From the Guidelines
Iron supplementation in patients with anemia of chronic disease (ACD) should be initiated when there is concurrent iron deficiency, as confirmed by laboratory tests showing low ferritin (<30 ng/mL) or low transferrin saturation (<20%) despite elevated inflammatory markers. The decision to start iron supplements should be based on the presence of iron deficiency, rather than solely on the diagnosis of ACD. According to the European Crohn's and Colitis Organization (ECCO) guidelines 1, iron supplementation is recommended in all patients with iron-deficiency anemia, and the choice between oral and intravenous iron should be based on the severity of the disease, patient tolerance, and response to treatment.
When iron deficiency is confirmed alongside ACD, oral iron supplements like ferrous sulfate (325 mg 1-3 times daily), ferrous gluconate (300-325 mg daily), or ferrous fumarate (200 mg daily) can be prescribed. If oral iron is ineffective or poorly tolerated, intravenous iron formulations such as iron sucrose, ferric carboxymaltose, or iron dextran may be more appropriate, especially in inflammatory conditions where oral iron absorption is impaired 1. The ECCO guidelines suggest that intravenous iron should be considered as first-line treatment in patients with clinically active inflammatory bowel disease, with previous intolerance to oral iron, with hemoglobin below 100 g/L, and in patients who need erythropoiesis-stimulating agents.
It is essential to monitor hemoglobin, ferritin, and inflammatory markers regularly to assess treatment response and adjust the iron supplementation regimen as needed. The goal of treatment is to normalize hemoglobin levels and replenish iron stores, which can typically be achieved within 3-6 months. Iron supplementation without confirmed deficiency in ACD can be harmful, as it may increase infection risk, exacerbate inflammation, and contribute to oxidative stress 1.
In patients with ACD, it is crucial to balance the need for iron supplementation with the potential risks and benefits. The ECCO guidelines recommend that iron supplementation should be individualized based on the patient's history, symptoms, and preferences 1. By following these guidelines and carefully monitoring treatment response, healthcare providers can optimize iron supplementation in patients with ACD and improve their overall quality of life.
From the Research
Initiation of Iron Supplementation in Anemia of Chronic Disease (ACD)
- Iron supplementation is crucial for the treatment of anemia in patients with chronic kidney disease (CKD) 2, 3, 4, 5
- The decision to initiate iron supplementation in ACD should be based on the presence of iron deficiency, which can be diagnosed by low serum ferritin levels and transferrin saturation 2, 4, 6
- Intravenous iron supplementation is considered superior to oral iron supplementation, especially in patients with CKD stages 3 to 5 and those undergoing dialysis 2, 3, 4, 5
- The choice of intravenous iron formulation should be based on the patient's individual needs and the potential risks and benefits of each formulation 3, 4, 5
- Ferric carboxymaltose and ferumoxytol are examples of intravenous iron formulations that have been shown to be effective and well-tolerated in patients with CKD and iron deficiency anemia 3, 4
Factors to Consider When Initiating Iron Supplementation
- Presence of iron deficiency, as diagnosed by low serum ferritin levels and transferrin saturation 2, 4, 6
- CKD stage and presence of dialysis 2, 3, 4, 5
- Patient's individual needs and potential risks and benefits of each intravenous iron formulation 3, 4, 5
- Presence of underlying diseases, such as chronic heart failure and chronic inflammatory disorders, which may affect iron absorption and utilization 6