Iron deficiency anemia in inflammatory bowel disease

Table 1 Causes of anemia in inflammatory bowel disease

Common causes	Less common causes	Rare causes
Iron deficiency anemia	B12 deficiency	Hemolysis
Anemia of chronic inflammation	Folic acid deficiency	Chronic renal insufficiency
	Medications causing B12/Folate deficiency	Myelodysplastic syndrome
		Medication induced aplasia
		Congenital hemoglobinopathies
		Protein starvation
		Anemia in liver disease

Table 2 Laboratory findings in iron deficiency anemia, anemia of chronic disease, mixed iron deficiency anem and anemia of chronic disease[16,31]

Laboratory measures	IDA	ACD	IDA and ACD
Serum iron	↓	↓	↓
Hemoglobin	↓	↓	↓
MCV	↓	↓ or normal	↓ or normal
CRP	Normal	↑↑	↑
Serum ferritin	↓	↑	↑ or normal
Transferrin	↑	↓ or normal	↓
Transferrin saturation	↓	↓	↓
sTfR	↑	↓	↑ or normal
sTfR- Ferritin index	High (> 2)	Low (< 1)	High (> 2)
Reticulocyte Hb content (CHr, pg)	< 28	≥ 28	< 28
Zinc protoporphyrin (μmol/mol heme)	> 40	< 40	> 40
Percentage of hypochromic RBC	> 5	< 5	> 5
Hepcidin	↓	↑	↑

↓: Low/decreases; ↑: High/increases; ↑↑: Very high; IDA: Iron deficiency anemia; ACD: Anemia of chronic disease; MCV: Mean corpuscular volume; CRP: C-reactive protein; sTfR: Soluble transferrin receptor; Hb: Hemoglobin; RBC: Red blood cell.

Table 3 Available preparations for intravenous iron supplementation[16,24,26]

	Iron dextran (LMW)	Irongluconate	Ironsucrose	Ferriccarboxymaltose	Ferumoxytol	Ironisomaltoside
Product/Europe Product/United States	CosmoFer® INFeD®	Ferrlecit® Ferrlecit®	Venofer® Venofer®	Ferinject® Injectafer®	Rienso® Feraheme®	Monofer® Not available in United States
Manufacturer	Pharmacosmos	Sanofi-Aventis	Vifor	Vifor	AMAG	Pharmacosmos
Test dose required	Yes	No	Yes (in Europe)/No	No	No	No
Maximum approved dose	20 mg/kg	125 mg	200 mg (500 mg in few countries) 7 mg/kg	Ferinject- 1000 mg, or up to maximum of 20 mg/kg Injectafer-1500 mg if patient’s weight > 50 kg 15 mg/kg if < 50 kg	1020 mg	20 mg/kg
	Iron dextran (LMW)	Iron gluconate	Iron sucrose	Ferric carboxymaltose	Ferumoxytol	Iron isomaltoside
Maximum injectable single dose	100 mg (2 mL)	125 mg (10 mL)	200 mg (10 mL)	Ferinject- 1000 mg or up to maximum of 20 mg/kg Injectafer- 750 mg (15 mL)	510 mg (17 mL)	200 mg (2 mL)
Maximum infusion time	360 min (6 h)	30-60 min	210 min (3.5 h)	15 min	15 min	15 min
Maximum injection time	2 min	10 min	5-10 min	Bolus push over 7.5 min	17 s (1 mL/s)	Bolus push
Dose-related reactions	Dextran induced IgE -mediated anaphylaxis, hypotension, edema	Hypotension, edema	Hypotension, edema	None reported	None reported	None reported
Relative risk of adverse side effects	Moderate	Low	Very low	None reported	Very low	None reported
Costs per 500 mg in €1 Costs per maximum single injectable dose in United States dollars	84-86 € $37.70	52-56 € $76.32	105-100 € $120	170-175 € $993.75	82.12 $658.54	170-175 € Not available
FDA Pregnancy category	INFeD-category C Cosmofer - no data available	B	B	C	C	Can be used in 2nd and 3rd trimester
Additional comments		FDA approved for IDA in CKD receiving hemodialysis and supplemental epoetin therapy	FDA approved for IDA in CKD patients	Has been studied in patients with IDA associated with CKD either dialysis and nondialysis dependant, IBD, CHF, post-partum and pregnancy patients. Transient hypophosphatemia has been reported	FDA approved for IDA in CKD patients May transiently interfere with “tissue” diagnostic ability of MRI for up to 3 mo and “vascular” MRI for up to 2 d	Very low immunogenic potential

¹In Germany August 2012. Prescribing information of marketed products, package inserts. LMW: Low molecular weight; CKD: Chronic kidney disease; CHF: Congestive heart failure; IDA: Iron deficiency anemia; IBD: Inflammatory bowel disease.

Table 4 Determination of the Cumulative Iron Dose[46]

Hemoglobin (g/dL)	Body weight < 70 kg	Body weight > 70 kg
> 10	1000 mg	1500 mg
7-10	1500 mg	2000 mg