Diagnosis and treatment of iron-deficiency anemia in gastrointestinal bleeding: A systematic review

José Cotter, Cilénia Baldaia, Manuela Ferreira, Guilherme Macedo, Isabel Pedroto, José Cotter, Cilénia Baldaia, Manuela Ferreira, Guilherme Macedo, Isabel Pedroto

Abstract

Background: Anemia is considered a public health issue and is often caused by iron deficiency. Iron-deficiency anemia (IDA) often originates from blood loss from lesions in the gastrointestinal tract in men and postmenopausal women, and its prevalence among patients with gastrointestinal bleeding has been estimated to be 61%. However, few guidelines regarding the appropriate investigation of patients with IDA due to gastrointestinal bleeding have been published.

Aim: To review current evidence and guidelines concerning IDA management in gastrointestinal bleeding patients to develop recommendations for its diagnosis and therapy.

Methods: Five gastroenterology experts formed the Digestive Bleeding and Anemia Workgroup and conducted a systematic literature search in PubMed and professional association websites. MEDLINE (via PubMed) searches combined medical subject headings (MeSH) terms and the keywords "gastrointestinal bleeding" with "iron-deficiency anemia" and "diagnosis" or "treatment" or "management" or "prognosis" or "prevalence" or "safety" or "iron" or "transfusion" or "quality of life", or other terms to identify relevant articles reporting the management of IDA in patients over the age of 18 years with gastrointestinal bleeding; retrieved studies were published in English between January 2003 and April 2019. Worldwide professional association websites were searched for clinical practice guidelines. Reference lists from guidelines were reviewed to identify additional relevant articles. The recommendations were developed by consensus during two meetings and were supported by the published literature identified during the systematic search.

Results: From 494 Literature citations found during the initial literature search, 17 original articles, one meta-analysis, and 13 clinical practice guidelines were analyzed. Based on the published evidence and clinical experience, the workgroup developed the following ten recommendations for the management of IDA in patients with gastrointestinal bleeding: (1) Evaluation of hemoglobin and iron status; (2) Laboratory testing; (3) Target treatment population identification; (4) Indications for erythrocyte transfusion; (5) Treatment targets for erythrocyte transfusion; (6) Indications for intravenous iron; (7) Dosages; (8) Monitoring; (9) Indications for intravenous ferric carboxymaltose treatment; and (10) Treatment targets and monitoring of patients. The workgroup also proposed a summary algorithm for the diagnosis and treatment of IDA in patients with acute or chronic gastrointestinal bleeding, which should be implemented during the hospital stay and follow-up visits after patient discharge.

Conclusion: These recommendations may serve as a starting point for clinicians to better diagnose and treat IDA in patients with gastrointestinal bleeding, which ultimately may improve health outcomes in these patients.

Keywords: Anemia iron-deficiency; Erythrocyte transfusion; Ferric carboxymaltose; Gastrointestinal hemorrhage; Iron; Practice guidelines as topic.

Conflict of interest statement

Conflict-of-interest statement: Author Cilénia Baldaia has received fees for serving as a speaker, consultant and/or advisory board member from CSL Behring and OM Pharma. Author Isabel Pedroto has received fees for serving as a speaker, consultant and/or advisory board member from Abbvie, Gilead, and MSD. Authors José Cotter, Manuela Ferreira, and Guilherme Macedo declare that they have no competing interests relevant to this work.

©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.

Figures

Figure 1
Figure 1
Flowchart of the selected articles. Adapted from Moher et al[18].
Figure 2
Figure 2
Algorithm for the diagnosis and treatment of iron-deficiency anemia in patients with acute or chronic gastrointestinal bleeding. Hb: Hemoglobin; TSAT: Transferrin saturation; CRP: C-reactive protein; FCM: Ferric carboxy maltose; RET: Reticulocyte.

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