Iron Deficiency Anemia In Adults Research Articles

O-022 Intravenous Iron Sucrose for Treatment of Iron Deficiency Anemia in Pediatric Inflammatory Bowel Disease

Iron deficiency anemia (IDA) is a common complication of pediatric inflammatory bowel disease (IBD). The effectiveness of oral iron supplementation in the treatment of IDA is limited by its slow onset of action, daily dosing, gastrointestinal side effects, and potential for exacerbation of intestinal inflammation. Intravenous iron sucrose (IS) is an effective and safe alternative treatment for IDA in adults with IBD, but its role in the treatment of IDA in pediatric IBD is unclear. The primary aim of this study was to evaluate the use of IS in pediatric IBD patients with IDA and determine the clinical response measured by improvement in hemoglobin. Secondary aim was to describe adverse events associated with IS use in this population. A retrospective chart review of all pediatric IBD patients receiving IS infusions for IDA at The Children's Hospital of Philadelphia between January 2011 and August 2015 was performed. The diagnosis of IDA was based on low hemoglobin for age and sex, although serum concentrations of iron, ferritin, mean corpuscular volume, total iron-binding capacity, and red blood cell distribution width were also referenced to confirm the diagnosis. Patients who had a transfusion of blood products within 2 months of an IS infusion or who had no follow-up laboratory evaluation within 2 months of the last IS infusion were excluded from the efficacy analysis. Adverse events were reported descriptively. Repeated measures ANOVA was used to evaluate paired continuous variables with post-hoc testing performed using Tukey's test. Seventy-five patients (57 with Crohn disease, 10 with ulcerative colitis, and 8 with indeterminate colitis) received a total of 280 IS infusions with 4 patients receiving multiple treatment courses. Patients were administered 200 mg per dose, 2 mg/kg per dose, or dosing calculated based on total iron deficit. The mean treatment course (±SD) was 3.5 ± 1.6 doses. Fifty-two patients qualified for analysis. The mean age (±SD) was 14.6 ± 3.1 years. There was a statistically significant increase in hemoglobin over the treatment course, with mean hemoglobin increasing from 9.6 ± 1.2 g/dL at baseline to 12.0 ± 1.3 g/dL after IS treatment (P < 0.0001). Post-hoc analysis revealed that change in hemoglobin was greatest after 4 infusions with subsequent dosing having no increased benefit. There were no statistically significant differences in change in hemoglobin between the 3 different IS doses. Twenty-two adverse events were reported in 15 patients (7.9% of the total number of infusions), including blood pressure (8/22) and pulse fluctuations (6/22), pain at IV site (6/22), chills (1/22), and IV infiltration (1/22). No anaphylaxis reactions occurred. The patient with IV infiltration required IS infusion discontinuation. Otherwise, none of the adverse events resulted in IS discontinuation and none were life-threatening, required treatment, or hospitalization. This is one of the first reported studies on IS therapy in a cohort of children with IBD and suggests that IS is a safe and potentially efficacious treatment for IDA in pediatric IBD.

Ferumoxytol as an off-label contrast agent in body 3T MR angiography: a pilot study in children.

Ferumoxytol is an ultrasmall superparamagnetic iron oxide (USPIO) nanoparticle agent used to treat iron deficiency anemia in adults with chronic kidney disease. We aim to determine the feasibility of using ferumoxytol for clinical pediatric cardiac and vascular imaging. We retrospectively identified 23 consecutive children who underwent MRI with ferumoxytol (11 males; mean age: 7.4years, range: 3days-18years), yielding 12 abdominal MR angiography and 15 cardiac MRI studies. Medical records were reviewed for the clinical indication, ferumoxytol dose, injection rate, sedation and any complication. A two-reader consensus scored the images on a five-point scale for overall image quality and delineation of various anatomical structures. Signal-to-background ratios for abdominal aorta and inferior vena cava for abdominal cases and blood pool-myocardium contrast ratios for cardiac cases were calculated. The confidence intervals for obtaining a score of three or above for each image parameter were calculated by using adjusted Wald method. For abdominal MR angiography, average scores for overall image quality, as well as delineation of the hepatic artery, superior mesenteric artery, renal artery and veins were 4.5, 4.3, 4.3, 3.7 and 4.7, respectively. For cardiac exams, the average scores for overall image quality, systemic arteries, pulmonary arteries, pulmonary veins, valves and ventricles were 4.4, 4.6, 4.1, 4.8, 4.1 and 4.7, respectively. For all parameters, the lower bound for the proportion of cases to have a score of 3 or above was 65%. Signal-to-background ratios for aorta and abdominal veins averaged 86 +/- 74 and 86 +/- 77 for full-dose images, and 23 and 18 for half-dose images, respectively. Mean blood pool to myocardium contrast ratio was 3:3. Ferumoxytol can provide excellent image quality for pediatric body MR angiography/MR venography at a dose of 1.5 or 3mg Fe/kg. Further investigation should be directed toward understanding the lowest dose that can be administered.

Effect of Ferumoxytol Treatment on Secondary Thrombocytosis in Patients With Iron Deficiency Anemia and Inflammatory Bowel Disease

Introduction: Iron deficiency anemia (IDA) is common in patients with gastrointestinal (GI) disease due to multiple factors, such as blood loss and malabsorption, and with IBD, exacerbated by inflammation. Secondary thrombocytosis, a consequence of both IDA and inflammation, is a frequent complication of IBD. This subgroup analysis of a randomized, placebo-controlled, double-blind, study explored the impact of treatment with ferumoxytol (FER), an IV iron indicated for the treatment of IDA in adults with chronic kidney disease, on secondary thrombocytosis in patients whose underlying cause of IDA was IBD vs. those with other GI disorders (e.g., gastric bypass, GI bleed). Methods: Patients with a history of unsatisfactory oral iron therapy or in whom oral iron cannot be used, Hgb <10 and >7 g/dL, and TSAT <20% were randomized 3:1 to either 2 injections of 510 mg of FER 5±3 days apart or normal saline (placebo). Measures of hematology and iron status (including: platelets [PLT], Hgb, reticulocyte Hgb content [CHr] (sensitive marker of iron availability), transferrin saturation [TSAT], ferritin) were assessed at baseline and weekly up to week 5. Baseline values were compared between patients whose underlying cause of IDA was IBD vs. other non-inflammatory GI disorders using T-test. Changes from baseline were compared between treatment groups using ANCOVA controlling for baseline values and IBD subgroup. Results: The degree of iron deficiency and anemia was similar in both subgroups at baseline, with no difference in mean Hgb, CHr, TSAT, or ferritin. Consistent with a greater degree of inflammation among IBD patients, their leukocyte count trended higher, and while mean PLT count was elevated in both subgroups, it was significantly higher in the IBD subgroup. Independent of IBD status, mean PLT count decreased significantly more following FER than placebo, with the proportion of patients with PLT>400 decreasing in the FER group from 35% to 10% (p<0.0001, McNemar’s) and remaining unchanged in the placebo group. These changes were accompanied by significantly greater improvement in all markers of iron status with FER than placebo, and no change in leukocyte count in either group. Conclusion: Treatment with IV iron decreased elevated PLT count independent of IBD status or apparent effect on inflammation. Disclosure - Dr Dahl - employee: AMAG Pharmaceuticals, Inc.; Dr Strauss - employee: AMAG Pharmaceuticals, Inc.; Dr Kaper - employee: AMAG Pharmaceuticals, Inc; Ms Bernard employee: AMAG Pharmaceuticals, Inc. This research was supported by an industry grant from AMAG Pharmaceuticals, Inc.Table 1

Ferumoxytol-Enhanced Magnetic Resonance Angiography is a Feasible Method for the Clinical Evaluation of Lower Extremity Arterial Disease

Renal toxicity from conventional, iodinated, intravenous contrast agents is a common complication in patients with peripheral artery disease (PAD). Similarly, the potential for serious side effects prevents the use of gadolinium-based agents in many patients with depressed renal function. Ferumoxytol-enhanced magnetic resonance angiography (Fe-MRA) is a novel technique that uses an intravenous, ultrasmall, superparamagnetic, iron oxide preparation, currently approved by the Food and Drug Administration for the treatment of iron deficiency anemia in adults with chronic kidney disease. Our objective was to determine the feasibility of Fe-MRA for clinical decision making in PAD patients. This was a prospective pilot study assessing 10 patients with suspected arterial occlusive disease with contrast-enhanced MRA of the aorta and lower extremities. Of those, 5 had renal insufficiency and were imaged with Fe-MRA, whereas the remainder underwent gadolinium-enhanced MRA. Qualitative and quantitative evaluations of deidentified images at each arterial station were independently performed by 4 blinded vascular surgeons. All patients were men, with an average age of 68 ± 4 years. The 2 groups had similar incidences of diabetes, hypertension, hyperlipidemia, and coronary artery disease. Patients undergoing Fe-MRA had significantly decreased renal function (estimated glomerular filtration rate, 35.4 vs. 77.6; P = 0.02). There were no adverse events during contrast administration in either group. No difference was found in the overall quality of the ferumoxytol versus the gadolinium studies (7.1 ± 2.0 vs. 7.4 ± 2.4, P = 0.67). Similarly, reviewers felt comfortable basing clinical decisions on the images 89% of the time with both the ferumoxytol and gadolinium groups (P = 1.00). This is the first report of an important alternative to conventional computed tomography angiography and MRA in PAD patients, particularly in the setting of renal insufficiency. Fe-MRA provides a useful tool in patients with suspected lower extremity PAD without the potential risks of gadolinium.

Dramatic and prompt efficacy of Helicobacter pylori eradication in the treatment of severe refractory iron deficiency anemia in adults

Dear Editor, Iron deficiency anemia (IDA) is one of the most common nutritional diseases worldwide. The basic treatment for IDA is oral iron medication; however, some patients with IDA are occasionally refractory to this type of therapy [1]. Recently, the role of Helicobacter pylori in the etiology of IDA has become a focus of considerable interest [2, 3]. Although the association of H. pylori with IDA has been examined extensively, most studies have focused on mild IDA in school-aged children and young people [4–6]. Here, we report two adult cases of severe IDA refractory to oral iron therapy in which the anemia was dramatically and promptly improved by H. pylori eradication (Fig. 1).

Prevalence and Risk Factors for Iron Deficiency Anemia in the Korean Population: Results of the Fifth Korea National Health and Nutrition Examination Survey

This study assessed the prevalence of, and risk factors for, iron deficiency (ID) and iron deficiency anemia (IDA) among participants of the fifth Korean Health and Nutrition Examination Survey, 2010. Of 8,958 participants, 6,758 individuals ≥10 yr had sufficient data for the analysis of anemia and iron status. ID was defined as a transferrin saturation <10% or serum ferritin <15 µg/L. The prevalence of ID and IDA was 2.0% (95% confidence interval [CI], 1.3%-2.6%) and 0.7% (95% CI, 0.3%-1.0%), respectively, in males, and 22.4% (95% CI, 20.7%-24.2%) and 8.0% (95% CI, 6.8%-9.2%), respectively, in females. In reproductive age females, the prevalence of ID and IDA was 31.4% (95% CI, 28.9%-33.8%) and 11.5% (95% CI, 9.6%-13.4%), respectively. Compared to the prevalence of IDA in adult males 18-49 yr, the relative risks of IDA in adults ≥65 yr, lactating females, premenopausal females, and pregnant females were 8.1, 35.7, 42.8, and 95.5, respectively. Low income, underweight, iron- or vitamin C-poor diets were also associated with IDA. For populations with defined risk factors in terms of age, gender, physiological state and socioeconomic and nutritional status, national health policy to reduce IDA is needed.

A Rare Case of an Enterogenous Cyst of the Small Bowel Causing Intussusception and Iron Deficiency Anemia in Adults

Introduction: An enterogenous cyst is a rare finding usually detected during infancy or childhood. Clinical manifestations include obstruction, and less commonly, intussusception or gastrointestinal bleeding. We report a case of an enterogenous cyst causing intussusception and iron deficiency anemia in an adult. Case Report: A 34-year-old male with no past medical history presented with diffuse intermittent abdominal pain for three months. He also noted a 10 lb weight loss. Outpatient blood work up showed iron deficiency anemia (IDA) and fecal occult blood was positive. Outpatient EGD and colonoscopy were done to further investigate the cause of IDA. EGD showed non-erosive gastritis. Colonoscopy was unremarkable. CT scan was ordered for further investigation, which showed distal small bowel intussusception. Symptoms worsened so laparoscopic exploration was performed and a large mass with an area of intussusception was identified in the mid ileum. A small incision was made and the affected portion was resected and anastomosed. Pathological findings were consistent with the diagnosis of an enterogenous cyst of the small bowel causing intussusception. The patient's postoperative course was uneventful. Subsequently, he was discharged home and the patient remained asymptomatic at two weeks follow up. Discussion: Enterogenous cysts are a rare anomaly. The most widely accepted explanation for cyst formation is that duplication of the gut occurs due to pinching off of a diverticulum during embryological development. Symptoms most commonly present between the ages of 6 months to 2 years. Gastrointestinal bleeding is more common with enterogenous cysts that communicate with the bowel lumen and are lined with gastric mucosa. Bleeding is caused by peptic ulceration within the cyst or adjacent bowel secondary to acid secretion by ectopic gastric mucosa that may line the cyst. Rarely, enterogenous cysts may cause intussusception when lead points are retracted into the distal bowel. As such, CT is recommended as the major diagnostic tool for identification of lesions. Treatment of choice is resection of the lead point with adjacent small intestine.Figure: Cyst lining.

Phase III, Randomized, Placebo-controlled Evaluation of Ferumoxytol Treatment for Iron Deficiency Anemia in Patients Who Have a History of Unsatisfactory Oral Iron Therapy: Fatigue and Health-related Quality of Life in Patients with Gastrointestinal Disorders: Presidential Poster

Purpose: Iron is essential for the function of key proteins including hemoglobin (Hgb) and myoglobin, cytochromes, various enzymes, and for immune function. Iron deficiency can, therefore, negatively impact patients' health-related quality of life (HRQL). Iron deficiency anemia (IDA) is common in patients with gastrointestinal (GI) disease due to multiple factors, such as blood loss, inflammation and malabsorption. Although oral iron is the preferred first-line treatment, many patients cannot take it, do not tolerate it, or do not adequately respond; many of these patients, therefore, live with chronic anemia and related negative effects on their HRQL. Ferumoxytol (FER) is an IV iron indicated for the treatment of IDA in adults with chronic kidney disease. To explore the impact of FER treatment on patient reported outcomes in IDA patients who have a history of unsatisfactory oral iron therapy or in whom oral iron cannot be used, this randomized, placebo-controlled, double-blinded, Phase 3 study included: Functional Assessment of Chronic Illness Therapy-Fatigue Scale (FACIT-Fatigue), SF-36, and LASA. Methods: Patients with Hgb <10 and >7 g/dL, and TSAT <20% were randomized 3:1 to either 2 injections of 510 mg of FER 5±3 days apart or normal saline (placebo). FACIT-Fatigue, SF-36 and LASA domains were assessed at baseline and weekly up to Week 5. This is a post-hoc analysis of the pre-specified subgroup of 231 patients whose underlying cause of IDA was GI disorders. Results: Baseline FACIT-Fatigue scores (22.4 ±11.7) were lower than general US population norms (40.1), and comparable to anemic cancer patients receiving chemotherapy (23.9). Baseline SF-36 Domain and Summary scores were also below general population norms (50). By Week 5, in parallel with a robust increase in Hgb, FER-treated patients demonstrated significantly greater improvements in FACIT-Fatigue scores than placebo, approaching general population norms, and significantly greater improvements than placebo in 9 of the 10 SF-36 Domain and Summary scores (p< 0.05). Improvements in LASA domains were similar to the overall IDA population. Conclusion: This analysis found that patients with IDA due to GI disorders, who had been unsuccessfully treated with oral iron, had very poor baseline HRQOL scores. In this study, treatment with FER resulted not only in increased Hgb, but also in significant improvements in measures of health-related quality of life. Disclosure - Naomi Dahl, William Strauss, Gloria Lau, Kristine Bernard - Employees: AMAG Pharmaceuticals; Kendra DeBusk -Employee: Oxford Outcomes Charles Barish - None David Ford - Speaker's Bureau: Takeda. This research was supported by an industry grant from AMAG Pharmaceuticals.Table

Ferric carboxymaltose approved for iron deficiency anemia

FDA has approved the marketing of ferric carboxymaltose injection, or Injectafer, for the treatment of iron deficiency anemia in adults who need an alternative to oral iron supplements or have non-dialysis-dependent chronic kidney disease, American Regent Inc. announced July 26. Up to 1500 mg of

Ferumoxytol: a guide to its use in iron deficiency anaemia in adults with chronic kidney disease in the EU

Ferumoxytol, a high-molecular-weight carbohydrate-iron complex, is indicated for the intravenous treatment of iron deficiency anaemia in adults with chronic kidney disease. In this population, a repletion course of intravenous ferumoxytol is significantly more effective than a short course of oral iron in increasing haemoglobin levels and improving most other iron indices, irrespective of whether patients are on haemodialysis or not on dialysis, and is generally well tolerated.

Iron deficiency anemia in patients with inflammatory bowel disease

Iron deficiency anemia is the most common form of anemia worldwide, caused by poor iron intake, chronic blood loss, or impaired absorption. Patients with inflammatory bowel disease (IBD) are increasingly likely to have iron deficiency anemia, with an estimated prevalence of 36%–76%. Detection of iron deficiency is problematic as outward signs and symptoms are not always present. Iron deficiency can have a significant impact on a patient’s quality of life, necessitating prompt management and treatment. Effective treatment includes identifying and treating the underlying cause and initiating iron replacement therapy with either oral or intravenous iron. Numerous formulations for oral iron are available, with ferrous fumarate, sulfate, and gluconate being the most commonly prescribed. Available intravenous formulations include iron dextran, iron sucrose, ferric gluconate, and ferumoxytol. Low-molecular weight iron dextran and iron sucrose have been shown to be safe, efficacious, and effective in a host of gastrointestinal disorders. Ferumoxytol is the newest US Food and Drug Administration-approved intravenous iron therapy, indicated for iron deficiency anemia in adults with chronic kidney disease. Ferumoxytol is also being investigated in Phase 3 studies for the treatment of iron deficiency anemia in patients without chronic kidney disease, including subgroups with IBD. A review of the efficacy and safety of iron replacement in IBD, therapeutic considerations, and recommendations for the practicing gastroenterologist are presented.

The Safety and Efficacy of Total Dose Infusion of 1020 Mg of Ferumoxytol Administered in 15 Minutes

Abstract 1042 Title:The safety and efficacy of total dose infusion of 1020 mg of ferumoxytol administered in 15 minutes Background:For the past two years, it has been our standard to treat iron deficiency anemia (IDA) with intravenous iron (low molecular weight iron dextran) administered as a total dose infusion (TDI) of 1 g over one hour. We recently published our experience with 1266 such infusions administered to 888 patients, in whom no serious adverse events (SAEs) were reported (AJH, in press by ). In June 2009, ferumoxytol (FER) was approved for the treatment of IDA in adults with chronic kidney disease, administered as 2 × 510 mg boluses in less than 1 minute, separated by 3 to 8 days, for a total dose of 1020 mg. After administering >300 510 mg doses per label, we sought to explore the potential convenience for clinics and patients of delivering the full dose at a single administration. Methods: This was a single-arm, open-label, single-center clinical trial conducted under an investigator IND with IRB approval. A total of 30 patients with IDA (Hgb <11g/dL, ferritin <100 ng/mL, TSAT <19%) and a history of intolerance of or inadequate response to oral iron received 1020mg (34ml) of FER diluted in 100 mL normal saline via infusion pump in 15 minutes. Patients with anemia due to another cause, active use of epoetin, parenteral iron therapy in the prior 30 days or known sensitivity to FER were excluded. Vital signs were measured for one hour post-dose, and phone calls were made at 1, 2, and 7 days post-dose to assess AEs; efficacy assessments (Hgb, TSAT, ferritin, RDW) occurred at 4 and 8 weeks post-dose. The primary endpoint was the safety and tolerability, while secondary efficacy endpoints included mean change in Hgb and TSAT from baseline to week 4. Results: At the time of submission, the trial remains ongoing and has enrolled 24 of 30 IDA patients. Of these, 9 patients have completed the Week 4 assessments. These preliminary results are presented below; complete results from all 30 patients will be available by the time of presentation. For the 24 enrolled patients, the mean age was 51 years (range 24–80 years). Eighty-three percent (83%) were female, while 79% were white and 21% black. The most common associated diagnoses were gastric bypass and menorrhagia (both 33%). There were no SAEs. One patient discontinued due to flushing, which resolved in 2 minutes without treatment. Minor AEs were experienced by 12 of 24 patients (50%), with the most common being headache (17%), arthralgia/myalgia/cramps (17%), and mild nausea (13%). All of these AEs were self-limited and resolved without therapy.Immediately post-dose5 to 60 min post-dose≤ 24 hours post-doseNausea (3)Metallic taste (1)Headache (2)Achiness/cramps (2)Myalgia (1)Back pain (1)Chest pain (2)Chest tightness (1)Dizziness (2)Muscle spasms (1)Headache (2)Pruritus (2)Arthralgia/myalgia (1)Back Pain (1)Consistent with previously published data, 4 of the 12 subjects who experienced AEs had a known medication allergy. The mean Hgb (N=24) prior to treatment was 9.3 g/dL, while the mean Hgb at week 4 (N=8) was 11.4 g/dL. Of the 8 evaluable patients at week 4, the mean change from baseline was 2.0 g/dL; 7 of 8 patients (87%) had a >1 g rise in Hgb from baseline to week 4. All 8 patients with week 4 data had elevated RDWs, reflective of an ongoing hematopoietic response. Conclusions: FER administered as a TDI of 1020 mg TDI in 15 minutes was well tolerated and effective in patients with IDA with a variety of underlying conditions. If confirmed through randomized controlled studies, TDI administration of intravenous iron provides a more convenient method for the treatment of IDA for both physicians and patients. Disclosures:Off Label Use: Total dose iron replace with 1020 mg of ferumoxytol in 15 minutes (under auspices of FDA IND 112001).

Cutoff Value of Serum Ferritin Requiring Gastrointestinal Endoscopic Evaluation for Anemia

Abstract 5282 BACKGROUND:The laboratory test with the highest sensitivity and specificity for the diagnosis of iron deficiency anemia (IDA) is serum ferritin. Chronic blood loss, one of the common causes of IDA in adults, is often associated with an occult gastrointestinal (GI) malignancy, especially in adult males and postmenopausal females. It is difficult to set the cutoff ferritin level for GI endoscopic evaluation in adult patients with anemia which is presupposed to result from GI malignancies. To answer this question, we conducted a retrospective study to find out the optimum values of serum ferritin and other hematologic indices in adult anemic patients to be referred for thorough GI endoscopic evaluation. METHODS:We reviewed retrospectively patients' medical records. The subject of study was adult anemic patients (n=544) at Konkuk University Medical Center who underwent upper and lower GI endoscopy to search for possible GI blood loss from August 2005 to August 2009. Patients were stratified into three groups according to the results of GI endoscopy: benign group vs. premalignant group vs. malignant group. RESULTS:Among a total of 544, benign, premalignant and malignant diseases were detected in 265, 220 and 59 patients, respectively. The prevalence of GI malignant diseases was 10.8% (59/544) for all patients, 13.9% (34/244) for male patients and 8.3% (25/300) for female patients. As compared to non-malignant groups (benign and premalignant), malignant group demonstrated statistically significant differences in terms of median values of age (56 vs. 66 vs. 70 years, P < 0.001), male gender (41.89 vs. 45 vs. 57.63%, P = 0.0367), MCV (86.7 vs. 88.2 vs. 78.6 fL, P = 0.0005), ferritin (69.39 vs. 108.5 vs. 21.7 ng/mL, P = 0.0002), Fe (35 vs. 38 vs. 13.5 μg/dL, P < 0.001), TIBC (279 vs. 259 vs. 320 μg/dL, P = 0.0024), and TIBC saturation (13.07 vs. 14.78 vs. 4.64%, P < 0.001). However, Hb, Hct and RDW did not show significant differences. By ROC curve analyses to find out optimum cut-off points of the serum ferritin and TIBC saturation which distinguish between non-malignant diseases and malignant diseases, the cut-off ferritin value of 44.33 ng/mL in male had a sensitivity of 72.73% and a specificity of 70.95% (AUC 0.705 and P = 0.0001). In contrast, ROC curve analyses were not useful for ferritin in female (AUC 0.609 and P =0.0787). The cut-off TIBC saturation value of 9.13% in male had a sensitivity of 73.33% and a specificity of 70.92% (AUC 0.750 and P = 0.0001). And the cut-off TIBC saturation value of 6.16% in female had a sensitivity of 69.57% and a specificity of 65.13% (AUC 0.643 and P = 0.0262). CONCLUSION:Our study proposes that adult male patients with anemia require thorough endoscopic evaluation to detect GI malignancy when their serum ferritin levels are ≤ 44 ng/mL or TIBC saturation values are ≤ 9%. For adult female anemic patients, only TIBC saturation values less than 6% may contribute to determining whether they require GI endoscopic evaluation. Disclosures:No relevant conflicts of interest to declare.

Ferumoxytol Use as an Intravenous Contrast Agent for Magnetic Resonance Angiography

To evaluate the efficacy and safety of ferumoxytol for use in magnetic resonance angiography (MRA) of the vasculature. Literature was accessed through MEDLINE (1946-September 2011) and EMBASE (1947-September 2011) using the terms ferumoxytol, magnetic resonance imaging and angiography, blood pool agent, and superparamagnetic iron oxide. Reference citations from identified publications were reviewed for relevant information. All English-language articles and human studies (N = 9) were identified that evaluated ferumoxytol use in magnetic resonance imaging (MRI). Articles that evaluated the use of the drug in first-pass and equilibrium phase imaging of the vasculature were included (n = 4). Contrast agents for MRI improve disease characterization and diagnosis. Ferumoxytol, a medication approved for treatment of iron deficiency anemia in adults with chronic kidney disease, has superparamagnetic properties. As a blood pool agent, ferumoxytol remains primarily in the intravascular space. Therefore, its use in MRI may increase image sensitivity and specificity and have a decreased adverse effect profile compared to other contrast agents. Specifically, ferumoxytol may be an option for MRA, a specific type of MRI that images blood vessels. In the 4 studies evaluated here, ferumoxytol was administered primarily to healthy adults as an accumulative dose of 4 mg Fe/kg injected at 1 mL/sec. Not all studies reported adverse events and addressed safety monitoring. The evaluated studies are limited by small size, open-label design, and noncomparative methodology. Data from small pilot studies suggest that ferumoxytol may improve image quality in MRA; however, further investigation is necessary to establish its efficacy and safety. Large randomized, active-comparator trials are needed to establish optimal dosing, imaging procedures, and safety monitoring.

Ferumoxytol: a new era of iron deficiency anemia treatment for patients with chronic kidney disease

Ferumoxytol is a new product approved for intravenous use by the US Food and Drug Administration (FDA) in the treatment of iron deficiency anemia in adults with chronic kidney disease. This approval was based on data from 3 open-label, randomized, controlled clinical trials. In all of these trials, ferumoxytol was well tolerated, and hemoglobin levels were significantly increased compared with those achieved by orally administered iron. Ferumoxytol, a superparamagnetic iron oxide coated with a carbohydrate shell, is also used as a magnetic resonance imaging (MRI) agent due to its magnetic properties. In addition, it has demonstrated a greater T1 relaxation time than MRI gadolinium-contrast agents. Currently, the Ferumoxytol Compared to Iron Sucrose Trial (FIRST) has started. This is a multicenter randomized trial of ferumoxytol compared with iron sucrose for the treatment of iron deficiency anemia in adult subjects with chronic kidney disease, where intravenous ferumoxytol is being compared with other intravenous agents to evaluate the safety of ferumoxytol and assess changes in hemoglobin level.

Trichuris dysentery syndrome: a common cause of chronic iron deficiency anemia in adults in an endemic area (with videos)

There are few published reports of Trichuris dysentery syndrome (TDS) in children. The disease has not been reported in adults. To report the clinical, colonoscopic, and histologic findings of TDS in adults in an endemic area. Case series. Tertiary gastroenterology center. Eighty-four consecutive adult patients with chronic iron deficiency anemia over a 3-year period were investigated. Ten patients had severe Trichuris trichiura infection and received a diagnosis of TDS. Colonoscopy and colonic biopsies. Patients received anthelmintic treatment, and their response was assessed. Ten patients with TDS were studied, including 8 female and 2 male patients with a mean (+/- standard deviation) age of 43 (+/- 15.5) years (range 15-65 years) and a hemoglobin level (+/- standard deviation) of 6.0 +/- 1.5 g/dL (range 4-8 g/dL); the duration (+/- standard deviation) of disease was 2.1 +/- 1.1 years (range 1.5-8.5 years). None of the patients had growth retardation, malnutrition, or immunodeficiency. Abdominal symptoms included abdominal pain, diarrhea, and hematochezia in 1 patient. Nine other patients had no abdominal symptoms. Colonoscopy revealed actively motile T. trichiura worms in large numbers in the right colon in 7 patients, in the ileum in 1, in the left colon in 1, and worms carpeting of the whole colonic mucosa in 1. Associated mucosal changes included petechial lesions, blotchy mucosal hemorrhages, and active mucosal oozing. Biopsy of the colon revealed worm segments with a thick outer cuticle. The posterior segment of the worm contained gravid uterus with numerous characteristic T. trichiura eggs. There was paucity of associated mucosal changes in most of the sections. Similar studies in other endemic areas are lacking. TDS should be considered in all patients in endemic areas with chronic iron deficiency anemia and/or occult blood loss.

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HEMORHEOLOGICAL PARAMETERS IN CHILDREN WITH IRON-DEFICIENCY ANEMIA AND THE ALTERATIONS IN THESE PARAMETERS IN RESPONSE TO IRON REPLACEMENT

Aim: Iron-deficiency anemia (IDA) is a common disorder in pediatric patients. There are a limited number of studies having controversial results in investigating red blood cell (RBC) deformability and aggregation in adult IDA patients. The aim of this study is to determine the change of hemorheological parameters, including RBC deformability, aggregation, and plasma and whole blood viscosity, in children with IDA following iron supplementation therapy. Materials and Methods: The study was performed on 20 children with IDA (average age 35.5 ± 6.5 months) and 20 age-matched healthy children. The anemia group was treated with 5 mg/kg/day peroral iron for 2 months. Hematological and hemorheological parameters were determined before and after treatment. An ectacytometer was used for the assessment of RBC deformability and aggregation and a cone-plate rotational viscometer for plasma and whole blood viscosities. Hematological parameters were determined using an electronic hematology analyzer. Results: Although IDA resulted in a decrement in RBC deformability, aggregation, plasma, and whole blood viscosities, these parameters returned to control values after iron supplementation therapy. Serum ferritin levels and hematological parameters (Hb, MCV, MCH, MCHC) that were lower in IDA patients were also found to be increased after treatment. Conclusion: Iron treatment not only reverses the symptoms of anemia but also may contribute to blood flow regulation by causing increments in the alterations observed in hemorheological parameters during anemia.

Treatment of Iron-Deficiency Anemia with IV Ferumoxytol in CKD Patients: Efficacy Compared with Oral Iron across Different Age Groups.

Iron deficiency anemia is common in the elderly. It is an important medical issue particularly in patients with chronic kidney disease (CKD) because of the associated complications, including increased mortality, loss of functional independence, and cognitive and cardiovascular abnormalities. Oral iron replacement is frequently ineffective, being poorly tolerated due to GI side effects. Ferumoxytol, a novel semi-synthetic carbohydrate-coated iron oxide nanoparticle, is being developed as an IV iron therapy to treat iron deficiency anemia in adults and elderly CKD patients. Ferumoxytol is isotonic with plasma, has lower free iron than other available IV products, and can be given as a 510 mg dose via rapid IV bolus. To evaluate the safety and efficacy of iron replacement with ferumoxytol relative to oral iron in adults and elderly subjects with CKD, data were pooled from three open-label, multicenter, randomized Phase III trials (ClinicalTrials.gov identifiers NCT00255437, NCT00255424, and NCT00233597). In a modified ITT Population (subjects randomized and dosed), a total of 884 subjects with CKD stages 1–5 and 5D received either 2 doses of 510 mg of IV ferumoxytol within 5±3 days or 200 mg of elemental oral iron daily for 21 days (Ferro-Sequels®). The mean change from baseline to Day 35 for hemoglobin (Hgb, the primary endpoint in these Phase III studies) was analyzed using an ANOVA with fixed effects for treatment and age categories (<50, 50 to <65, 65 to <75, and ≥75 years) and their interaction. There was a highly significantly greater Hgb response with IV ferumoxytol relative to oral iron across all age groups (mean ± SD were 1.03±1.22 g/dL for ferumoxytol vs. 0.42±1.05 g/dL for oral iron, p<0.0001). The Hgb response to IV ferumoxytol was consistently observed regardless of age and was greater than the response seen with oral iron (see Table for mean ± SD values). By contrast, there appeared to be a diminished response to oral iron with increasing age. Subject incidences of adverse events with ferumoxytol were similar to or lower than those observed with oral iron in all 3 studies. Multiple factors, including patient compliance, concomitant medications, and impaired GI absorption and/or side effects, may contribute to the ineffectiveness of oral iron. Therefore, physicians should consider the use of IV iron to more effectively treat iron deficiency anemia in all adult CKD patients, including the elderly.Change in Hemoglobin at Day 35Ferumoxytol 2×510 mgOral IronAgeNBaseline HgbChange in Hgb at Day 35NBaseline HgbChange in Hgb at Day 35Relative Change in Hgb (Ferumoxytol vs Oral Iron)All60510.15 ± 0.811.03 ± 1.2227910.33 ± 0.780.42 ± 1.05245%<5010510.22 ± 0.961.06 ± 1.383810.16 ± 0.960.58 ± 1.42183%50 to <6519210.14 ± 0.801.00 ± 1.1311210.40 ± 0.790.43 ± 1.07233%65 to <7516310.14 ± 0.760.92± 1.197010.33 ± 0.750.46 ± 0.89200%≥7514510.10 ± 0.741.17 ± 1.275910.28 ± 0.690.25 ± 0.89468%

Deep cerebral vein thrombosis associated with iron deficiency anaemia in adults

Cerebral venous thrombosis (CVT) is rare and has a wide spectrum of symptoms, therefore it is difficult to diagnose. Thrombosis of the deep cerebral veins occurs very rarely: it has been reported that approximately 6% of patients with CVT have deep CVT, and the prognosis for patients with this condition is poor. CVT has been reported in association with dehydration, a hypercoagulable state, mastoiditis, tumour invasion of a venous sinus, use of oral contraceptives, pregnancy, puerperium, head trauma, vasculitis, and intracranial and systemic infections. However, in the literature, there are few reported cases of CVT in association with iron deficiency anaemia, especially in adults. We present here two patients with bilateral thalamic and basal ganglionic lesions due to thrombosis of the deep cerebral veins. Both of our patients had severe hypochromic microcytic anaemia due to iron deficiency, and both had a good prognosis after 2 months.