Background

Assessment and Management for iron deficient with or without anaemia

1. Consider investigations as appropriate
   • The underlying cause of iron deficiency should be investigated in conjunction with treatment.
   • Consider gender, age, family history and presence of menstruation.
   • Determine cause and need for GI investigations.
   • Remember that ferritin may be elevated in the setting of inflammation, but iron deficiency may still be present.
   • Consider giving iron where ferritin is <100ug/L and there is a raised CRP.
   • We recognise that for some cases of chronic anaemia, a cause may not be found, and it is possible that surgery may proceed under certain circumstances.  In these circumstances, please send a letter of explanation to the Preassessment Clinic at Tauranga Hospital for an anaesthetist to review.

2. Give oral iron for 6 weeks

   • Give oral iron unless contraindicated or not tolerated, usually ferrous fumarate. Taking one tablet on alternative days leads to better compliance and absorption.
   • Provide a patient information leaflet which shows how to take the medication and what to do about other medications that may impact iron absorption.
   • Give IV iron infusion if oral iron contraindicated or not tolerated. Do not give IM iron.
   • Optimising iron stores prior to elective surgery where projected blood loss is high (egjoint replacement) leads to substantially lower patient morbidity and mortality.

3. Iron infusion if indicated

   • Give IV iron infusion if oral iron contraindicated or not tolerated. Do not give IM iron.
   • Ferric carboxymaltose (Ferinject) is Pharmac funded with a special authority if ferritin is <20ug/L or approved by specialist, e.g. anaesthetist.
   • If unable to provide iron infusion in the community, please send a BPAC ereferral to General Medicine and note ‘For Iron Infusion’ in the subject line.

4. Repeat FBC ferritin and CRP

5. If investigations complete or not needed and bloods normalised, patient to notify Pre-Assessment Clinic

   • On completion of investigations and treatment, please ask the patient to notify the Preassessment Clinic (PAC).
   • The contact details are on their letter from PAC. The telephone number is 07 579 8260, or email address is Tga.preassessment@bopdhb.govt.nz 

6. If patient remains anaemic or iron deficient

   • Arrange iron infusion & consider specialist referral
     • Give IV iron infusion if oral iron contraindicated or not tolerated. Do not give IM iron.
     • Ferric carboxymaltose (Ferinject) is Pharmac funded with a special authority if ferritin is <20ug/L or approved by specialist, e.g. anaesthetist.
     • If unable to provide iron infusion in the community, please send a BPAC ereferral to General Medicine and note ‘For Iron Infusion’ in the subject line.
     • Consider referral to a specialist team as appropriate (e.g. gastroenterology, general medicine or gynaecology).
     • If anaemia persists despite adequate iron replacement, a haematology referral may be appropriate.
   • Patient to Notify Pre-Assessment Clinic
     • On completion of investigations and treatment, please ask the patient to notify the Preassessment Clinic (PAC).
     • The contact details are on their letter from PAC. The telephone number is 07 579 8260, or email address is Tga.preassessment@bopdhb.govt.nz

Assessment and Management for Anaemic and Not Iron Deficient

1. Investigate cause

   • Consider alternative causes of anaemia
     • thalassaemia and other haemoglobinopathies
     • anaemia of chronic disease
     • haemolytic anaemia
     • B12 deficiency
     • folate deficiency
     • other
   • Ferritin may be elevated in the setting of inflammation.
   • However, iron deficiency may still be present.
   • Consider giving iron where ferritin is <100ug/L and there is either a raised CRP or transferrin saturation is <20%.
   • Suggested investigations
     • Renal function, MCV/MCH and blood film
     • Check B12/folate levels and reticulocyte count
     • Check liver and thyroid function
     • Check serum protein electrophoresis

2. If cause found

   • Optimise Hb by treating cause
   • Patient to Notify Pre-Assessment Clinic
     • On completion of investigations and treatment, please ask the patient to notify the Preassessment Clinic (PAC).
     • The contact details are on their letter from PAC. The telephone number is 07 579 8260, or email address is Tga.preassessment@bopdhb.govt.nz

3. If cause not found

   • Consider specialist referral
     • Seek haematology advice, especially if Hb <100g/L, there are additional cytopenias or a progressive unexplained anaemia.
     • In the presence of chronic kidney disease, seek renal advice.
     • We recognise that for some cases of chronic anaemia, a cause may not be found, and it is possible that surgery may proceed under certain circumstances. In these circumstances, please send a letter of explanation to the Preassessment Clinic at Tauranga Hospital (fax 07 571 0132) for an anaesthetist to review.
   • Patient to Notify Pre-Assessment Clinic
     • On completion of investigations and treatment, please ask the patient to notify the Preassessment Clinic (PAC).
     • The contact details are on their letter from PAC. The telephone number is 07 579 8260, or email address is Tga.preassessment@bopdhb.govt.nz

Information

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.