse HRQoL than patients without depression); 73.7% of associations between diabetes mellitus and HRQoL (patients with diabetes mellitus had up to 21.8% worse HRQoL than patients without diabetes mellitus); 75% of associations between anemia and/or iron deficiency and HRQoL (patients with anemia and/or iron deficiency had up to 25.6% worse HRQoL than between patients without anemia and/or iron deficiency); and 61.5% of associations between respiratory diseases and HRQoL (patients with a respiratory disease had up to 21.3% worse HRQoL than patients without a respiratory disease).

CONCLUSION

The comprehensive management of patients with CHF should include the management of comorbidities which have been associated with a worse HRQoL, with special emphasis on anemia and iron deficiency, mental and behavioral disorders, diabetes mellitus, and respiratory diseases. An adequate control of these comorbidities may have a positive impact on the HRQoL of patients.

Intravenous iron: a framework for changing the management of iron deficiency

For decades intravenous iron was considered dangerous. Newer formulations with carbohydrate cores binding elemental iron more tightly allow complete iron replacement within 15-60 min in one visit. Meta-analyses and prospective comparisons of different formulations support equivalent safety to placebo with less toxicity than oral iron. Of the available formulations, the preponderance of published evidence supports equal safety and efficacy. In this Viewpoint, we report evidence supporting repositioning of intravenous iron to the frontline in multiple disorders with iron deficiency, which include heart failure, chronic kidney disease, inflammatory bowel disease, patient blood management in the perioperative period, and obstetrics and gynaecology. We have also highlighted neonatal evidence supporting the inadequacy of oral iron in late pregnancy, a critical period of iron need for normal foetal brain development. Physicians should consider prioritising the use of intravenous iron rather than oral iron as a treatment for iron deficiency in some of these clinical scenarios.

Association between atopic disease and anemia in pediatrics: a cross-sectional study

BACKGROUND

Atopic diseases, such as atopic dermatitis, allergic rhinitis, and asthma, are inflammatory diseases common in pediatric patients. This study investigated whether these inflammatory atopic diseases were associated with anemia in pediatrics.

METHODS

A cross-sectional study was conducted using a pediatric dataset from the Health Insurance Review and Assessment Service (HIRA) of South Korea in 2016. Multivariable logistic regression, adjusting for demographic covariates was used for analyse the association between atopic disease and iron deficiency anemia (IDA).

RESULTS

A total of 846,718 pediatric patients were included in the study. Of these, 19,594 (2.31%) had a diagnosis of IDA. The logistic regression analyses including covariates revealed there were association between atopic disease and IDA. The adjusted OR (aOR) of IDA was 1.42 (95% CI, 1.37-1.47) for atopic dermatitis, 1.25 (95% CI, 1.21-1.29) for allergic rhinitis, and 1.71 (95% CI, 1.65-1.76) for asthma. IDA was more prevalent in patients with multiple comorbid atopic diseases, with aOR of 1.30 (95% CI, 1.25-1.35), 1.81 (95% CI, 1.73-1.89), and 2.58 (95% CI, 2.43-2.73) for 1, 2, or 3 atopic diagnoses. There was no evidence of multicollinearity among covariates.

CONCLUSIONS

Our findings suggest that atopic disease was associated with IDA. Further study is needed to clarify the distinction between IDA and/or AI to better understand the cause of anemia in patients with inflammatory diseases.

Importance of Initial Complete Parenteral Iron Repletion on Hemoglobin Level Normalization and Health Care Resource Utilization: A Retrospective Analysis

STUDY OBJECTIVE

Iron deficiency anemia is the most common form of anemia, and parenteral iron therapy is necessary in select patients. The objective of this analysis was to assess the impact of initial complete parenteral iron repletion on serum hemoglobin (Hgb) level normalization and on health care resource utilization in real-world practice.

DESIGN

Retrospective observational study.

DATA SOURCE

Decision Resources Group Real-World Data Repository (United States databases).

PATIENTS

A total of 2966 patients who had a baseline Hgb level below normal (< 12 g/dl for females and < 13.5 g/dl for males) and were treated with parenteral iron between March 2015 and February 2017.

MEASUREMENTS AND MAIN RESULTS

The effect of receiving the required parenteral iron dose to replete the deficit, calculated by a modified Ganzoni formula, within 3 weeks of the first parenteral iron therapy claim (index date) on the likelihood of Hgb level normalization, was estimated by using logistic regression. All analyses were adjusted for sex, age, comorbidities, and use of prescription oral iron therapy. The adjusted mean numbers of all-cause inpatient admissions, outpatient visits, and emergency department (ED) visits within 6 months and 1 year after the index date were compared between patients with and without normalized Hgb levels by using negative binomial regression. Of the 2966 included patients, 33.9% received the required iron dose within 3 weeks of the index date, and 19.6%, 48.2%, and 53.9% had a normalized Hgb level within 8 weeks of the index date, within 1 year of the index date, and until the end of data availability, respectively. Patients who received the required iron dose within 3 weeks of the index date were significantly more likely to have a normalized Hgb level within 8 weeks of the index date and at any time during the study period than those who did not: adjusted odds ratio (OR) (95% confidence interval [CI]) 2.67 (2.20, 3.24) and 2.33 (1.96, 2.77), respectively. Hgb level normalization within 1 year of the index date was associated with fewer inpatient admissions and outpatient visits and a similar number of ED visits compared with no Hgb level normalization 1 year after the index date.

CONCLUSION

The results of these analyses underscore the importance of initial complete parenteral iron repletion for rapidly improving clinical outcomes. Prompt achievement of a normalized Hgb level may also provide an opportunity to reduce health care resource utilization in patients with iron deficiency anemia receiving parenteral iron therapy.

Iron deficiency in long standing type 1 diabetes mellitus and its association with depression and impaired quality of life

AIMS

Iron deficiency (ID) is the most frequent malnutrition worldwide and often associated with reduced quality of life (QoL) and depression. We aimed to investigate the iron status in middle-aged type 1 diabetes in relation to depression and QoL.

METHODS

109 people with type 1 diabetes (54.1% male, mean age 56.2 years) were enrolled in a cross-sectional study at the diabetes clinic of the Goethe University Hospital. Iron, haemoglobin and ferritin levels were measured. Treatment satisfaction, QoL and depression were assessed using standardized questionnaires (Disease Specific Quality of Life scale, CES-D (Center for Epidemiological Studies Depression Scale) and WHO-5 well-being index.

RESULTS

Decreased serum iron (<60 µg/dl) and ferritin levels (<50 pg/nl) were observed in 18 (16.8%) and 28 (26.7%) patients, respectively. Anemia was present in 20 patients (18.34%). A high rate of depression was observed: 42.2% (WHO-5) and 40.7% (CES-D). The personal goals and current diabetes therapy satisfaction score (PWTSS) was significantly better in patients with sufficient iron status (ferritin level > 50 pg/ml, p = 0.018). Multiple regression analysis revealed iron status (p = 0.03) to be an independent predictor for better PWTSS. Insufficient iron status correlated significantly with depression as measured by WHO-5 (p = 0.044) and CES-D (p = 0.029).

CONCLUSIONS

Type 1 diabetes patients in the current study were frequently depressive and reported an impaired QoL that associated with iron insufficiency. If confirmed a better awareness is needed for depression and ID in long standing disease.