Screen women of reproductive age for iron deficiency, especially if pregnant: experts

Canadian experts advise physicians to actively screen and treat women of reproductive age for iron deficiency, especially those who are pregnant, according to a review paper recently published in CMAJ.“The problem of iron deficiency among women of reproductive age is so common and so problematic but often overlooked and undiagnosed and unaddressed,” said Dr. Michelle Sholzberg, lead author of the paper, hematologist at St. Michael’s Hospital in Toronto and associate professor at University of Toronto.The paper highlights the importance of recognizing and treating both non-anemic iron deficiency and iron deficiency anemia. In non-anemic iron deficiency, the red blood cell production is maintained in the body but the iron stores are low. It’s now recognized to carry important morbidity and mortality, and is associated with poor health-related quality of life, mood disorders and sleep disturbances, among other factors. Menstrual bleeding contributes to iron deficiency, with heavy menstrual bleeding linked to a higher risk of iron deficiency. When iron deficiency progresses to anemia, it’s associated with more severe morbidity and is especially concerning in people who are pregnant, because it could lead to poor outcomes in the child. It’s associated with intellectual disability, ADHD or autism in the child.“One of the reasons to highlight these things is that it’s totally treatable.” Dr. Sholzberg said. Non-anemic iron deficiency is typically defined as when ferritin levels are below 30 µg/L in adults. Iron deficiency anemia is due to a reduced production of red blood cell and is usually defined as a hemoglobin lower than 120 g/L and below 130 g/L.Work by Hemequity lab, a research lab at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto, has been successful at getting three large Ontario laboratories to change the clinical decision limit for ferritin. Now, ferritin levels below 30 µg/L are labeled as iron deficiency and those between 50 and 30 µg/L are flagged at risk for iron deficiency. Previously, most labs flagged ferritin levels below 15 µg/L as iron deficiency. “We have structurally transformed the way that lab reports are released to highlight this condition for the very busy clinician,” Dr. Sholzberg said. Physicians who review thousands of lab reports can now rely on these laboratory flags.In Ontario, LifeLabs, DynaCare and Alpha labs have all changed the ferritin clinical decision limit, but to change in other provinces and territories depends on local laboratories and provincial and territorial regulatory bodies. Dr. Sholzberg said she has been discussing potential changes in other regions and “I think there is an appetite.” A few very large health systems in the U.S. have adopted the lower levels. There are also international guideline efforts underway that could further support this change.PregnancyWomen of reproductive age living with non-anemic iron deficiency or iron-deficiency anemia puts them at serious risk for iron deficiency or iron-deficiency anemia in pregnancy, said Dr. Michelle Zeller, a clinical hematologist and associate professor of medicine at McMaster University in Hamilton, Ont. Iron stores that were low prior to pregnancy become further depleted during pregnancy. It takes 1000 mg of iron to support fetal growth, the increase in maternal blood volume and other physiological needs during gestation and the postpartum period. Often that cannot be supported through iron in the diet.The World Health Organization recommends 30 to 60 mg of elemental iron a day for people who are pregnant. ScreeningWhile there’s no national screening recommendations for iron deficiency, the CMAJ authors state that it is reasonable to carry out CBC and ferritin testing in asymptomatic females of reproductive age every three years, especially if they experience heavy menstrual bleeding.“I think we need to be much more proactive with screening and treatment,” Dr. Sholzberg said.The symptoms of iron deficiency are subtle and people sometimes adapt to their symptoms. “A lot of the symptoms people are experiencing, maybe we shouldn’t be normalizing.” Screening in pregnancy is especially important. “There’s so much more benefit rather than risk to take that one more tube of blood to test for a ferritin level during your early pregnancy screen,” said Dr. Zeller, when asked to comment on the CMAJ paper. “There’s nothing to lose. There’s only something to gain from that test.”TreatmentFerrous gluconate, ferrous sulfate or ferrous fumarate supplements are first-line therapy for iron deficiency (if hemoglobin is above 100 g/L) and should be offered once daily, ideally on an empty stomach, the authors note. “The best iron supplement is the one that a patient tolerates and takes consistently,” they write. When patients cannot tolerate oral iron, or if it is ineffective, IV iron can be considered. Ferritin levels should be re-assessed a few months after treatment.Treatment can improve quality of life for people who have low ferritin levels but are not considered anemic. Dr. Zeller gave the example of a person with a ferritin of 20 µg/L and hemoglobin of 120 mg/L. “When you get them to a ferritin of 50 and a hemoglobin of 140, they feel amazing,” she said. “It’s that anecdotal experience that I’m privileged to see time and time again.” The CMAJ paper authors highlight the recommended diagnosis and treatment algorithm for iron deficiency in pregnancy developed by experts from Unity Health in Toronto. The algorithm recommends oral iron supplementation for people with a ferritin below 50 µg/L per litre and hemoglobin above 110 g/L at the first prenatal visit. IV iron can be considered for those with ferritin below 50 µg/L and hemoglobin below 110 mg/L in the second or third trimester. Iron deficiency is “one of those few aspects in medicine where you can fix the problem,” Dr. Zeller said. “We can have huge impacts, profound impacts on the quality of people’s lives in a relatively straightforward way, but the first step is recognition.” The CMAJ paper was published in early July.

Screen women of reproductive age for iron deficiency, especially if pregnant: experts

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