Dr Aidin Rawshani

Anemia and iron deficiency (iron deficiency anemia)

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Anemia is a common condition that affects people of all ages. The medical term for anemia is anemia. There are many causes of anemia, both acute and chronic. Moreover, the causes differ between different communities. The most common cause of low blood count (anemia) globally are parasitic diseases. Approximately 2 billion people are infected with parasites that cause anemia. However, in Sweden, parasitic disease is a very rare cause of anemia. The most common cause of anemia in Sweden is iron deficiency (iron deficiency), which is called iron deficiency anemia.

The very lack of blood means that you have too few red blood cells (erythrocytes) in your blood. The volume of blood may still be normal, but the number of red blood cells is too low. The red blood cells transport oxygen (oxygen) with the help of hemoglobin, which is found in the red blood cells. To diagnose anemia, measure the number of red blood cells and their hemoglobin content. If the number of red blood cells or the amount of hemoglobin is too low, you have anemia.

Symptoms of anemia

If the blood, deficiency develops rapidly, then, as a rule, one has more pronounced symptoms. If the anemia develops gradually, then one can be completely asymptomatic, even if the anemia is very pronounced. This is explained by the fact that the body is better at adapting if the anemia develops slowly. The following symptoms are common in anemia:

  • Fatigue, muscle weakness
  • Dizziness (especially when erupted)
  • Blood pressure drop
  • Headache
  • Palpitations
  • Shortness of breath
  • Chest discomfort (angina pectoris)
  • Neuropathy
  • Restless legs
  • Weightloss

Signs of having anemia

  • Pale (skin, pale whites of the eyes)
  • High heart rate (tachycardia)
  • Heart murmur heart failure
  • Low blood pressure (hypotension)
  • Jaundice, which is due to the decay of red blood cells
  • Iron deficiency + vitamin B12 deficiency
  • Atrophic tongue mucosa (vitamin B12 deficiency)
  • Impaired vibration sensation and worse reflexes (B12 deficiency)

Iron deficiency: a common cause of anemia

One of the most common causes of low blood count is iron deficiency. Iron is a chemical element (a metal) that is vital for us to survive. Iron is needed to create normal and well-functioning red blood cells. If you do not have enough iron in your body, you gradually suffer from anemia. This variant of anemia is called iron deficiency anemia. Pronounced iron deficiency anemia can cause fatigue, shortness of breath, chest pain, confusion, palpitations and several other symptoms.

If your doctor diagnoses iron deficiency anemia, treatment will be dictated by the underlying cause and the severity of anemia. In simple cases, the doctor may recommend dietary changes and/or iron supplements. Sometimes intravenous iron therapy is needed. In more pronounced cases, transfusion of red blood cells is needed. It is fundamental to clarify why iron deficiency anemia has arisen, and there are many reasons for this.

Causes of iron deficiency anemia

Your body needs iron to produce healthy red blood cell to your bloodstream. Iron deficiency anemia usually develops over time because the body’s intake of iron is too low. Low levels of iron in the blood may be due to blood loss, lower intake of iron than recommended daily amounts, or other conditions affecting the absorption of iron in the gastrointestinal tract.

Blood loss

The most common cause of iron deficiency anemia in men and postmenopausal women is bleeding in the gastrointestinal tract (gastrointestinal bleeding). Red blood cells contain iron, so blood loss also leads to loss of iron. There are several causes of blood loss such as menstrual bleeding, gastrointestinal bleeding, peptic ulcer, bleeding disorders and urinary bleeding. The bleeding can occur quickly or slowly. Slow, chronic blood loss in the body, such as stomach ulcers, vascular malformations (angiodysplasia), inflammatory bowel disease, polyp or gastrointestinal cancer (eg colon cancer), can cause iron-deficiency anemia.

Gastrointestinal bleeding may also be due to the regular use of certain groups of drugs, such as non-steroidal anti-inflammatory drugs (eg, acetylsalicylic acid), as well as antiplatelet agents such as clopidogrel and anticoagulants such as warfarin. These drugs increase the tendency to bleeding of existing sources of bleeding. Women with severe or prolonged bleeding during menstruation sometimes develop temporary or chronic iron deficiency anemia due to blood loss.

Parasitic disease

The main cause of iron deficiency anemia worldwide is a parasitic disease called helminthiasis caused by parasitic worms (helminths); specifically hookworms. The World Health Organization (WHO) estimates that about two billion people are infected with soil-transmitted parasites all over the world. Parasitic worms cause both inflammation and chronic blood loss by causing hemorrhages in the mucosa of the small intestine.

Abundant menstruation

Menstrual bleeding is a common cause of iron deficiency anemia in women of childbearing age. Women with menorrhagia (heavy menstruation) are at risk of iron deficiency anemia. Most women lose about 40 ml of blood per cycle. The iron loss is linked to the loss of blood because the iron is in our red blood cells.

Low intake of iron

Iron deficiency anemia can be caused by insufficient amounts of iron being consumed by the individual. The recommended daily amounts of iron depend on sex, age and whether you are pregnant or breastfeeding. The body normally gets the iron it needs from the food. If a person consumes too little iron or absorbs insufficient iron, iron deficiency may eventually develop.

Examples of iron-rich foods are meat, eggs, leafy vegetables and iron-enriched foods. For proper growth and development, infants and children need iron from the diet. For children, a high intake of cow’s milk is associated with an increased risk of iron deficiency anemia. Other risk factors for iron deficiency anemia include low meat intake and low intake of iron-enriched products.

Difficulties in absorbing iron

Iron from food is absorbed into the bloodstream of the small intestine, mainly in the duodenum. Even if you consume enough iron, your body may not be able to absorb the iron. Some conditions or medicines can reduce the body’s ability to absorb iron and cause iron-deficiency anemia. Iron malabsorption, however, is a less common cause of iron deficiency anemia.

Examples of other medical conditions affecting iron uptake

  • Diseases of the intestinal and digestive organs, such as celiac disease; inflammatory bowel diseases, including ulcerative colitis and Crohn’s disease; and Helicobacter Pylori infection.
  • Previously gastrointestinal surgery, such as obesity surgery, especially gastric bypass or gastrectomy.
  • Some rare genetic conditions, such as the TMRPSS6 gene mutation that makes you produce too much of a hormone called hepcidin. Hepcidin blocks the intestines from taking up iron.
  • Renal failure often affects blood counts. The kidneys contain specialized cells that make a substance (erythropoietin) that stimulates the bone marrow to produce more red blood cells (erythrocytes). Thus, renal function is important for blood counts and individuals with renal failure have impaired function in the cells that produce the hormone erythropoietin. In addition, several red blood cells are destroyed during dialysis, which also leads to blood loss.
  • Proton pump inhibitors are a drug used in the treatment of peptic ulcer and acid regurgitation. These drugs interfere with iron absorption, in addition, it is known that blood thinning drugs increase the likelihood of bleeding in the gastrointestinal tract.
  • Various inflammatory conditions can lead to chronic inflammation. An inflammatory surge in the body leads to increased levels of the hormone hepcidin, which in turn suppresses the absorption of iron. In chronic inflammation, such as autoimmune disease, cancer and chronic renal failure, several substances (cytokines) are released that stimulate and activate the immune system while suppressing the production of red blood cells (erythrocytes) in the bone marrow.

Brief summary of causes of iron deficiency anemia

  • Gastrointestinal bleeding, ulcers, colon cancer or regular use of medicines such as acetylsalicylic acid or non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen
  • Some rare genetic conditions such as hereditary hemorrhagic telangiectasia, causing bleeding in the intestines
  • Frequent blood donation
  • Parasitic disease
  • Frequent blood tests, especially in infants and small children pronounced menstruations
  • Injury or surgery
  • Bleeding from the urinary tract

Diabetes and anemia

If you have diabetes, you need to check your blood regularly for anemia. It is common for people with diabetes to also develop anemia.

In diabetes, it happens that you do not have enough red blood cells. It can make you more likely to develop diabetic complications, such as eye and nerve damage. In addition, it can worsen kidney, heart and vascular diseases, which are more common in people with diabetes.

Diabetes often leads to kidney damage, and impaired renal function can cause anemia. Healthy kidneys know when your body needs new red blood cells. They release a hormone called erythropoietin (EPO), which signals your bone marrow to produce more red blood cells.

Some medicines used to treat diabetes may affect your levels of hemoglobin, which is needed to transport oxygen through your blood. These drugs include ACE inhibitors, fibrates, metformin and thiazolidinediones. If you are taking any of these, tell your doctor about your risk of anemia.

People with high blood sugar levels should check the levels of hemoglobin regularly in the blood, as sugar (glucose) binds to red blood cells and affects their ability to transport oxygen. Individuals with good blood sugar levels have more well-functioning red blood cells that can engage in transporting oxygen to their organs.

Risk factors for iron deficiency anemia

You may have an increased risk of iron deficiency anemia due to your age, unhealthy environments, hereditary factors (genetics), lifestyle habits or gender.

Age

Age groups have an increased risk of iron deficiency:

  • Infants between 6 and 12 months, especially if they receive only breast milk or substitute that is not enriched with iron.
  • Children born prematurely also have an increased risk of iron deficiency.
  • Children between the ages of 1 and 2, especially if they drink a lot of cow’s milk. Cow’s milk does not contain very much iron.
  • Teenagers, who have an increased need for iron during the growth phase.
  • Older adults, especially those over 65 years of age.

Unhealthy environments contributing to iron deficiency

Children playing in environments with heavy metals, for example, lead can get it into their blood, lead destroys the body’s ability to produce hemoglobin, a substance necessary for our red blood cells.

Hereditary factors (genetics)

Von Willebrand disease is a hereditary disease that affects the production of products in the blood, the disease leads to a deterioration in the ability to coagulate. This makes it more difficult to stop bleeding and may increase the risk of iron deficiency anemia from trauma, surgery or severe menstruation.

People with a special gene have an increased risk of hemophilia, including symptomatic female carriers who have profuse menstrual periods, may be at risk of iron deficiency anemia.

Lifestyle habits

Lifestyle habits that may increase the risk of iron deficiency anemia:

  • Vegetarian or vegan food patterns. Not eating enough iron-rich foods, such as meat and fish, can lead to you getting less than the recommended daily amount of iron.
  • Frequent blood donation. People who donate blood can often be at risk of iron deficiency anemia.
  • Athletes, especially young women, are at risk of iron deficiency. Athletes engaged in cardio training lose iron through the gastrointestinal tract. Athletes also lose iron by the breakdown of red blood cells, called hemolysis. Hemolysis, in this case, is caused by strong muscle contractions and the effects of feet that repeatedly hit the ground, for example, with marathon runners.
  • Alcohol consumption increases the risk of anemia.

Gender

Women between 14 and 50 years old need more iron than boys and men of the same age.

Conditions contributing to iron deficiency anemia in women

  • Heavy menstruations
  • During pregnancy, after childbirth or during breastfeeding. This is because your need for iron increases during these periods, and it can be difficult to replace the recommended amount of iron with food alone.
  • Pregnant women need more iron to promote the growth of their unborn children.

Screening for iron deficiency anemia

Your doctor can check if you have iron-deficiency anemia. To prevent iron deficiency anemia, you should eat healthy foods and control any other disease conditions that can cause iron-deficiency anemia.

To diagnose iron-deficiency anemia, your doctor can order a simple blood test that measures several factors in the blood. The blood test reveals your blood count to see if you have a lower concentration of red blood cells than normal, they also measure the levels of hemoglobin, hematocrit and mean corpuscular volume (MCV) that may indicate anaemia.

However, screening uses a simple blood test that only measures the levels of hemoglobin (Hb) in the blood. A person with low Hb will need to supplement with additional samples to proceed in the investigation. A low blood count usually leads to low iron deposits in the body.

Red blood cells (erythrocytes)

Red blood cells or erythrocytes (from Greek erythrosis for “red” and cyte for “cell”), are the most common type of blood cells and the substance responsible for the absorption of oxygen into the lungs, or gills in fish.

Inside the cells there is a cell fluid called cytoplasm in medical language, the cell fluid in erythrocytes contains a lot of hemoglobin, which is an iron-containing molecule that can bind oxygen and is responsible for the red color of red in blood.

Approximately 2.4 million new erythrocytes are produced every second in adult humans. The cells develop in the bone marrow and each red blood cell circulates for about 100-120 days in the body before they are broken down and recovered by specialized immune cells called macrophages. Approximately half of the blood volume consists of red blood cells.

Strategies for the prevention of iron deficiency anemia

If you have certain risk factors for iron deficiency anemia, for example, if you eat only vegetarian food, your doctor may recommend dietary supplements to get the recommended daily amount of iron. If you have other medical conditions that cause iron deficiency anemia, such as bleeding in the stomach or urinary tract or heavy menstrual bleeding, your doctor will want to treat these conditions with either medicines or medical procedures. There are several preventive strategies to prevent or slow down bleeding sources to reduce the degree of iron deficiency anemia.

Foods containing iron include dried beans, dried fruits, eggs, lean red meat, salmon, iron-enriched bread and cereals, peas, tofu and dark green leafy vegetables. Vitamin C can help increase your absorption of iron, foods rich in vitamin C are oranges, strawberries and tomatoes.

Signs, symptoms and complications of iron deficiency anemia

There is a huge variety in iron deficiency anemia, depending on the cause and severity of iron deficiency anemia, the symptoms and complications vary. People with mild or moderate iron-deficiency anemia do not always have to have any signs or symptoms. Symptoms generally worsen when anemia becomes more severe. If the anemia is left untreated, the low blood count and, above all, iron deficiency can cause complications and can be life-threatening.

Common signs of iron deficiency anemia include

  • Fragility nails
  • Cracks on the sides of the mouth
  • Pale skin
  • Swelling or soreness of the tongue

Common symptoms of iron deficiency anemia include

  • Chest pain
  • Cold hands and feet
  • Difficulties of concentration
  • Dizziness and feeling fainting.
  • It can be difficult to find the energy to do normal activities.
  • Headache
  • Regular heartbeats. This is a sign of more serious iron deficiency anemia.
  • Restless legs syndrome
  • Shortness of breath
  • Weakness

Complications in iron deficiency anemia

Undiagnosed or untreated iron deficiency anemia can cause the following complications:

  • Depression
  • Heart problems. If you do not have enough hemoglobin, your heart will have to work harder to transport oxygen-rich blood through the body. Cells in tissues need a steady supply of oxygen to function well. Normally, hemoglobin in red blood cells takes up oxygen in the lungs and carries it to all tissues of the body. When your heart has to work harder, this can lead to several conditions: irregular heartbeat called arrhythmias, a heart murmur, an enlarged heart or even heart failure.
  • Myocardial infarction and chest pain
  • Increased risk of infection
  • Motor or cognitive developmental in children
  • Pregnancy complications such as premature birth or fetuses with low birth weight
  • If people have other chronic conditions, iron deficiency anemia may worsen their basic condition or affect treatment.

How to put the diagnosis of iron deficiency anemia?

Iron deficiency anemia can be detected during routine blood tests. To diagnose iron deficiency anemia, your doctor can ask questions about your risk factors, conduct a physical examination and order blood tests or other diagnostic tests.

Your doctor may ask about your medical history and any symptoms you experience, and perform a physical examination to look for any of the following signs that may help diagnose iron deficiency anemia:

  • Check for bleeding in the skin and mucous membranes. Dark stool, traces of blood in stool or urine?
  • Look to see if your tongue, nails or the inside of the eyelids are pale.
  • Check your nails to see if they are pale or brittle, and how quickly they are refilled with blood after compression.
  • Listen to your heart for rapid or irregular heartbeats.
  • Listen to your lungs for fast or uneven breathing.
  • Feel your abdomen to check the size of your liver and spleen.

Blood test for iron deficiency anemia

Your doctor should prescribe a blood test that measures several components of the blood. Initially, the levels of hemoglobin (Hb) are measured, anemia is often indicated as Hb in the reference range (according to WHO classification) Hb 130g/L in men, 120 g/L in women. At each time, Hb levels vary by about 10 -15%, but a doctor should start an anemia study if the Hb value differs 15 g/L between two different tests. Pronounced anemia is defined as Hb 60-65 g/l, especially if the individual simultaneously experiences circulatory symptoms or organ damage (ischemia) due to low blood counts.

Iron can be measured in the blood, the concentration of iron in the blood can be normal even if the total amount of iron in the body is low. The blood test also shows the levels of a protein called Ferritin, which reflects how much of the body’s stored iron was used. Ferritin is a protein that helps store iron in the body. The blood test also shows the level of reticulocytes showing the production of red blood cells (erythrocytes). The size of the red blood cells is also measured in this blood test.

Other blood tests in the investigation of anemia

  • White blood cells (LPK), platelets (TPK)
  • LD, bilirubin (The samples increase if blood cells burst)
  • Haptoglobin (low test if blood cells burst)
  • Liver test (AST and ALT)
  • Faeces Hb (F-Hb x more) as signs of hemorrhage in the gastrointestinal tract
  • Kidney test and urinary samples (PK, APTT)
  • Thyroid samples (TSH, free T4)
  • S-Fe (Iron), TIBC, S-ferritin, S-B12 and folat
  • In some cases, inflammation samples (SR, CRP, elphoresis) or alcohol samples (CDT)

Exclude bleeding in the gastrointestinal tract

To investigate if gastrointestinal bleeding is causing your iron deficiency anemia, your doctor may order the following examinations and tests.

A fecal blood test to check traces of blood (hemoglobin) in the stool. Blood in the stool indicates bleeding in the gastrointestinal tract and may require additional examinations.

In case of suspicion of bleeding in the gastrointestinal tract, one needs to identify the source of bleeding with imaging diagnostics. We have standardized the investigation of gastrointestinal bleeding, first investigating the esophagus, stomach and the first part of the small intestine with gastroscopy, an endoscopic examination where the inside of the upper gastrointestinal tract is examined by camera. A tube with a small camera is inserted through the mouth down to the stomach and upper small intestine to see the mucous membrane of the upper gastrointestinal tract.

Colonoscopy is also an endoscopic examination that is performed to search for bleeding or other abnormalities, such as growth or cancer of the large intestine. For this examination, a small camera is inserted into the colon during sedation to see the colon directly.

Treatment of iron deficiency anemia

Treatment of iron deficiency anemia depends on its cause and severity. Treatments include iron supplements, procedures, surgery and dietary changes. Severe iron deficiency anemia may require intravenous (IV) iron therapy or blood transfusion.

Iron supplements

Your doctor may recommend that you take iron supplements, also called iron pills or oral iron, by mouth to increase iron in your body. This is the most common treatment in case of iron deficiency. It generally takes three to six months to replenish your iron stores.

Iron supplements are sometimes recommended by your doctor during pregnancy. If your condition is caused by some rare genetic conditions, such as a gene mutation in the TMRPS6 gene, you may not respond to oral iron supplements.

Iron supplements are generally not recommended to people who do not suffer from iron deficiency anemia. This is due to the fact that too much iron can damage your organs.

Do not stop taking your prescribed iron supplements without talking to your doctor first. Talk to your doctor if you experience side effects such as poor metallic taste in the mouth, vomiting, diarrhea, constipation or upset stomach. Your doctor may recommend alternatives such as taking your food supplements, lowering the dose, trying other types of iron supplements or offering intravenous (IV) iron as well as medicines that stimulate increased blood production (EPO injections).

Other methods of treatment in iron deficiency anemia

  • People with severe iron deficiency anemia or who have chronic conditions such as kidney disease or celiac disease may be more likely to receive intravenous iron. You may experience vomiting, headache or other side effects immediately after the IV iron, but these side effects usually disappear within one or two days.
  • Transfusion with red blood cells can be used for people with severe iron deficiency anemia to quickly increase the amount of red blood cells and iron in the blood. Your doctor may recommend this if you have serious complications of iron deficiency anemia, such as chest pain.
  • Surgery is used to treat bleeding sources either with open surgery or endoscopic methods that stop bleeding.

If you have chronic kidney disease and iron deficiency anemia, your doctor may recommend erythropoiesis stimulating drugs. These drugs stimulate the bone marrow to produce more red blood cells. This method of treatment is usually used when treatment with iron tablets or IV iron alone is not enough.

Tablet treatment in case of iron deficiency anemia (Duroferon)

Duroferon is a drug containing iron (iron sulfate). It is used to treat anemia due to low levels of iron in the blood. The drug is also used for treatment in pregnant women. The drug can be purchased without a prescription.

Tips and advice in the treatment with Duroferon

Only people with a verified iron deficiency should use Duroferon because too much iron can be harmful to the organs. Long-acting tablets (prolonged release tablets) must be swallowed whole, this variant acts in the body for a long time. Prolonged tablets are associated with better efficacy and lower risk of side effects. The reason why the tablets should be swallowed is that iron can irritate the esophagus. Drink a glass of juice with the tablet as vitamin C enhances the absorption of iron. Avoid large amounts of milk, sugary drinks, tea or coffee together with the tablets.

Dosage

Adult individuals with iron deficiency usually take 1 tablet morning and evening while preventive treatment in pregnant and after blood donation usually takes 1 tablet a day. For preventive treatment during pregnancy and after blood donation, you usually take 1 tablet a day. Keep the tablets out of the reach of children and do not take an extra dose if you forget to take the medicine one day.

Duroferon is a medicine that interacts with many other medicines, please consult your doctor if medicines or supplements that you are taking may interact with iron tablets.

Common side effects in the treatment with iron tablets

Some people who use iron tablets may experience nausea, stomach pain, constipation or diarrhea. Some may get darker stools of the drug. Stomach discomfort may decrease if you take the medicine with food.

Lifestyle habits affecting iron levels in the blood

  • Adopt healthy lifestyle changes such as healthy eating habits.
  • Increase your daily intake of iron-rich foods to help treat your iron deficiency anemia. See preventive strategies to learn about foods that have high levels of iron.
  • Increase your intake of vitamin C to help your body absorb iron.
  • Avoid drinking black tea, which reduces iron absorption.
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