British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults

Abstract

Iron deficiency anaemia (IDA) is a major cause of morbidity and burden of disease worldwide. It can generally be diagnosed by blood testing and remedied by iron replacement therapy (IRT) using the oral or intravenous route. The many causes of iron deficiency include poor dietary intake and malabsorption of dietary iron, as well as a number of significant gastrointestinal (GI) pathologies. Because blood is iron-rich it can result from chronic blood loss, and this is a common mechanism underlying the development of IDA—for example, as a consequence of menstrual or GI blood loss.Approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract. Therefore optimal management of IDA requires IRT in combination with appropriate investigation to establish the underlying cause. Unexplained IDA in all at-risk individuals is an accepted indication for fast-track secondary care referral in the UK because GI malignancies can present in this way, often in the absence of specific symptoms. Bidirectional GI endoscopy is the standard diagnostic approach to examination of the upper and lower GI tract, though radiological scanning is an alternative in some situations for assessing the large bowel. In recurrent or refractory IDA, wireless capsule endoscopy plays an important role in assessment of the small bowel.IDA may present in primary care or across a range of specialties in secondary care, and because of this and the insidious nature of the condition it has not always been optimally managed despite the considerable burden of disease— with investigation sometimes being inappropriate, incorrectly timed or incomplete, and the role of IRT for symptom relief neglected. It is therefore important that contemporary guidelines for the management of IDA are available to all clinicians. This document is a revision of previous British Society of Gastroenterology guidelines, updated in the light of subsequent evidence and developments.

Iron Replacement Therapy with Oral Ferric Maltol: Review of the Evidence and Expert Opinion

“…An easy-to-use oral iron therapy with good absorption and low risk of gastrointestinal adverse events would minimize the burden of treatment on patients requiring long-term iron replacement. Various alternatives to oral ferrous iron formulations have been developed, including polysaccharide-ferric iron complexes, sucrosomial iron, sodium feredate, ferric citrate, and ferric maltol [27,[45][46][47].…”

“…To date, ferric maltol has been assessed in almost 750 adults and adolescents (661 in clinical trials and 87 in real-world studies) with a range of underlying conditions, including IBD, CKD, and pulmonary hypertension. The clinical trials were designed, as far as possible, to reflect the real-world settings in which ferric maltol will be used, with primary endpoints at 12 or 16 weeks followed by longer-term maintenance treatment in line with recommended treatment durations for oral iron therapies and current understanding of the time required for physiologic restoration of iron stores [45,[88][89][90][91]. A further phase III study is being planned in infants and children (age range 1 month to 17 years) with IBD and irondeficiency anemia, which will use an oral suspension currently under investigation [92].…”

Small Bowel Malignancies in Patients Undergoing Capsule Endoscopy for Iron Deficiency Anemia

“…About 5–12% of healthy premenopausal women have IDA, which is attributed to inadequate dietary intake, menstrual blood loss, pregnancy, and breastfeeding [ 27 , 28 ]. In premenopausal women, the prevalence of GI malignancy is low and bidirectional endoscopy is not generally recommended [ 29 ]. However, premenopausal women sometimes develop GI tract cancers or benign bleeding lesions such as peptic ulcers.…”

“…However, premenopausal women sometimes develop GI tract cancers or benign bleeding lesions such as peptic ulcers. Therefore, GI investigation of premenopausal women with IDA is justified, particularly in patients with recurrent IDA, symptoms, or a family history of GI malignancy [ 7 , 29 ]. In addition, studies have reported a high frequency of upper GI and colorectal cancers in premenopausal women [ 30 , 31 ].…”

“…Thus, GI evaluation at the same level as for the elderly is recommended for young men [ 25 , 32 ]. Men and postmenopausal women have a higher prevalence of upper GI and colorectal malignancies than premenopausal women; thus, bidirectional endoscopy is recommended [ 7 , 29 ]. Some studies have reported high frequencies of upper GI and colorectal cancers in men and postmenopausal women [ 33 , 34 ].…”