Intravenous iron has been found to provide a more rapid recovery from anaemia, higher haemoglobin level and better replenishment of iron stores than oral iron.33 Furthermore, improvements in quality of life and patient-reported outcomes have also been shown.40 The response to therapy should be assessed two weeks after the first treatment. Depending on the stage of the pregnancy and response to initial therapy, further iron can be administered if required. Postpartum anaemia is common, and some women will benefit from iron replacement after the birth. Iron stores should be reassessed approximately six weeks postpartum.
Iron deficiency, inflammation and chronic disease
Diagnosis and management of iron deficiency in the setting of inflammation and chronic disease is challenging. An expert panel has proposed that iron deficiency be diagnosed in patients with chronic heart failure, chronic kidney disease or inflammatory bowel disease if either of the following is present:12
- serum ferritin level less than 100mcg/L
- total transferrin saturation less than 20%.
Australian guidelines on chronic kidney disease suggest targets for ferritin and transferrin saturation both before starting treatment with erythropoiesis-stimulating agents (ferritin more than 100mcg/L and transferrin saturation more than 20%) and during treatment (ferritin 200 to 500mcg/L and transferrin saturation 20 to 30%).41
In treating iron deficiency in patients with chronic disease or inflammation, an additional priority is to minimise the activity of the chronic or inflammatory process to restore normal iron physiology. In this context, IV iron is often required; it has been shown to be more efficacious in patients with chronic heart failure and chronic kidney disease and avoids the tolerability concerns common in patients with inflammatory bowel disease.12
Iron deficiency remains a common finding, and should alert medical practitioners to the possibility of underlying disease. Comprehensive clinical assessment and investigations are required to ensure that the patient is adequately evaluated for potential causes of iron deficiency. Parenteral iron formulations with safety profiles that permit safe outpatient infusions are now available to facilitate iron replacement, but oral replacement remains an effective first-line strategy in patients who can tolerate it. MT