For the Sunday series today we have picked an article by Dr. Abhay Bhave where he answers questions on treatment approach for anaemia, thalassemia and offers clarity on available oral iron therapies and transfusion protocol for anaemic pregnant and non-pregnant patients. 

Question1: Is FCM (ferric carboxymaltose) completely safe?

Dr. Bhave: No medicine is ever completely safe, but where it is essential and you have evidence to use it, one should use it for the betterment of the patient. There is no test dose that is needed. The suggested approach is:

• Give it over 30 to 45 minutes and not beyond that
• Don’t exceed 1000 mg at a time
• You may split the doses- either once a week for two weeks or twice in a week

Recommendation: Use either FCM, iron sucrose, isomaltoside, or ferumoxytol in a facility where you can take care of the side effects, if there were to be any. Usually nothing much happens, but if it does, that one event can create problems.

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Question 2: What is the role of reticulocyte count in diagnosis?

Dr. Bhave: Reticulocyte count is a marker to check whether the blood production line is good or not. So if one gets reticulocytopenia, that is less reticulocytes, it means the amount of blood production is less. And if it’s a production fault, if there is reticulocytosis- it would either signal blood breaking down or ongoing haemolysis in the patient.

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Question 3: How to manage anaemia in old age?

Dr. Bhave: In other words, how much haemoglobin do you need in old age? Well, the geriatric population should also have good haemoglobin levels. A haemoglobin of 12+ for a male and 11+ for a female would be ideal to have good quality of life. More often than not, older anaemic patients have bleeding manifestations and malabsorption.

Note: Oral iron is a problem for older patients, as is constipation. Many of them have fissures and therefore, they refuse to take iron because their constipation gets worse. So giving them IV iron is a very good option and there is no bar to using that in old age.

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Question 4: How to differentiate between early iron deficiency and thalassemia for a patient who is on erythropoietin (EPO) in chronic kidney disease (CKD)?

Dr. Bhave: So you have iron deficiency, thalassemia and CKD - three issues, which all cause hypochromic microcytic anaemia together. Sometimes doing ferritin test in this is not good as because of CKD, the ferritin may be slightly high or normal. You can’t diagnose iron deficiency. However, beta thalassemia can be picked up by doing HB electrophoresis and a blood DNA PCR will pick up alpha thalassemia.

So then one would have to choose between using erythropoietin for CKD and giving oral iron therapy for iron-deficiency anaemia. In this particular case, a trial of iron therapy would be very good. You can see whether the haemoglobin rises in addition to the erythropoietin that is given to the patient at the time of the dialysis.

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Question 5: Should anaemia be addressed first in a female patient, who is 65 years old with haemoglobin of 9.2 and all other parameters low, except that in the last two years, the platelets have been on the lower side- 1.2 lakhs accompanied by body weakness?

Dr. Bhave: In this case, MCH, MCV, and MCHC is low, and haemoglobin of 9.2, is certainly low. The patient complains of weakness, but a low platelet count does not cause weakness, so her symptoms are related to anaemia. Therefore, one should first find the cause of anaemia and then treat it.

The normal value of platelets is 1,50,000 to 4,00,000. A value between 1,00,000 to 1,50,000 may not give you too many answers. Unless, there is something very obvious or sinister like bleeding or malignancy, lymphadenopathy, or jaundice, one may not feel the need to look at the platelets. It would help to look at the peripheral smear to check for large platelets. Sometimes large platelets are not counted when in a peripheral smear view. In such an instance, MPV (mean platelet volume) could also be high and therefore, one would only treat for low haemoglobin in such patients.

Suggestion: It is important to find out the cause, treat it, and see what happens to the platelet count. Although, the platelets will not increase when one is treating for anaemia, as part of the anaemia diagnosis, it is possible to pick up a reason for both. This is called bicytopenia and sometimes a marrow examination could be done for more answers.

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Question 6: What is the level of haemoglobin at which one should transfuse packed cells to patients?

Dr. Bhave: We don’t decide transfusion for a level of haemoglobin; we decide transfusion on the basis of the need of the patient. If the patient is clinically unwell, then the level does not matter. So, assuming you got a G6PD (glucose-6-phosphate dehydrogenase) deficiency patient whose haemoglobin was 14 a few days ago and now it is 8.2. There is a drop of 6 grams and if it is expected to drop further, it helps to keep packed cells ready for this patient. If it drops any further, it will become necessary to use it. So it really comes down to the clinical situation.

As per the British Committee on Standards in Haematology (BCSH), transfusion is mandatory if the haemoglobin is 5 or below 5. But in that case, in India, doctors would be transfusing blood to most patients living in the high altitude regions, because there may be many people whose haemoglobin may be between 5 and 6; so that is not the answer to every situation. It is mandatory at 5 or below. Between 5 and 7 it’s a clinician’s call. Identify a cause, treat it, and if the haemoglobin comes up, there would not be a reason to worry.

However, note that this approach would change if the patient is pregnant. In pregnancy, a haemoglobin of 7 and below would be worrisome. The doctor has to make decisions based on the patient’s status– pregnant or non-pregnant and the haemoglobin level. That’s the clinical path correlation; we want to see, whether they need any blood or not.

For people with cardiac problems or those haemolysing actively or bleeding actively, elderly patients who are sick in the hospital, transfusion would have to be given to bring up the haemoglobin.

• The current cut off for IHD (ischaemic heart disease) patients is 8, if below, give transfusion
• For non-IHD patients with haemoglobin of 7 or below, it is necessary to transfuse blood

This is called restrictive transfusion or liberal transfusion. A level of 7 or below is restrictive, 8 or below is restrictive, and it is preferrable not to transfuse above that; liberal transfusions are not given.

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Question 7: What is the cut off for haemoglobin to give iron sucrose?

Dr. Bhave: There is no cut off for haemoglobin. Giving iron sucrose is a very good alternative if the patient has anaemia and is not responding, has iron deficiency and not responding to either iron diets or to oral iron therapy, or is intolerant or not responsive, or is pregnant. Therefore, there is no cut off for haemoglobin.

For instance, if the haemoglobin is 9 and a patient is not responding to therapy, it would be reasonable to give IV iron. In pregnancy, this is even more valuable. Iron sucrose in pregnancy, especially, in the second trimester is very useful. It is best to follow the British Transfusion Society policy, according to which if the haemoglobin is less than 9 and the patient has proven iron deficiency in the form of ferritin with a value of less than 30, iron sucrose (200 mg for two consecutive days) should be given.

After one week, the haemoglobin should be checked and if it is still below 9, the iron sucrose should be repeated for two consecutive days. Again, haemoglobin should be checked after a week, if it is going above 9 but remains below 10, iron sucrose can be given for one more day. If it goes above 10, one can hold on. This can be done until 1000 mg of iron sucrose dose is reached in pregnancy. The same can be followed for non-pregnant patients who are intolerant or not able to comply to oral iron.

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Question 8: Do all CCF (congestive cardiac failure) patients, without anaemia, need treatment with FCM? And is there any role for FCM in anaemia for chronic renal failure?

Dr. Bhave: For CCF patients who are iron-deficient, it is best to avoid transfusion, because they can have a reaction. For anaemia of chronic renal failure, if there is proven iron deficiency, yes. Otherwise the answer is ‘no’. There is a new drug coming up called ferumoxytol, which may help patients with iron deficiency or anaemia of chronic kidney disease. Especially in renal patients, it can do much more than what carboxymaltose might.

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Question 9: Which is the best oral iron preparation in terms of tolerance and efficacy?

Dr. Bhave: The best oral iron preparation is the one which the patient can tolerate. There are ascorbates, fumarate, sulfates, calcium citrates. One should use whichever suits the patients.

Calcium citrate tends to have a better bonding between the salt and the iron, therefore, when it goes to the stomach, its release of free iron into the stomach is less, so gastric irritation is lesser. Therefore, calcium citrate tends to be more favoured. But, there are patients who respond to ascorbates and fumarates as well. Anything that a patient can swallow and swallow every day, for the haemoglobin to rise is the best oral iron for that patient.

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Question 10: What is the level of haemoglobin required for transfusion in beta thalassemia and in transfusion-dependent thalassemia?

Dr. Bhave: Generally, haemoglobin close to 10 is recommended in beta thalassemia. Beta thalassemia entails less haemoglobin production; otherwise all systems are working well. So to keep all their functions adequate, haemoglobin of 10 would be ideal for beta thalassemia. Because they need recurrent transfusion, 10, would be a very good cut off. A haemoglobin level of 9, 10, up to 11 may also be fine. These patients tend to do very well. But, because they can’t make blood, they have to have frequent transfusion. However, overzealous transfusion is not good either. It will deposit ferritin in the body tissue, which is not good for their overall health. Therefore, keeping haemoglobin around 10, but monitoring the ferritin, the endocrine function, spleen size, and giving them good quality blood, washed transfusion if possible, or using filtered blood is the way to go for beta thalassemia.

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Question 11: Is it valid to transfuse blood in haemoglobin more than 7?

Dr. Bhave: If it’s a haemoglobin of 7.5 and the patient is unwell in terms of active bleeding or haemolysis, there is no choice but to transfuse blood. It is not about the cut off of a value, but the clinical picture, which determines if transfusion should be given.

There may be many patients in India from poorer areas whose haemoglobin levels would be 2 and 3, and yet, they would be fine. For them, oral iron may work well along with a shot of B12 once in a while. They may do very well on such treatment. So, it is not about the haemoglobin number, but the clinical picture which determines what is to be done.

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This article is second in the transcription series from a webinar by Dr. Abhay Bhave. To read the first article, click Anaemia case files with Dr. Abhay Bhave.

Disclaimer

This document is a transcription of a portion of the webinar, produced for audience with bandwidth limitations that could possibly restrict them from viewing the video. While it is believed to be accurate, it is not warranted to be so. Divergence in format is to be expected.

The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.