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

Abstract

Many patients experiencing acute gastrointestinal bleeding (GIB) require iron supplementation to treat subsequent iron deficiency (ID) or iron-deficiency anemia (IDA). Guidelines regarding management of these patients are lacking. We aimed to identify areas of unmet need in patients with ID/IDA following acute GIB in terms of patient management and physician guidance. We formed an international working group of gastroenterologists to conduct a narrative review based on PubMed and EMBASE database searches (from January 2000 to February 2021), integrated with observations from our own clinical experience. Published data on this subject are limited and disparate, and those relating to post-discharge outcomes, such as persistent anemia and re-hospitalization, are particularly lacking. Often, there is no post-discharge follow-up of these patients by a gastroenterologist. Acute GIB-related ID/IDA, however, is a prevalent condition both at the time of hospital admission and at hospital discharge and is likely underdiagnosed and undertreated. Despite limited data, there appears to be notable variation in the prescribing of intravenous (IV)/oral iron regimens. There is also some evidence suggesting that, compared with oral iron, IV iron may restore iron levels faster following acute GIB, have a better tolerability profile, and be more beneficial in terms of quality of life. Gaps in patient care exist in the management of acute GIB-related ID/IDA, yet further data from large population-based studies are needed to confirm this. We advocate the formulation of evidence-based guidance on the use of iron therapies in these patients, aiding a more standardized best-practice approach to patient care.

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

“…30,31 If we had not assessed IV iron as appropriate when severe ID was present and acute anemia superimposed leading to a large iron deficit or when certain patient characteristics argued against oral administration, an even higher rate of inappropriate IV iron prescriptions would have been observed. As significant care gaps exist in this patient group, 32 further studies comparing IV and oral iron therapies are needed in the setting of GIB. 32 In contrast, treatment of ID in patients with chronic heart failure has been thoroughly investigated.…”

“…As significant care gaps exist in this patient group, 32 further studies comparing IV and oral iron therapies are needed in the setting of GIB. 32 In contrast, treatment of ID in patients with chronic heart failure has been thoroughly investigated. Evidence suggests that IV iron (but not oral iron) 33 reduces hospital admissions for patients with HFrEF.…”

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

“…Treating anaemia and iron deficiency in patients with AUGIB involves erythrocyte transfusion, intravenous iron or oral iron therapy. 6,7 As pointed out in the review, blood transfusion is restricted in AUGIB and is only recommended if a patient is haemodynamically unstable or has a haemoglobin <7 g/dL (<8 g/dL in patients with cardiovascular disease). 1 Since over half of the patients with AUGIB are discharged with anaemia, initiating iron repletion therapy (IRT) at discharge is pertinent.…”

“…5 Additionally, since iron stores typically amount to approximately 10 mg/kg body weight in males and approximately 6-8 mg/kg in females, 5 loss of 1000-2000 mL translates to a depletion of 500-1000 mg of iron, precipitating anaemia and iron deficiency.Treating anaemia and iron deficiency in patients with AUGIB involves erythrocyte transfusion, intravenous iron or oral iron therapy. 6,7 As pointed out in the review, blood transfusion is restricted in AUGIB and is only recommended if a patient is haemodynamically unstable or has a haemoglobin <7 g/dL (<8 g/dL in patients with cardiovascular disease). 1 Since over half of the patients with AUGIB are discharged with anaemia, initiating iron repletion therapy (IRT) at discharge is pertinent.…”

“…1 Since over half of the patients with AUGIB are discharged with anaemia, initiating iron repletion therapy (IRT) at discharge is pertinent. 6,7 A randomised, double-blind, placebo-controlled trial investigated iron substitution post non-variceal AUGIB. 8 Oral iron (200 mg daily for 3 months; 56% adherence) was compared to intravenous iron (500-1000 mg at discharge; 100% adherence).…”