Do you have iron deficiency anemia?

By Jaime Moreno

Is it possible that you have low iron levels in your body? Iron deficiency anemia is one of the most frequent causes of longstanding malaise in human beings. Worldwide, it is estimated that 1.24 billion individuals have iron deficiency anemia and over two billion have insufficient iron.

Iron deficiency has medical and social impacts, including impairment of cognitive performance in children, pregnancy complications for mothers and newborns, decreased work capacity in adults, and both physical and cognitive loss in the elderly.

Types of anemia
Iron deficiency is the most frequent anemia, but it certainly is not the only one. There are at least 40 types of anemia that are treated in a different fashion. Nevertheless, it is common practice to start oral iron tablets or liquid iron ampules, as soon as anemia is detected with a CBC (Complete Blood Count). This habit should not only be avoided but it should be prohibited because, first, if you have an anemia of a different cause, iron will not help; second, if it is iron deficiency but its cause is not defined, serious diseases as gynecologic or colon cancers may be concealed; and third, this therapeutic manipulation may confuse your doctors when approaching anemia in a professional way, because the laboratory results may be spurious, false.

Hepcidin, a hormone produced in the liver, was discovered in 2001. Iron deficiency affects homeostasis (organic equilibrium), inducing adaptive mechanisms primarily in the hepcidin-ferroportin axis. Iron is exclusively exported from the cells via ferroportin, and is facilitated when hepcidin is low or absent. Iron is stored in the molecule ferritin, it is exported via ferroportin and is transported in the bloodstream via transferrin. Increased iron mobilization is performed in cells that absorb iron (enterocytes, small intestine), cells that recycle iron (macrophages) and storage cells (hepatocytes).

This technical summary, which hopefully did not drive away some readers, is important because, with the use of oral iron, including ferrous sulfate tablets (60-240 mg), hepcidin levels are increased, with ferroportin degradation, and decreased iron absorption which is an extreme need in iron-deficient patients.

Causes of iron deficiency anemia and low iron levels
An incomplete list of causes of low iron levels and iron deficiency anemia is presented, so that you can consider if you or some relatives may belong to one or more of these etiologic categories:

1) Increased iron requirements: infants, preschool children, adolescents, pregnant women in their second or third-trimester pregnancies.

2) Low iron intake: malnutrition, vegans.

3) Decreased intestinal iron absorption: gastrectomy, duodenal bypass, bariatric surgery to lose weight, gluten-induced enteropathy, autoimmune atrophic gastritis, Helicobacter pylori infection, drugs such as proton pump inhibitors (omeprazole, pantoprazol), H2 blockers (Zantac, Taural), green tea intake, genetic IRIDA (iron-refractory iron deficiency anemia).

4) Chronic blood loss: Hookworm infestation, gastrointestinal benign and malignant lesions (cancer); salicylates (aspirin), corticosteroids, nonsteroidal anti-inflammatory drugs (ibuprofen, Advil); heavy menstrual bleeding defects of hemostasis, hematuria; intravascular hemolysis, paroxysmal nocturnal hemoglobinuria (PNH); anticoagulant and antiplatelet drugs; defects of hemostasis (hereditary hemorrhagic telangiectasia, von Willebrand disease, hemophilia); frequent blood donors, repeated bloodletting.

5) Multiple causes (absolute iron deficiency associated with inflammation): chronic infections in malnutrition, chronic kidney disease, chronic systolic heart failure, inflammatory bowel disease; postoperative anemia of major surgery.

When approaching this prevalent and complex syndrome (aggregate of signs and symptoms), prior to starting any treatment we must search for the correct diagnosis, which is not always easy even for the experts.

Anemia clinical signs and symptoms are nonspecific, and frequently they are not even considered. Pale skin, fatigue, pica (compulsive intake of non-nutritive substances, as ice, clay, soil, hair), iron deficiency dysphagia called Plummer-Vinson o Paterson-Kelly syndromes. In elderly patients, iron deficiency anemias can produce heart failure or angina.

A correct diagnosis requires a laboratory workup: CBC, iron, ferritin, transferrin, reticulocytes, peripheral blood smear with direct vision under the microscope and interpreted by well-trained personnel. In clinical practice, it is not necessary to measure transferrin saturation or hepcidin, except in special and infrequent cases such as IRIDA (iron-refractory iron deficiency anemia).

Only after the anemia syndrome has been well-defined as iron deficiency anemia, its treatment should be started. The chosen oral iron dose should be administered every other day for six months. There are parenteral iron products to be administered intravenously, and many times they are preferred because of its prompt therapeutic effect, observed in a few weeks, not in months.

After the correct treatment, it is mandatory to investigate the causes of iron deficiency, going through the causal list presented before in this article. It is stressed that to correct the anemia is fundamental, but the investigation and management of its causes is of paramount importance.

(Ref. Camaschella. Iron Deficiency. Blood. 2019;133(1):30-39)

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Dr. Jaime Moreno Aguilar is an internist with specialties in hematology and oncology, with offices in Cuenca.

Dr. Moreno writes the InfoHealth blog.
For more information and the InfoSalud Spanish language version please click here.
Dr. Jaime Moreno Aguilar
Consultorios Santa Inés, Torre 1, Oficinas 003 y 102
Daniel Córdova y Federico Proaño
Teléfonos: 072843136 – 0997281884 – 0997257585
jaime.moreno@yahoo.com