Standard iron deficiency anemia. Algorithms for the diagnosis and treatment of iron deficiency anemia. List of main diagnostic measures

For citation: Dvoretsky L.I. Algorithms for the diagnosis and treatment of iron deficiency anemia // RMJ. 2002. No. 17. S. 743

MMA named after I.M. Sechenov

AND iron deficiency anemia (IDA) is a clinical and hematological syndrome characterized by a violation of hemoglobin synthesis as a result of iron deficiency, which develops against the background of various pathological (physiological) processes, and is manifested by signs of anemia and sideropenia.

The importance of rational and effective therapy for IDA is due to medical and social significance and high prevalence of this condition among the population , especially women of childbearing age, because:

• women of childbearing age are the main risk group for developing IDA
• iron stores in the body of women are 3 times less than in men
• iron intake in girls and fertile women in developed countries (USA) is 55-60% of what should be
• IDA accounts for 75-95% of all anemias in pregnancy
• in Russia, about 12% of women of childbearing age suffer from IDA
• latent iron deficiency in some regions of Russia reaches 50%.

2 - diagnosis of the iron deficiency nature of anemia

3 - diagnosis of the cause of IDA.

1. Diagnosis of hypochromic anemia. All IDAs are hypochromic. Therefore, the hypochromic nature of anemia is a key sign that allows suspecting IDA in the first place and determining the further direction of the diagnostic search.

The clinician, when interpreting the results of a blood test, must necessarily pay attention not only to the color index (it can be calculated incorrectly if the laboratory assistant calculates the number of erythrocytes), but also to the morphological picture of erythrocytes, which is described by the laboratory assistant when viewing a smear (for example, hypochromia , microcytosis, etc.).

2. Diagnosis of the iron deficiency nature of anemia (differential diagnosis of hypochromic anemia). Not all hypochromic anemias are iron deficiency. With this in mind, the presence of hypochromic anemia does not exclude hypochromic anemia of another origin. In this regard, at this stage of the diagnostic search, it is necessary to conduct a differential diagnosis between IDA and the so-called sideroahrestic (achresia - disuse) anemia. At sideroachrestic anemias (group concept), also referred to as iron-saturated anemia, the iron content in the body is within the normal range or even there is an excess of it, however, for various reasons, iron is not used to build heme in the hemoglobin molecule, which ultimately leads to the formation of hypochromic erythrocytes with low hemoglobin content. Unused iron enters reserves, is deposited in organs and tissues (liver, pancreas, skin, macrophage system, etc.), leading to the development of hemosiderosis.

Correctly recognizing IDA and distinguishing it from sideroachrestic anemia is extremely important, since an erroneous diagnosis of IDA in patients with iron-saturated anemia can lead to unjustified administration of iron preparations to such patients, which in this situation will lead to an even greater "overload" of organs and tissues with iron. In this case, the therapeutic effect of iron preparations will be absent.

The main hypochromic anemias with which the differential diagnosis of IDA should be made , are the following:

• anemia associated with impaired heme synthesis resulting from the inhibition of the activity of certain enzymes (hemisynthetase), which ensure the incorporation of iron into the heme molecule. This enzyme defect can be hereditary (hereditary sideroachretic anemia) or result from exposure to certain medications (isoniazid, PAS, etc.), chronic alcohol intoxication, contact with lead, etc.;
• thalassemia , belongs to the group of hereditary hemolytic anemias associated with impaired synthesis of globin, the protein part of hemoglobin. The disease has several variants and is characterized by signs of hemolysis (reticulocytosis, increased levels of indirect bilirubin, enlarged spleen), high iron content in serum and depot, hypochromic anemia. In fact, with thalassemia, we are also talking about sideroachresia, i.e. about the non-use of iron, but not as a result of defects in the enzymes involved in the synthesis of heme, but as a result of a violation of the process of building the hemoglobin molecule as a whole due to the pathology of its globin part;
• anemia associated with chronic diseases . This term is used to denote a group of anemias that occur in patients against the background of various diseases, most often of an inflammatory nature (infectious and non-infectious). An example is anemia in suppurative diseases of various localization (lungs, abdominal cavity, osteomyelitis), sepsis, tuberculosis, infective endocarditis, rheumatoid arthritis, malignant tumors in the absence of chronic blood loss. With all the variety of pathogenetic mechanisms of anemia in these situations, one of the main ones is the redistribution of iron into the cells of the macrophage system, which is activated during inflammatory and tumor processes. Since true iron deficiency is not observed in these anemias, it is more justified to speak not of IDA, but of iron-redistributive anemias. The latter are, as a rule, moderately hypochromic in nature, the content of iron in the serum can be slightly reduced, the total body resistance is usually within the normal range or moderately reduced, which distinguishes this variant of anemia from IDA. An increase in the level of ferritin in the blood is characteristic. Understanding and correct interpretation of the pathogenetic mechanisms of anemia development in the above diseases allow the doctor to refrain from prescribing iron preparations to these patients, which are usually ineffective.

• the study should be carried out before starting treatment with iron preparations. Otherwise, even when taking drugs for a short period of time, the obtained indicators do not reflect the true content of iron in the serum. If iron preparations were prescribed, then the study can be carried out no earlier than 7 days after their cancellation;
• erythrocyte transfusions, often carried out before the nature of anemia is clarified (a pronounced decrease in hemoglobin, signs of heart failure, etc.), also distort the assessment of the true content of iron in serum;
• for the study of serum for iron content, special test tubes washed twice with distilled water should be used, since the use of tap water for washing containing small amounts of iron affects the results of the study. Drying cabinets should not be used to dry the test tubes, since a small amount of iron gets into the dishes from their walls when heated;
• at present, for the study of iron, it is customary to use bathophenanthralin as a reagent, which forms a color complex with iron ions with a stable color and a high molar extinction coefficient; the accuracy of the method is quite high;
• blood for analysis should be taken in the morning, as there are daily fluctuations in the concentration of iron in the serum (in the morning, the level of iron is higher);
• serum iron levels are affected by the phase of the menstrual cycle (immediately before and during menstruation, serum iron levels are higher), pregnancy (increased iron levels in the first weeks of pregnancy), oral contraceptives (increased), acute hepatitis and cirrhosis of the liver (increased ). There may be random variations in the studied parameters.

3. Identification of the cause of IDA. After confirming the iron deficiency nature of anemia, i.e., verifying the IDA syndrome, it is no less important to establish the cause of this anemic syndrome. Recognition of the cause of the development of IDA in each case is the final stage of the diagnostic search. Orientation to nosological diagnostics is very important, since in most cases, in the treatment of anemia, it is possible to influence the underlying pathological process.

Algorithm for the diagnosis of iron deficiency anemia

- chronic blood loss different localization (gastrointestinal, uterine, nasal, renal) due to various diseases;

- malabsorption of dietary iron in the intestine (enteritis, resection of the small intestine, insufficient absorption syndrome, blind loop syndrome);

- increased need for iron (pregnancy, lactation, intensive growth, etc.);

- nutritional iron deficiency (malnutrition, anorexia of various origins, vegetarianism, etc.).

Causes of iron deficiency anemia

Iron preparations (ID) are the means of choice for correcting iron deficiency and hemoglobin levels in patients with IDA. Pancreas should be preferred to foods containing iron.

Iron medicines for the treatment of iron deficiency anemia

Currently, the doctor has a large arsenal of medicinal pancreas, characterized by different composition and properties, the amount of iron they contain, the presence of additional components that affect the pharmacokinetics of the drug, and the dosage form.

In clinical practice, medicinal prostates are administered orally or parenterally. The route of administration of the drug in patients with IDA is determined by the specific clinical situation. In addition, all iron-containing preparations can be divided into two groups - preparations of iron salts and preparations in the form of iron-containing complexes that have some distinctive properties (composition, pharmacokinetics, tolerability, etc.), see table. one.

1. Route of administration of iron preparations

1. Route of administration of iron preparations

Clinical situation

In the vast majority of cases, iron preparations should be administered orally.

Parenteral iron preparations can be used in the following clinical situations:

Malabsorption in intestinal pathology (enteritis, malabsorption syndrome, resection of the small intestine, resection of the stomach according to Billroth II with the inclusion of the duodenum);

Exacerbation of peptic ulcer of the stomach or duodenum;

Intolerance to the pancreas for oral administration, not allowing to continue treatment;

The need for faster saturation of the body with iron, for example, in patients with IDA who are to undergo surgery (uterine fibroids, hemorrhoids, etc.).

2. Choice of an oral iron preparation

• The amount of ferrous iron
• The presence in the preparation of substances that improve the absorption of iron
• Tolerability of the drug

At choosing a specific drug and the optimal dosing regimen it must be borne in mind that an adequate increase in hemoglobin parameters in the presence of IDA can be ensured by the intake of 30 to 100 mg of ferrous iron into the body. Given that with the development of IDA, iron absorption increases compared to the norm and amounts to 25-30% (with normal iron reserves - only 3-7%), it is necessary to prescribe from 100 to 300 mg of ferrous iron per day. The use of higher doses does not make sense, since the absorption of iron does not increase. Thus, the minimum effective dose is 100 mg, the maximum is 300 mg of ferrous iron per day. Individual fluctuations in the amount of iron needed are due to the degree of iron deficiency in the body, depletion of reserves, the rate of erythropoiesis, absorbability, tolerance, and some other factors. With this in mind, when choosing a medicinal pancreas, one should focus not only on the content of the total amount in it, but mainly on the amount of ferrous iron, which is absorbed only in the intestine.

PG should be taken with meals. At the same time, iron absorption is better when taking medications before meals.

Preferably preparations containing ascorbic acid (Sorbifer Durules) . It is not recommended to drink tea with iron preparations, since tannin forms poorly soluble complexes with iron. It is not necessary to take calcium preparations, tetracycline and fluoroquinolone antibiotics simultaneously with iron preparations.

3. Evaluation of the effectiveness of the prescribed drug

• The number of reticulocytes 7-10 days after the appointment of the drug
• The amount and rate of increase in hemoglobin every week

Substances affecting the absorption of iron preparations

With the appointment of pancreas in a sufficient dose on the 7-10th day from the start of treatment, an increase in the number of reticulocytes is observed. Normalization of hemoglobin levels is observed in most cases after 3-4 weeks of treatment, but sometimes the time for normalization of hemoglobin values ​​is delayed up to 6-8 weeks and a sharp abrupt increase in hemoglobin can be observed. These individual manifestations and features may be due to the severity of IDA, the degree of depletion of iron stores, as well as an incompletely eliminated cause (chronic blood loss, etc.).

4. Assessment of tolerability of the drug when administered orally

• Patient care, treatment control

Among side effects against the background of the use of pancreas inside, nausea, anorexia, a metallic taste in the mouth, constipation, and less often diarrhea occur most often. The development of constipation is most likely due to the binding of hydrogen sulfide in the intestine, which is one of the stimuli of intestinal motility. In most cases, modern pancreas cause minor side effects that require their abolition and transition to the parenteral route of administration.

Evaluation of tolerability of oral administration of an iron preparation

Dyspeptic disorders may decrease when taking drugs after meals or by reducing the dose.

According to modern technologies, pancreas with a delayed release of iron from them (Sorbifer Durules) is currently being produced due to the presence of inert substances, from which iron gradually enters through small pores. This provides a prolonged absorption effect and reduces the incidence of gastrointestinal disturbances.

5. Duration of saturating therapy

• Growth rate of hemoglobin level
• Terms of normalization of hemoglobin levels
• Clinical situation

The duration of the so-called saturating therapy with iron preparations is determined by the rate of growth of hemoglobin, and hence the timing of the normalization of hemoglobin levels. This, in turn, may depend on the activity of the iron preparation, on the degree of iron depletion in the body. According to our data, a high rate of hemoglobin growth is observed during treatment with sorbifer-durules. The average increase in hemoglobin per day is about 2 g/l, which allows you to complete the course of saturating therapy in 2-3 weeks.

6. Need for maintenance therapy

• Clinical situation (pregnancy, intractable menorrhagia and nosebleeds, etc.)

Treatment with oral iron preparations

In most cases, to correct iron deficiency in the absence of special indications, PZh should be administered orally.

Currently, the Russian pharmaceutical market has a large number of iron preparations for oral administration - in the form of various iron salts or in the form of iron-containing complexes. Preparations differ in the amount of iron salts they contain, including ferrous iron, the presence of additional components (ascorbic and succinic acids, vitamins, fructose, etc.), dosage forms (tablets, dragees, syrups, solutions) and cost.

The main iron-containing preparations are presented in the form of ferrous sulfate, gluconate, chloride, ferrous fumarate, glycine sulfate, and iron sulfate preparations have the highest degree of absorption, and glycine sulfate the least.

Table 2 presents the main medicinal products registered in Russia in the form of salts and iron-containing complexes for oral administration. The reasons for the ineffectiveness of oral iron therapy and methods of correction are shown in Table 3.

Unlike pancreas for oral administration, iron in injectable preparations is always in the trivalent form.

Unlike pancreas for oral administration, iron in injectable preparations is always in the trivalent form.

Against the background of parenteral treatment of the pancreas, especially when administered intravenously, allergic reactions often occur in the form of urticaria, fever, anaphylactic shock. In addition, with intramuscular injection of the pancreas, darkening of the skin at the injection sites, infiltrates, abscesses may occur. With intravenous administration, the development of phlebitis is possible. If pancreas for parenteral administration is prescribed to patients with hypochromic anemia not associated with iron deficiency, there is an increased risk of severe disorders due to iron overload of various organs and tissues (liver, pancreas, etc.) with the development of hemosiderosis. At the same time, with an erroneous appointment of the pancreas inside, the occurrence of hemosiderosis is never observed.

Table 4 shows the pancreas used for parenteral administration.

IDA in newborns and children . The main cause of IDA in newborns is considered to be the presence of IDA or latent iron deficiency in the mother during pregnancy. In young children, the most common cause of IDA is a nutritional factor, in particular, feeding exclusively with milk, since the iron contained in women's milk is absorbed in small quantities. Among the pancreas, which are indicated for newborns and children, along with appropriate nutrition correction (vitamins, mineral salts, animal protein), oral preparations containing small and medium doses of ferrous iron (10-45 mg) should be prescribed. It is preferable to prescribe pancreas in drops or in the form of syrup. In young children, it is convenient to use the iron polymaltose complex in the form of chewable tablets (maltoferfol).

IDA in adolescent girls is most often the result of insufficient iron stores as a result of iron deficiency in the mother during pregnancy. At the same time, their relative iron deficiency during the period of intensive growth and with the appearance of menstrual blood loss can lead to the development of clinical and hematological signs of IDA. Such patients are indicated for oral therapy. It is advisable to use ferrous sulfate preparations containing various vitamins, since during the period of intensive growth the need for vitamins of groups A, B, C increases. After the restoration of hemoglobin values ​​to normal values, repeated courses of treatment should be recommended, especially if heavy periods are established or there are other minor blood loss (nasal, gum).

IDA in pregnant women is the most common pathogenetic variant of anemia that occurs during pregnancy. Most often, IDA is diagnosed in the II-III trimester and requires correction with medicinal pancreas. It is advisable to prescribe ferrous sulfate preparations containing ascorbic acid. The content of ascorbic acid should exceed 2-5 times the amount of iron in the preparation. Daily doses of ferrous iron in pregnant women with non-severe forms of IDA may not exceed 100 mg, since at higher doses, various dyspeptic disorders are likely to occur, to which pregnant women are already prone. The combination of pancreas with vitamin B 12 and folic acid, as well as pancreas containing folic acid, is not justified, since folic acid deficiency anemia in pregnant women is rare and has specific clinical and laboratory signs.

The parenteral route of administration of the pancreas in most pregnant women without special indications should be considered inappropriate. Treatment of the pancreas in the verification of IDA in pregnant women should be carried out until the end of pregnancy. This is of fundamental importance not only for the correction of anemia in a pregnant woman, but mainly for the prevention of iron deficiency in the fetus.

IDA in women with menorrhagia . Regardless of the cause of menorrhagia (myoma, endometriosis, ovarian dysfunction, thrombocytopathy, etc.) and the need to influence the corresponding factor, long-term prostate therapy for oral administration is necessary. The dose, dosing regimen and specific pancreas are selected individually, taking into account the iron content in the preparation, its tolerability, etc. With severe anemia with clinical signs of hyposiderosis, it is advisable to prescribe drugs with a high content of ferrous iron (100 mg), which allows, on the one hand, to adequately compensate for iron deficiency, and on the other hand, it makes it easier and more convenient to take iron-containing drugs (1-2 times per day). After the normalization of the hemoglobin level, it is necessary to carry out maintenance therapy of the pancreas within 5-7 days after the end of menstruation. With a satisfactory condition and stable hemoglobin levels, interruptions in treatment are possible, which, however, should not be long, since women's ongoing menorrhagia quickly depletes iron stores with the risk of relapse of IDA.

IDA in patients with malabsorption (enteritis, resection of the small intestine, blind loop syndrome) requires the appointment of pancreas for parenteral administration along with the treatment of the underlying disease. The pancreas is prescribed in the form of an iron-polymaltose complex for intramuscular or intravenous administration. Do not use more than 100 mg of iron per day (the content of 1 ampoule of the drug). It should be remembered about the possibility of developing side effects with parenteral administration of the pancreas (phlebitis, infiltrates, darkening of the skin at the injection sites, allergic reactions).

IDA in the elderly and senile may be of a polyetiological nature. For example, the causes of the development of IDA in this age group may be chronic blood loss against the background of a tumor process in the stomach, large intestine (difficult to detect localization of the tumor in the elderly), malabsorption, alimentary insufficiency of iron and protein. There may be cases of a combination of IDA and B 12 deficiency anemia. In addition, signs of IDA may appear in patients with B12 deficiency anemia (the most common anemic syndrome in later life) during treatment with vitamin B12. The resulting activation of normoblastic hematopoiesis requires an increased consumption of iron, the reserves of which in the elderly can be limited for various reasons.

1. Definition

Iron deficiency anemia (IDA) is a pathological condition characterized by a decrease in hemoglobin content due to iron deficiency in the body in violation of its intake, absorption or pathological losses.

According to WHO (1973) - the lower limit of capillary blood hemoglobin in children under the age of 6 years is 110 g / l, and after 6 years - 120 g / l.

Causes of IDA in children:

Insufficient level of iron in the body (disorders of the uteroplacental circulation, feto-maternal and feto-placental bleeding, fetal transfusion syndrome in multiple pregnancies, intrauterine melena, prematurity, multiple pregnancy, deep and long-term iron deficiency in the body of a pregnant woman, premature or late ligation of the umbilical cord, intranatal bleeding due to traumatic obstetric interventions or anomalies in the development of the placenta and umbilical cord vessels) Increased need for iron (premature, children with high birth weight, with a lymphatic type of constitution, children in the second half of life). Insufficient amount of iron in food (early artificial feeding with cow's or goat's milk, flour, dairy or milk-vegetarian food, an unbalanced diet that does not contain enough dairy products) Increased iron loss due to bleeding of various etiologies, intestinal absorption disorders (chronic bowel diseases, malabsorption syndrome), as well as significant and prolonged hemorrhagic uterine bleeding in girls. Disorders of iron metabolism in the body (pre and pubertal hormonal imbalance) Disorders of iron transport and utilization (hypo and atransferinemia, enzymopathies, autoimmune processes) Insufficient resorption of iron in the digestive tract (post-resection and agastric conditions).

Stages of development of IDA(WHO, 1977)

Prelatent (depletion of tissue iron stores; blood counts are normal; there are no clinical manifestations). latent (iron deficiency in tissues and a decrease in its transport fund; blood counts are normal; the clinical picture is due to trophic disorders that develop as a result of a decrease in the activity of iron-containing enzymes and are manifested by sideropenic syndrome - epithelial changes in the skin, nails, hair, mucous membranes, distortion of taste, smell , violations of the processes of intestinal absorption and asthenovegetative functions, a decrease in local immunity).

Iron deficiency anemia (more pronounced depletion of tissue reserves of iron and mechanisms for compensating for its deficiency; abnormal blood counts depending on the severity of the process; clinical manifestations in the form of syederopenic syndrome and general anemic symptoms that are caused by anemic hypoxia - tachycardia, muffled heart sounds, systolic murmur , shortness of breath during physical exertion, pallor of the skin and mucous membranes, arterial hypotension, increased astheno-neurotic disorders).

The severity of anemic hypoxia depends not only on the level of hemoglobin, but also on the rate of development of anemia and on the compensatory capabilities of the body. In severe cases, a syndrome of metabolic intoxication develops in the form of memory loss, subfebrile condition, headache, fatigue, hepatolienal syndrome, etc.
Iron deficiency contributes to a decrease in immunity, a delay in the psychomotor and physical development of children.

According to hemoglobin level IDA is divided into degrees of severity:

Mild - Hb 110-91 g/l moderate - Hb 90-71 g/l severe - Hb 70-51 g/l super-heavy - Hb 50 g/l or less

2. Laboratory criteria for the diagnosis of IDA

Blood test with the determination of: hemoglobin level, erythrocytes morphological changes in erythrocytes color index of the average diameter of erythrocytes average hemoglobin concentration in erythrocytes (MCHC) average volume of erythrocytes (MC) level of reticulocytes blood with the calculation of the coefficient of saturation of transferrin with iron

3. Basic principles of treatment

Elimination of etiological factors rational therapeutic nutrition (for newborns - breastfeeding, and in the absence of milk from the mother - adapted milk formulas enriched with iron. Timely introduction of complementary foods, meat, especially veal, offal, buckwheat and oatmeal, fruit and vegetable purees, solid varieties of cheese, reducing the intake of phytates, phosphates, tannin, calcium, which impair the absorption of iron.Pathogenetic treatment with iron preparations, mainly in the form of drops, syrups, tablets.

Parenteral administration of iron preparations is indicated only: in the syndrome of impaired intestinal absorption and conditions after extensive resection of the small intestine, ulcerative colitis, severe chronic enterocolitis and dysbacteriosis, intolerance to oral preparations of glandular diseases, severe anemia.

Preventive measures to prevent the recurrence of anemia

Correction of iron deficiency in mild anemia is carried out mainly due to rational nutrition, sufficient exposure of the child to fresh air. The appointment of iron preparations at a hemoglobin level of 100 g / l and above is not indicated.

Daily therapeutic doses of oral iron preparations for moderate and severe IDA:
up to 3 years - 3-5 mg / kg / day of elemental iron
from 3 to 7 years - 50-70 mg / day of elemental iron
older than 7 years - up to 100 mg / day of elemental iron

Monitoring the effectiveness of the prescribed dose is carried out by determining the rise in the level of reticulocytes on the 10-14th day of treatment. Iron therapy is carried out until the hemoglobin level normalizes, with a further dose reduction by ½. Duration of treatment - 6 months, and for premature babies - for 2 years to replenish iron stores in the body.

In older children, the maintenance dose is a course of 3 to 6 months, in girls of puberty - intermittently for a year - every week after menstruation.

It is advisable to prescribe ferric iron preparations due to their optimal absorption and the absence of side effects.

In young children, IDA is predominantly of alimentary origin and most often represents a combination of not only iron deficiency, but also protein, vitamins, which leads to the appointment of vitamins C, B1, B6, folic acid, and correction of protein content in the diet.

Since 50-100% of premature babies develop late anemia, from 20-25 days of life at a gestational age of 27-32 weeks, body weight 800-1600 g, (during the decrease in blood hemoglobin concentration below 110 g / l, the number of red blood cells is 3.0 ґ 10 12 / l, reticulocytes less than 10%), except for iron preparations (3-5 mg / kg / day) and sufficient protein supply (3-3.5 g / kg / day), erythropoietin is prescribed s / c , 250 units/kg/day thrice daily for 2-4 weeks, with vitamin E (10-20mg/kg/day) and folic acid (1mg/kg/day). Longer-term use of erythropoietin - 5 times a week, followed by a decrease to 3 times, is prescribed for children with severe intrauterine or postnatal infection, as well as children with a low reticulocyte response to therapy.

Parenteral iron preparations should be used strictly only for special indications, due to the high risk of developing local and systemic adverse reactions.

The daily dose of elemental iron for parenteral administration is:
for children 1-12 months - up to 25 mg / day
1-3 years - 25-40 mg / day
older than 3 years - 40-50 mg / day
The course dose of elemental iron is calculated by the formula:
МТґ (78-0.35ґ Hb), where
BW - body weight (kg)
Hb - child's hemoglobin (g / l)
Heading dose of an iron-containing drug - KJ: SZhP, where
KJ - course dose of iron (mg);
FFP - iron content (mg) in 1 ml of the drug
Course number of injections - KDP: ADP, where
KDP - course dose of the drug (ml);
ADP - daily dose of the drug (ml)

Blood transfusions are carried out only for health reasons, when there is an acute massive blood loss. The advantage is given to the packed red blood cells or washed red blood cells.

Ferrotherapy contraindications: aplastic and hemolytic anemia hemochromatosis, hemosiderosis sideroachrestic anemia thalassemia other types of anemia not associated with iron deficiency in the body

4. Prevention
Antenatal: women from the 2nd half of pregnancy are prescribed iron supplements or iron-fortified multivitamins.
In case of repeated or multiple pregnancy, it is mandatory to take iron supplements during the 2nd and 3rd trimester.
Postnatal prophylaxis for children from high-risk groups for developing IDA.

This group is formed by:

All premature babies children born from multiple pregnancies and with a aggravated course of the second half of pregnancy (preeclampsia, fetoplacental insufficiency, complications of chronic diseases) children with intestinal dysbacteriosis, food allergies children who are bottle-fed children who grow ahead of generally accepted standards of physical development .

Regular diagnostics of the possible development of IDA is envisaged and, when it is determined, prophylactic doses of iron preparations (0.5-1 mg / kg / day) are prescribed for 3-6 months.

5. Dispensary observation
After normalization of blood counts, a complete blood count is performed once a month during the first year, then quarterly for the next 3 years.

Iron deficiency anemia in children

Profile: pediatric.
Stage: polyclinic (outpatient).
Purpose of the stage: increase in hemoglobin and hematocrit to normal.
Duration of treatment (days): 21.

Dynamic observation of a patient receiving iron preparations is carried out every 10-14 days. After normalization of the hemogram, ferrotherapy continues at maintenance doses (1-2 mg/kg/day) for another 2-3 months to replenish the pool of deposited iron (rehabilitation therapy).
At the same time, a dispensary examination is carried out once a month.
Then quarterly.
After 6-12 months from the normalization of clinical and laboratory parameters, the child is removed from the dispensary and transferred from the second health group to the first.

ICD codes:
D53 Other nutritional anemias.
D50 Iron deficiency anemia.

Definition: Iron deficiency anemia is a pathological condition characterized by a decrease in the concentration of hemoglobin due to iron deficiency in the body as a result of a violation of its intake, absorption or pathological losses.

Clinical signs are characterized by sideropenic syndrome: epithelial disorders (trophic disorders of the skin, nails, hair, mucous membranes), perversion of taste and smell, astheno-vegetative disorders, impaired intestinal absorption, dysphagia and dyspeptic changes, decreased immunity.
According to WHO recommendations, the lower limit of normal hemoglobin in children under the age of 6 years should be considered 110 g/l, Ht=33; in children 6-12 years old - 115 g/l, Ht=34; 12-13 years old - 120 g/l, Ht=36.

Classification:
By etiology:
1. IDA with insufficient initial iron levels (anemia of premature babies, twins);
2. nutritional (or alimentary) IDA;
3. IDA of infectious or infectious-alimentary genesis;
4. IDA in resorption iron deficiency (malabsorption syndrome, etc.);
5. chronic posthemorrhagic IDA.
By severity: mild, moderate, severe.
By pathogenesis: acute posthemorrhagic, chronic.

Risk factors:
1. anemia of pregnant women;
2. prematurity;
3. poor nutrition;
4. diseases of the gastrointestinal tract;
5. helminthic invasion;
6. bleeding;
7. low society.

Diagnostic criteria:
In children younger than 5 years of age, IDA is determined when the blood hemoglobin concentration is less than 110 g/l or the hematocrit level is less than 33%.

1. Complete blood count (6 parameters);
2. Determination of hemoglobin;
3. Determination of reticulocytes.

List of main diagnostic measures:
1. ECG;
2. Determination of the total iron-binding capacity;
3. Consultation with a gastroenterologist.

Treatment tactics:
Until 6 months of age, exclusive breastfeeding is recommended. Breastfeeding children with IDA are recommended to start iron supplementation at 6 months of age.
Most formula-fed babies are advised to use an iron-fortified formula before the baby begins to eat solid foods (before 12 months of age). It is necessary to conduct education and consultations of parents on rational nutrition for the prevention of IDA.
Term babies should be tested for IDA (determination of Hb and Ht levels) at 6 months of age, and premature babies - no later than 3 months of age.

Children with established IDA should receive iron preparations - iron salts, single-component and combination preparations, oral solutions containing more than 20 mg / ml of iron salt with ascorbic acid, 1 table. or 1-2 tablets 3 times a day, folic acid 1 tab. 3 times a day.
Iron preparations are prescribed at the rate of 3 mg/kg of body weight per day until hemoglobin normalization, rehabilitation therapy - 1-2 mg/kg of body weight for at least 2-3 months.
Iron-fortified food (mixture).

To confirm the effectiveness of the prescribed therapy, in all young children with IDA, 4 weeks after the start of IDA treatment, Hb and Ht should be re-determined. If there is a positive result on the prescribed treatment (an increase in hemoglobin greater than or equal to 10 g / l, and an increase in Ht by 3% or more), or these indicators are determined within the normal range, then treatment should continue for another 2 months and after that the appointment of iron should be stopped.

In the absence of a positive result on the ongoing treatment or with an increase in hemoglobin less than 10 g / l, and an increase in Ht by less than 3%, the doctor should determine other possible causes of anemia by subsequently referring the patient to a hematologist.

Young children with moderate or severe IDA (Hb less than 90 g/l or Ht less than 27%) should be consulted by a hematologist.
Children 6-12 years of age who have risk factors for IDA (poor living or nutritional conditions) require repeat screening.

Adolescent girls should be screened for IDA at least once between 15 and 25 years of age. In the presence of risk factors (poor nutrition, large menstrual blood loss, blood donation, etc.) or a history of IDA, more frequent screening (every year) is required.

If IDA is suspected on the basis of a peripheral blood test taken from a finger, then the presence of IDA should preferably be confirmed by a blood test taken from a vein.
For adolescent girls, anemia is determined at a hemoglobin level below 120 g / l, Ht- below 36%.
When the hemoglobin concentration is more than 20 g/l below the above limit, adolescents should receive a therapeutic dose of elemental iron - 60 mg twice a day (total dose of 120 mg of iron), in addition, nutrition education is necessary. The doctor should check the effectiveness of the prescribed therapy after 1 month. If there is little or no result (increase in hemoglobin less than 10 g/l; or increase in Ht less than 3 units), the clinician should determine other possible causes of anemia by referring the patient to a hematologist.

In the presence of inflammatory or infectious processes, a low concentration of hemoglobin or hematocrit may indicate the development of IDA due to a violation of the distribution of iron in the body and requires additional treatment. Upon receipt of a positive result on the appointment of an iron preparation, therapy should continue until a hemoglobin concentration of 120 g / l is reached, after which the dose of iron can be reduced to 120 mg per week, and continue for 6 months.

Severe IDA is usually uncommon in adolescent girls, and iron deficiency is rarely the cause of this anemia. Detailed information on the progression of the disease, including dietary habits, a more in-depth examination, and additional laboratory tests (CBC, serum iron, transferrin content, ferritin concentration, reticulocyte count, total protein, total bilirubin and its fractions) are indicated for the final confirmation of IDA.

In adolescent girls, the use of a balanced diet to prevent IDA can stop the development of IDA and prevent iron supplementation. Therefore, it is necessary to pay special attention to the consumption of meat and foods rich in ascorbic acid (to increase the absorption of iron from food), to exclude the consumption of tea and coffee during meals.
In adolescent girls at high risk of multiple micronutrient deficiencies, prescribe multivitamin-mineral preparations containing about 30 mg of iron per tablet.

After the end of the course of treatment, it is recommended to take an elemental iron preparation for prophylactic purposes once a week for 6 months:

List of essential medicines:
1. Iron salts, single-component preparations and combined preparations containing more than 20 mg / ml of iron salt;
2. Ascorbic acid 50 mg, 100 mg, 500 mg tab.; 50 mg dragee;
3. Folic acid 1 mg tab.

List of additional medicines:
1. Preparation of elemental iron 30-60 mg tab.

Criteria for transfer to the next stage of treatment - hospital:
Lack of normalization of clinical and laboratory parameters after 2 weeks.

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FEDERAL AGENCY FOR TECHNICAL REGULATION AND METROLOGY

NATIONAL

STANDARD

RUSSIAN

FEDERATION

Official edition

Standartinform

Foreword

The goals and principles of standardization in the Russian Federation are established by the Federal Law of December 27, 2002 No. 184-FZ "On Technical Regulation", and the rules for the application of national standards of the Russian Federation - GOST R 1.0-2004 "Standardization in the Russian Federation. Basic Provisions»

About the standard

1 DEVELOPED by the Interregional Public Organization for the Promotion of Standardization and Improving the Quality of Medical Care

2 INTRODUCED by the Technical Committee for Standardization TC 466 "Medical Technologies"

3 APPROVED AND INTRODUCED BY Order No. 498-st of December 18, 2008 of the Federal Agency for Technical Regulation and Metrology

By order of the Federal Agency for Technical Regulation and Metrology dated December 31, 2008 No. 4196, the introduction date was postponed to January 1, 2010.

4 INTRODUCED FOR THE FIRST TIME

Information about changes to this standard is published in the annually published information index "National Standards", and the text of changes and amendments - in the monthly published information indexes "National Standards". In case of revision (replacement) or cancellation of this standard, a corresponding notice will be published in the monthly published information index "National Standards". Relevant information, notification and texts are also posted in the public information system - on the official website of the Federal Agency for Technical Regulation and Metrology on the Internet

© Standartinform, 2009

This standard cannot be fully or partially reproduced, replicated and distributed as an official publication without the permission of the Federal Agency for Technical Regulation and Metrology

GOST R 52600.4-2008

iron deficiency anemia without an obvious source of blood loss, a thorough laboratory and instrumental examination is carried out: X-ray and endoscopic studies

gastrointestinal tract, etc., aimed at determining the cause of iron deficiency anemia in accordance with the requirements of the diagnostic sections of other protocols for managing patients.

Iron deficiency anemia in children is characterized by the following features. Anemia in newborns and infants is a consequence of iron deficiency in the mother, not so much during pregnancy, but especially during lactation. In children with a high risk of iron deficiency anemia (high risk is implied by the low socioeconomic status of the child's family, low birth weight (less than 2500 g), feeding only cow's milk during the first year of life), repeated determinations of blood hemoglobin at 6 and 12 months

Iron deficiency anemia in pregnant women is characterized by the following features. In differential diagnosis, "false anemia" is excluded, which in pregnant women may be the result of hydremia (blood dilution). In this case, to clarify the diagnosis, it is necessary:

Examine the volume of circulating blood;

Assess the ratio of the volume of circulating plasma to the volume of circulating erythrocytes;

Determine the hypochromia of erythrocytes (an important sign);

Determine the content of serum iron (important sign);

Determine the content of ferritin in the blood;

Determine the content of soluble receptors for transferrin.

Anemia in pregnant women is also observed in nephropathy of pregnancy (preeclampsia), with chronic urinary tract infections, but in these cases refers to anemia of chronic disease.

Iron deficiency anemia in the elderly is characterized by the following features. Diagnostic studies are aimed at exclusion (detection) of microbleeding from the gastrointestinal tract (erosion and stomach ulcers, polyposis, hemorrhoids, etc.), oncological pathology in the intestine, dysbacteriosis, diverticulosis (competitive consumption of iron by bacteria), alimentary iron deficiency, malabsorption ( for example, with chronic pancreatitis), blood loss from the oral cavity due to problems with dentures. In differential diagnosis, B 12 deficiency anemia, anemia of chronic diseases is excluded.

Iron deficiency anemia, which cannot be corrected for a long time with adequate treatment, has the following features. In the case of persistent anemia, especially in combination with low-grade fever, lymphadenopathy, unreasonable sweating, it is necessary to diagnose the absence of tuberculosis.

Diagnostic stage errors:

The collection of anamnesis, physical examination was not completely carried out;

The cause of iron deficiency anemia has not been established;

No baseline study of serum iron and ferritin;

The initial determination of peripheral blood reticulocytes was not carried out;

The study of serum iron was carried out after taking iron supplements.

3.3 General approaches to the treatment of iron deficiency anemia

Principles of treatment of iron deficiency anemia:

Diet cannot cure iron deficiency anemia.

The use of drugs that strictly correspond to a certain pathogenetic variant of anemia, i.e. the use of only iron preparations.

Predominantly use of oral preparations.

Treatment is adequately high daily doses of a single drug with good tolerance.

Appointment of erythrocyte transfusion only for lifelong indications, including patients of older age groups with progressive angina pectoris, circulatory decompensation and cerebral hypoxic disorders.

Evaluation of the effect of treatment by clinical and laboratory signs, including reticulocyte crisis.

The use of drugs with an optimal cost / effectiveness ratio allows minimizing the cost of treatment.

Rational therapeutic tactics implies the beginning of treatment from the moment iron deficiency anemia is detected until complete clinical and hematological remission is achieved; if necessary, maintenance (preventive) therapy.

Elimination of the causes (diseases) of iron deficiency anemia.

Iron preparations are the mainstay of replacement therapy for iron deficiency in the treatment of iron deficiency anemia. Currently, two groups of iron preparations are used - containing

pressing divalent and trivalent iron. Due to the fact that iron from most modern iron-containing preparations is well absorbed by the intestines, in the vast majority of cases it is possible to use iron preparations orally. Parenteral iron preparations are prescribed only for special indications, which include:

The presence of intestinal pathology with malabsorption (severe enteritis, malabsorption syndrome, resection of the small intestine, etc.);

Absolute intolerance to iron preparations when taken orally (nausea, vomiting), even when using drugs from different groups, which does not allow to continue further treatment;

The need to quickly saturate the body with iron, for example, when patients with iron deficiency anemia are scheduled for surgery;

Treatment of patients with erythropoietin, in which the limiting factor of effectiveness is an insufficient amount of reserves and circulating iron.

No more than 10% - 12% of the iron contained in it is absorbed from the dosage form. With a severe degree of iron deficiency, the iron absorption rate can increase three times. The presence of ascorbic and succinic acids, fructose, cysteine ​​and other accelerators contributes to the increase in the bioavailability of iron, as well as the use of special matrices in a number of preparations that slow down the release of iron in the intestine (level of evidence B). Iron absorption may decrease under the influence of certain substances contained in food (tea tannin, phosphoric acid, phytin, calcium salts, milk), as well as with the simultaneous use of a number of medications (tetracycline drugs, almagel, phosphalugel, calcium preparations, chloramphenicol, penicillamine, etc. .). These substances do not affect the absorption of iron from the iron hydroxide polymaltose complex. To reduce the likelihood of side effects, iron salt preparations are taken before meals.

The calculation of the daily amount of the drug (DQP) for oral iron preparations is performed according to the following formula

where NSD is the required daily dose of divalent or trivalent (non-elemental) iron (in adults - 200 mg per day, in children - 30 - 100 mg per day);

The calculation of the approximate course dose of iron A, mg, administered parenterally, can be carried out according to the formula, taking into account the patient's body weight and hemoglobin level, reflecting the degree of iron deficiency

A \u003d M (Hbi - Hb 2) 0.24 + D, (5)

where M - body weight, kg;

Hbi - normative level of hemoglobin for body weight less than 35 kg 130 g/l, more than 35 kg - 150 g/l;

Hb 2 - the level of hemoglobin in the patient, g/l;

D - calculated value of iron depot for body weight less than 35 kg - 15 mg/kg, for body weight more than 35 kg - 500 mg.

The optimal daily dose for iron preparations in the treatment of iron deficiency anemia should correspond to the required daily dose and is calculated:

Iron in the preparations of iron salts is for children under 3 years old - 5-8 mg of ferrous iron per kg of body weight per day, over 3 years old - 100-120 mg of ferrous iron per day, adults - 200 mg of ferrous iron per day;

Iron in preparations of a polymaltose complex of iron hydroxide (ferric iron) for premature babies 2.5 - 5 mg per kg of body weight, children under one year old - 25 - 50 mg, 1-12 years old 50 - 100 mg, over 12 years old 100 - 300 mg , adults - 200 - 300 mg.

The use of smaller doses of drugs does not give an adequate clinical effect. With a latent iron deficiency or to saturate the depot after the end of the course of therapy, half the doses of drugs are used relative to the therapeutic dose.

Adult patients are parenterally administered no more than 200 mg of iron per day, according to special indications, drip, up to 500 mg per day. In children, the daily dose is 25-50 mg, depending on age, the drug

GOST R 52600.4-2008

injected in a jet, slowly - at least 10 minutes. The maximum allowable single dose is 7 mg of iron per kg of body weight administered once a week.

Monitoring the effectiveness of therapy is an essential component of the rational use of iron-containing drugs. In the first days of treatment, an assessment of subjective sensations is carried out, on the 5-8th day it is necessary to determine the reticulocyte crisis (2-10-fold increase in the number of reticulocytes compared to the initial value). At the 3rd week, the increase in hemoglobin and the number of erythrocytes is assessed. The absence of a reticulocyte crisis indicates either an erroneous prescription of the drug, or an inadequately low dose.

Normalization of hemoglobin levels, the disappearance of hypochromia usually occurs by the end of the first month of treatment (with adequate doses of drugs). However, to saturate the depot, it is recommended to use a half dose of iron-containing preparations for another 4 to 8 weeks. Depot saturation is determined using a comprehensive biochemical study. In the absence of these methods, treatment is carried out empirically.

Among the side effects against the background of oral administration of iron preparations, dyspeptic disorders (anorexia, a metallic taste in the mouth, a feeling of fullness in the stomach, pressure in the epigastric region, nausea, vomiting), constipation, and sometimes diarrhea occur most often. The development of constipation is associated with the formation of iron sulfide in the intestine, which is an active inhibitor of the function of the large intestine. In some patients, especially in children, when using iron salt preparations, brownish staining of tooth enamel occurs. The often occurring dark coloration of the stool has no clinical significance.

With parenteral administration of iron preparations, reactions may occur: local - phlebitis, venous spasm, darkening of the skin at the injection site, post-injection abscesses and general - hypotension, retrosternal pain, paresthesia, muscle pain, arthralgia, fever. In case of an overdose, iron overload with the development of hemosiderosis is possible. Malignancy is possible at the injection site.

Ferrous iron is very often included in complex vitamin preparations. However, the dose of iron in them in this case is insignificant, and therefore they cannot be used to treat iron deficiency conditions (level of evidence A).

The most common treatment errors have the following main causes:

Iron preparations are prescribed in inadequate (small) doses;

Treatment is short-term, adequate adherence of the patient to therapy is not achieved;

Vitamins, biologically active supplements or medicines with a low iron content are unreasonably prescribed.

Treatment of iron deficiency anemia in some age groups and under various conditions has the following features.

Iron deficiency anemia in children of puberty (juvenile chlorosis) is characterized by the following features. Iron deficiency during the period of rapid growth is the result of an uncompensated reduced supply of iron in the first years of life. A spasmodic increase in iron consumption by a rapidly growing organism, the appearance of menstrual blood loss exacerbate the relative deficiency. Therefore, during puberty, it is desirable to use dietary prophylaxis of iron deficiency, and when signs of hyposiderosis appear, prescribe iron preparations.

Iron deficiency anemia in menstruating women is characterized by the following features. A simple calculation of the approximate amount of iron lost in menstrual blood can help determine the source of blood loss. On average, a woman during menstruation loses about 50 ml of blood (25 mg of iron), which determines a two-fold loss of iron compared to men (if distributed over all days of the month, then an additional about 1 mg per day). At the same time, it is known that in women suffering from menorrhagia, the amount of blood lost reaches 200 ml or more (100 mg of iron or more), and, consequently, the additional average daily loss of iron is 4 mg or more. In such situations, the loss of iron in 1 month exceeds its possible intake with food by 30 mg, and in one year the deficit reaches 360 mg.

The rate of progression of anemia in uterine blood loss, in addition to the severity of menorrhagia, is affected by the initial value of iron reserves, nutritional habits, previous pregnancy and lactation, etc. To assess the volume of blood lost during menstruation, it is necessary to clarify the number of pads changed daily by a woman and their characteristics (pads with various absorbent properties have recently been used, a woman chooses pads for herself depending on the amount of blood loss), the presence of a large number of large clots. Relatively small, "normal" blood loss is considered to be the use of two pads per day, the presence of small (1 - 2 mm in diameter) and a small number of clots.

In the case when the cause of iron deficiency is menstrual blood loss, a single course of replacement therapy is not enough, as there will be a relapse in a few months. Therefore, maintenance prophylactic therapy is carried out, usually individually selecting the dose of the drug using titration. It is recommended to take iron-containing preparations with a high iron content from the first day of menstruation for 7 to 10 days. For some women, it is sufficient to carry out such maintenance therapy once a quarter or once every six months. A consensus must be reached between the doctor and the patient about the nature of anemia, methods of therapy, and the importance of prevention. All this significantly increases the compliance of treatment.

Iron deficiency anemia in women during pregnancy and lactation is characterized by the following features. For the prevention of anemia in this group of patients, combined preparations with a relatively low iron content (30-50 mg), including vitamins, including folic acid and vitamin B 12, are often used. The lack of effect of such prophylaxis has been proven (Level of Evidence A). Pregnant women with identified iron deficiency anemia are prescribed for the entire remaining period of pregnancy, drugs containing a large amount of iron (100 mg, 2 times a day), during lactation (in the absence of large blood loss during childbirth and menstrual loss and with full compensation for anemia), you can switch to drugs with a lower iron content (50 - 100 mg per day). If there is no effect from the therapy, first of all, the adequacy of the prescribed doses is analyzed (perhaps they should be increased), the correctness of the woman's prescribed prescriptions (compliance). In addition, there may be "false anemia" as a result of hydremia (blood dilution), often observed in pregnant women (for confirmation, it is necessary to examine the volume of circulating blood, evaluate the ratio of circulating plasma volume to the volume of circulating erythrocytes, erythrocyte hypochromia and serum iron content). Anemia is also observed with nephropathy (preeclampsia), with chronic infections (often of the urinary tract); in case of persistent anemia, especially in combination with subfebrile condition, lymphadenopathy, causeless sweating, it is necessary to exclude the presence of tuberculosis. In these cases, we are talking about anemia of chronic diseases. There are no direct contraindications for the use of parenteral iron preparations in pregnant women, however, large-scale studies in this group have not been performed.

Iron deficiency anemia in old age is characterized by the following features. The main forms of anemia in this group of patients are iron deficiency and B 12 deficiency. Specific treatment regimens for anemia are not required, and usually patients respond quickly to prescribed therapy. The ineffectiveness of the treatment of iron deficiency anemia is often associated with constipation caused by dysbacteriosis, impaired peristalsis. In such cases, lactulose can be added to therapy in an adequate dose of up to 50-100 ml, after obtaining a lasting effect, the dose of lactulose is halved.

4 Description of requirements

4.1 Patient model

Nosological form: iron deficiency anemia Stage: any Phase: any

Complication: regardless of complications ICD-10 code: 050.0

4.1.1 Criteria and features that define the patient model

The patient's condition must meet the following criteria and signs:

Decreased hemoglobin level below 120 g/l;

Reducing the level of erythrocytes below 4.2 10 12 /l;

Hypochromia of erythrocytes;

A decrease in one of the indicators of saturation of erythrocytes with hemoglobin (color index (CPI) below 0.85, the average corpuscular hemoglobin content (MCH) is below 24 pg, the average hemoglobin concentration in erythrocytes (MCHC) is below 30 - 38 g / dl);

Decreased serum iron levels below 13 µmol/L in men and below 12 µmol/L in women.

4.1.2 Requirements for outpatient diagnostics

The list of medical services (MU) for outpatient diagnostics according to the "Nomenclature of works and services in healthcare" is presented in Table 1.

4.1.3 Characteristics of algorithms and features of the implementation of non-drug care

Diagnosis for iron deficiency anemia:

1st stage - determination (confirmation) of the iron deficiency nature of anemia;

2nd stage - determination of the cause of iron deficiency.

The collection of anamnesis and complaints in diseases of the hematopoietic organs and blood is carried out as follows: first of all, signs of sideropenia are detected, including clarification of the diet (excluding vegetarianism and other diets with a low content of iron-containing foods); also clarify the possible source of blood loss or increased iron consumption.

An objective study in diseases of the hematopoietic organs and blood is aimed at identifying the patient's signs that characterize hyposiderosis, and identifying diseases (conditions) with increased iron consumption.

The study of the level of erythrocytes, leukocytes, platelets, reticulocytes of the color index, the ratio of leukocytes in the blood (blood formula), the study of the level of total hemoglobin is aimed at identifying signs of blood diseases that may be accompanied by anemia (see the 2nd stage of diagnosis). A decrease in the color index is decisive in the diagnosis of iron deficiency anemia. The results of all studies are analyzed by the doctor in aggregate, no single symptom is specific for iron deficiency.

Viewing a blood smear to analyze abnormalities in the morphology of red blood cells, platelets and white blood cells - the most accurate method for determining the hemoglobin content in red blood cells remains the morphological study of red blood cells. With iron deficiency anemia, a distinct hypochromia is detected, characterized by the presence of a wide enlightenment in the center of the erythrocyte, which resembles a donut or ring (anulocyte).

The study of serum iron levels is a mandatory diagnostic test for the diagnosis of iron deficiency anemia. It is necessary to pay attention to the causes of false positive results: if the research technology is not followed; the study is carried out shortly after taking (even a single) iron supplements; after hemo- and plasma transfusion.

When determining the average content of hemoglobin in erythrocytes, the technique used in automatic analyzers is used.

Studies of the level of transferrin, serum ferritin are necessary studies in case of doubt in the form of anemia. Research is carried out in the complex of research on iron metabolism. Determination of the level of serum transferrin makes it possible to exclude forms of anemia caused by a violation of iron transport (atransferrinemia).

A decrease in serum ferritin is the most sensitive and specific laboratory sign of iron deficiency.

The total iron-binding capacity of serum reflects the degree of "starvation" of the serum and saturation of transferrin with iron. Iron deficiency anemia is characterized by an increase in the total iron-binding capacity of serum.

Counting sideroblasts (erythroid cells of the bone marrow with iron granules) allows you to confirm the iron deficiency nature of anemia (their number in patients with iron deficiency anemia is significantly reduced). The study is rarely performed, only in complex differential diagnostic cases.

The study of osmotic and acid resistance of erythrocytes is carried out for differential diagnosis with membranopathies of erythrocytes.

Taking blood from a finger and from a peripheral vein is carried out strictly on an empty stomach. Blood sampling for the study of hemostasis is carried out without the use of a syringe and with a loose tourniquet, it is better to use vacuum tubes.

Determination of the cause of iron deficiency.

Stage 2 - determining the cause of iron deficiency is performed in accordance with the requirements provided for by other protocols for managing patients (gastric ulcer, uterine leiomyoma, etc.). In particular, with the help of erythrocytes labeled with radioactive chromium, the fact of blood loss through the gastrointestinal tract is confirmed.

If necessary, a cytological and histological examination of a bone marrow smear, a study of the acid resistance of erythrocytes, and a desferal test are carried out.

4.1.4 Requirements for outpatient care

The list of medical services (MU) for outpatient treatment according to the "Nomenclature of works and services in healthcare" is presented in Table 2.

4.1.5 Characteristics of algorithms and features of the implementation of non-drug care

The collection of anamnesis and complaints in diseases of the hematopoietic organs and blood, a physical examination is carried out twice to assess the dynamics in the general condition (well-being) of patients. "Small signs" of effectiveness are very important in terms of early evaluation of the effectiveness of therapy.

The first objective effect of taking therapy should be a reticulocyte crisis, manifested by a significant - 2-10 times increase in the number of reticulocytes compared with the initial value by the end of the first week of therapy. The absence of a reticulocyte crisis indicates either an erroneous prescription of the drug, or an inadequately low dose.

An increase in the level of hemoglobin, the number of erythrocytes is usually observed on the 3rd week of therapy, later hypochromia and microcytosis disappear. By the 21st - 22nd day of treatment, hemoglobin usually normalizes (with adequate doses), but the saturation of the depot does not occur.

If necessary, the level of the color index, the average content of hemoglobin in erythrocytes, the study of the level of serum iron, the level of ferritin, serum transferrin, the assessment of hematocrit and the iron-binding capacity of serum are carried out.

You can check the saturation of the depot only with the help of a comprehensive biochemical study. Thus, monitoring the effectiveness of therapy is an essential component of the rational use of iron-containing drugs.

Taking blood from a finger and from a peripheral vein is carried out strictly on an empty stomach. Blood sampling for the study of hemostasis is carried out without the use of a syringe and with a loose tourniquet, it is better to use vacuum tubes.

4.1.6 Requirements for outpatient drug care

Requirements for outpatient drug care are presented in Table 3.

4.1.7 Characteristics of algorithms and features of the use of medicines

Replacement therapy for iron deficiency is carried out with iron preparations. Currently, two groups of iron preparations are used - containing ferrous and ferric iron, in the vast majority of cases, used orally.

Apply one of the drugs: iron sulfate (orally), iron (III) hydroxide sucrose complex (intravenously), iron (III) hydroxide polymaltose complex (orally and parenterally).

Some drugs are available in the form of syrups and suspensions, which makes it easier to prescribe them to children. However, here, too, the recalculation of the daily dose should be carried out taking into account the iron content per unit volume.

For better tolerance, iron supplements are taken with meals. It should be borne in mind that under the influence of certain products and substances contained in food (tea tannin, phosphoric acid, phytin, calcium salts, milk), as well as with the simultaneous use of a number of medications (tetra-cycline preparations, Almagel, phospholugel, calcium preparations, levomycetin , penicillamine, etc.) iron absorption from iron salt preparations may decrease. These substances do not affect the absorption of iron from the iron III hydroxide polymaltose complex.

Prescribing iron supplements without recalculating the daily dose is ineffective and leads to the development of a false “refractory ™” (level of evidence C).

Iron preparations are prescribed for 3 weeks, after obtaining the effect, the dose of the drug is reduced by 2 times and is prescribed for another 3 weeks.

Ferrous sulfate: the optimal daily dose for iron preparations should correspond to the required daily dose of ferrous iron, which is 5-8 mg / kg per day for children under 3 years old, 100-120 mg / day for adults over 3 years old, 200 mg / day for adults ( 100 mg 2 times a day 1 hour before meals and 2 hours after meals). The duration of treatment is 3 weeks, followed by maintenance therapy (1/2 dose) for at least 3 weeks (Level of Evidence A).

Iron (III) hydroxide polymaltose complex is a new group of iron preparations containing trivalent iron as part of the polymaltose complex. They have no less pronounced effect in terms of the rate of saturation of the body with iron than ferrous iron. Ferric iron preparations have practically no side effects. Used in the form of a solution for intramuscular injection, solution and tablets in accordance with the requirements of formulary articles for drugs.

Iron (III) hydroxide sucrose complex - for parenteral administration, 2.5 ml is administered on the 1st day, 5 ml - on the 2nd and 10 ml on the 3rd day, then 10 ml 2 times a week. The dose of the drug is calculated taking into account the degree of anemia, body weight and iron stores.

Parenteral administration of iron preparations should be resorted to only in the following exceptional cases:

1 area of ​​use............................................... ....one

3 General provisions............................................... .....one

3.1 Classification of iron deficiency anemia .............................................4

3.2 General approaches to the diagnosis of iron deficiency anemia .............................................4

3.3 General approaches to the treatment of iron deficiency anemia ..............................................7

4 Characteristics of requirements...............................................10

4.1 Patient model .............................................................. ..ten

4.1.1 Criteria and features that define the patient model ..............................................10

4.1.2 Requirements for ambulatory polyclinic diagnostics .............................. 10

4.1.3 Characteristics of algorithms and features of the implementation of non-drug care. 12

4.1.4 Requirements for outpatient treatment ..............................................12

4.1.5 Characteristics of algorithms and features of the implementation of non-drug care. 13

4.1.6 Requirements for outpatient drug care ..............................14

4.1.7 Characteristics of algorithms and features of the use of medicines ..........14

4.1.8 Requirements for the regime of work, rest, treatment or rehabilitation ............... 15

4.1.9 Requirements for patient care and ancillary procedures .......................15

4.1.10 Requirements for dietary prescriptions and restrictions ..............................15

4.1.11 Features of the informed voluntary consent of the patient when performing

protocol of case management and additional information for the patient and his family members .............................................................. ..............16

4.1.12 Rules for changing requirements during protocol execution and termination

protocol requirements....................................16

4.1.13 Possible outcomes and their characteristics .............................................16

5 Graphical, schematic and tabular presentation of the protocol...................................16

5.1 Evaluation of the effectiveness of therapy with iron-containing drugs .............................16

5.2 Some characteristics of tablet forms of iron-containing preparations ............... 17

5.3 Some characteristics of syrups and other liquid forms of iron preparations. . 17

6 Monitoring .................................................................. ....eighteen

6.1 Criteria and methodology for monitoring and evaluating the effectiveness of protocol implementation .... 18

6.2 Randomization principles...............................................18

6.3 Procedure for assessing and documenting side effects and development of complications .......... 18

6.4 Intermediate assessment and protocol modifications .............................................18

6.5 Procedure for including and excluding a patient from monitoring .......................................19

6.6 Parameters for assessing the quality of life during the implementation of the protocol ....................................19

6.7 Estimating the cost of the protocol and the cost of quality .......................................19

6.8 Comparing results....................................................19

6.9 How to generate a report...............................................19

5.2 Some characteristics of iron tablets

Characteristics of tablet forms of iron-containing preparations are shown in table 6.

5.3 Some characteristics of syrups and other liquid forms of iron preparations

Characteristics of syrups and other liquid forms containing iron are given in table 7.

Annex A (informative) Unified scale for assessing the persuasiveness of evidence

feasibility of using medical technologies .................................20

Appendix B (reference) Some indicators of iron metabolism depending on the degree of iron

deficit ................................................. twenty

Annex B (informative) Questionnaire EQ-5D..................................................21

Appendix D (informative) Patient record form ..............................................27

Bibliography................................................. .......29

GOST R 52600.4-2008

NATIONAL STANDARD OF THE RUSSIAN FEDERATION

Protocol for the management of patients with IRON-DEFICIENCY ANEMIA

protocol for patient's management. Iron deficiency anemia

Introduction date - 2010-01-01

1 area of ​​use

This standard establishes the types, volume and quality indicators of medical care for patients with iron deficiency anemia.

This standard is intended for use by medical organizations and institutions of federal, territorial and municipal health authorities, systems of compulsory and voluntary medical insurance, other medical organizations of various organizational and legal forms of activity aimed at providing medical care.

2 Normative references

This standard uses normative reference to the following standard:

GOST R 52600.0-2006 Patient management protocols. General provisions

Note - When using this standard, it is advisable to check the validity of reference standards in the public information system - on the official website of the Federal Agency for Technical Regulation and Metrology on the Internet or according to the annually published information index "National Standards", which was published as of January 1 of the current year , and according to the corresponding monthly published information signs published in the current year. If the reference standard is replaced (modified), then when using this standard, you should be guided by the replacing (modified) standard. If the referenced standard is canceled without replacement, the provision in which the reference to it is given applies to the extent that this reference is not affected.

3 General

The protocol for the management of patients with "Iron deficiency anemia" was developed to solve the following problems:

Determining the range of diagnostic and therapeutic procedures provided to patients with iron deficiency anemia;

Definitions of algorithms for the diagnosis and treatment of iron deficiency anemia;

Establishing uniform requirements for the prevention, diagnosis and treatment of patients with iron deficiency anemia;

Unification of calculations of the cost of medical care, development of basic programs of compulsory medical insurance and tariffs for medical services and optimization of the system of mutual settlements between territories for medical care provided to patients with iron deficiency anemia;

Official edition

Formation of licensing requirements and conditions for the implementation of medical activities;

Definitions of formulary entries for drugs used to treat iron deficiency anemia;

Monitoring the volume, availability and quality of medical care provided to a patient in a medical institution within the framework of state guarantees for providing citizens with free medical care.

This standard uses a unified scale for assessing the credibility of evidence for the use of medical technologies and data in accordance with GOST R 52600.0 (see Appendix A).

From a clinical point of view, anemia is considered to be a decrease in the concentration of hemoglobin per unit volume of blood, often accompanied by a decrease in the number (concentration) of erythrocytes per unit volume of blood. The syndrome of iron deficiency anemia is characterized by a weakening of erythropoiesis due to iron deficiency, due to a mismatch between the intake and consumption (consumption, loss) of iron, a decrease in hemoglobin filling with iron, followed by a decrease in the hemoglobin content in the erythrocyte.

In accordance with the International Statistical Classification of Diseases, Injuries and Conditions Affecting Health, 10th revision, the following forms of anemia associated with iron deficiency are distinguished:

D50 Iron deficiency anemia (asiderotic, sideropenic, hypochromic);

D50.0 Iron deficiency anemia associated with chronic blood loss (chronic posthemorrhagic anemia);

D50.1 Sideropenic dysphagia (Kelly-Patterson and Plummer-Vinson syndromes);

D50.8 Other iron deficiency anemias;

D50.9 Iron deficiency anemia, unspecified

According to statistics, iron deficiency anemia ranks first among the 38 most common human diseases. Of all the forms of anemia, it is the most common: 70% - 80% of all diagnosed cases of anemia. Around 700 million people worldwide suffer from iron deficiency anemia. In the Russian Federation, iron deficiency anemia is detected in 6% - 30% of the population.

Risk groups for the development of iron deficiency anemia are:

newborns;

Children of puberty;

menstruating women;

Women during pregnancy and lactation;

Patients of older age groups.

A high risk of anemia occurs with a low socio-economic status of the family, donation, nutrition with limited iron intake, in children with a low birth weight (less than 2500 g), feeding only cow's milk during the first year of life.

Iron deficiency anemia is caused by a mismatch between the body's need for iron and its intake: in various diseases and conditions accompanied by minimal to significant blood loss, including frequent blood sampling, long-term donation. The causes of iron deficiency anemia are:

Increased need for iron (during the period of body growth, pregnancy, lactation);

Iron malabsorption;

Inadequate intake of iron with food (vegetarianism, starvation).

A rare cause of iron deficiency anemia is congenital iron deficiency.

The main diseases and conditions that may be accompanied by iron deficiency anemia:

Pregnancy;

Crohn's disease;

Vegetarianism;

Helminthiases;

Haemorrhoids;

Hemorrhagic esophagitis, gastritis;

Children who are bottle-fed with iron-deficient formulas;

Diverticulosis and diverticular bowel disease;

Dysfunctional uterine bleeding;

menorrhagia;

GOST R 52600.4-2008

uterine fibroids;

Nonspecific ulcerative colitis;

Operations and injuries with large blood loss;

Tumors of the stomach and intestines;

Early ligation of the umbilical cord and impaired placental blood supply;

endometriosis;

Enteritis;

duodenal ulcer or stomach ulcer;

Iatrogenic causes (donor, hemodialysis, frequent blood sampling for research).

It should be borne in mind that in many cases, not one, but several diseases and / or conditions can

be causes or risk factors for the development of iron deficiency anemia.

The pathogenesis of iron deficiency anemia is associated with the physiological role of iron in the body and its participation in the processes of tissue respiration. Iron is part of heme, a compound capable of reversibly binding oxygen. Heme is the non-protein part of the hemoglobin and myoglobin molecule. It binds oxygen, which, in particular, is necessary for contractile processes in muscles. In addition, heme is an integral part of tissue oxidative enzymes - cytochromes, catalase and peroxidase. In the deposition of iron in the body, the proteins ferritin and hemosiderin are of primary importance. Iron transport in the body is carried out by the protein transferrin. The body can only to a small extent regulate the intake of iron from food and does not control its consumption. With a negative balance of iron metabolism, iron is first consumed from the depot (latent iron deficiency), then tissue iron deficiency occurs, manifested by a violation of the enzymatic activity and respiratory function of tissues, and iron deficiency anemia develops only later.

The clinical picture of iron deficiency anemia is diverse and is caused by sideropenic (iron deficiency) and anemic syndromes.

Sideropenic syndrome (hyposiderosis) is associated with tissue iron deficiency, which is necessary for the functioning of cells. It is necessary to distinguish between hyposiderosis without anemia (subcompensated stage) and hyposiderosis accompanying anemia. There are 4 main groups of organs in which the manifestations of hyposiderosis are maximally expressed:

Skin, skin appendages and mucous membranes;

Gastrointestinal tract;

Nervous system (increased fatigue, tinnitus, dizziness, headaches, decreased intellectual abilities);

Cardiovascular system (tachycardia, diastolic dysfunction).

Symptoms of sideropenia in patients with iron deficiency anemia, in descending order of frequency of occurrence, are as follows:

Dry skin, forcing women to constantly use creams;

Brittleness and layering of nails, there is no way to grow nails, they have to be cut very short;

Transverse striation of the nails, the nails become flat, sometimes take a concave "spoon-shaped" shape (koilonychia);

Delamination of the ends of the hair, women are worried about the inability to grow hair;

Perversion of taste in the form of an irrepressible desire to eat chalk, toothpaste, ashes, paints, earth, etc. (pathophagy);

Unusual addiction to certain smells, more often - acetone, gasoline (pathoosmia); the streets of the older age groups often do not have a perversion of appetite and smell;

Violation of the integrity of the epidermis is rarely observed, in particular, in about 5% - 10% of patients, angular stomatitis (jamming) appears: ulcerations, cracks with an inflammatory shaft in the corners of the mouth (may also be a sign of hypovitaminosis B 2);

Only some patients report a burning sensation of the tongue, signs of glossitis;

An extremely rare sign may be a violation of the function of swallowing due to the formation of esophageal septa (sideropenic dysphagia - Plummer-Vinson syndrome);

Symptoms of gastritis (heaviness, pain) are not as pronounced as with gastritis of a different origin;

Dysuria and urinary incontinence when coughing, laughing, nocturnal enuresis is sometimes observed in girls, less often in adult women.

The presence of iron deficiency anemia causes neuropsychic functional disorders in children. According to special studies, with iron deficiency anemia in children of the first

years of life, the index of intellectual development is 96 by 12 months (in control 102), and physical - 89 (in control 100). There is an inverse correlation between physical and mental development, severity and duration of anemia.

Anemic syndrome with iron deficiency is manifested by non-specific symptoms: dizziness, headaches, tinnitus, flies before the eyes, weakness, fatigue, decreased performance, chronic fatigue, pale skin and mucous membranes, palpitations, shortness of breath during physical exertion. Some of the symptoms may be due not so much to anemia as to sideropenia.

3.1 Classification of iron deficiency anemia

There is no generally accepted classification of iron deficiency anemia. According to the severity of clinical manifestations, the following stages of development of an iron deficiency state are conditionally distinguished:

Stage 1 - the loss of iron exceeds its intake, the gradual depletion of reserves, absorption in the intestine compensatory increases.

Stage 2 - iron depletion (serum iron level below 13 µmol/l in men and below 12 µmol/l in women, transferrin saturation below 16%) prevents normal erythropoiesis, erythropoiesis begins to fall.

Stage 3 - the development of mild anemia (100 - 120 g / l hemoglobin, compensated) with a slight decrease in the color index and other indices of saturation of erythrocytes with hemoglobin.

Stage 4 - severe (less than 100 g / l hemoglobin, subcompensated) anemia with a clear decrease in the saturation of erythrocytes with hemoglobin.

5th stage - severe anemia (60 - 80 g / l of hemoglobin) with circulatory disorders and tissue hypoxia.

3.2 General approaches to the diagnosis of iron deficiency anemia

The process of diagnostic examination can be conventionally represented in the form of the following successive stages:

Identification of the actual anemic syndrome;

Determination (confirmation) of the iron deficiency nature of anemia;

Search for the cause of the disease underlying iron deficiency in this patient.

Identification of anemic syndrome - determination of a decrease in serum hemoglobin levels

blood - is carried out in patients with clinical signs of the disease, and may also be accidental during a routine analysis of peripheral blood, carried out in connection with another disease, a screening study.

Normal blood hemoglobin values: the lower threshold in an adult is -120 g / l (7.5 mmol / l) in women and 130 g / l (8.1 mmol / l) in men.

The establishment of the iron deficiency nature of anemia is the determination of the clinical manifestations of sideropenia, morphological signs of iron deficiency in erythrocytes, a decrease in the level of serum iron, iron stores in the body.

At this stage of the diagnosis of iron deficiency anemia, a thorough laboratory study is carried out, which necessarily includes: determining the level of hemoglobin, the number of erythrocytes, platelets, reticulocytes, leukocyte formula, calculating the color index or the average hemoglobin content in the erythrocyte, viewing a blood smear to determine abnormal forms of erythrocytes and their saturation with hemoglobin, leukocytes and cell inclusions.

Determination of the content of iron reserves

The color index (CPU) is calculated by the formula

With iron deficiency, the color index, as a rule, becomes below 0.85 (normal 1.0). Errors in the calculation of the color index are associated, first of all, with the incorrect determination of hemoglobin and the number of red blood cells. It is often necessary to observe in the results of a blood test that the color indicator is normal, and the red blood cells contain little hemoglobin - that is, there is an inadequate definition of this important indicator.

B is the number of erythrocytes in 1 liter of blood.

With iron deficiency, MSI is below 24 g.

The average concentration of hemoglobin in erythrocytes (MCHC) is calculated by the formula

MCHC = -, (3)

Ht - hematocrit, %.

The normal MCHC value is 30 - 38 g/dl.

The most accurate method for assessing the hemoglobin content in erythrocytes remains the morphological study of erythrocytes. With iron deficiency anemia, a distinct hypochromia is revealed, characterized by the presence of a wide enlightenment in the center of the erythrocyte, which resembles a ring (anulocyte). Normally, the ratio of the diameter of the central enlightenment and peripheral "darkening" in the erythrocyte correlates approximately as 1:1, with hypochromia - as 2-3:1. In the blood smear of patients with iron deficiency anemia, microcytes predominate - erythrocytes of reduced size, anisocytosis (unequal sizes) and poikilocytosis (various forms) of erythrocytes are noted. With iron deficiency anemia, target red blood cells can also be detected, although their number is 0.1% - 1.0% of the total number of cells.

The number of siderocytes (erythrocytes with iron granules, detected by special staining) is sharply reduced compared to the norm, up to their complete absence. The content of reticulocytes in the blood, as a rule, is within the normal range, with the exception of cases of severe blood loss with appropriate pathologies (abundant nasal and uterine bleeding) or during treatment with iron preparations (in these cases, it may increase). The number of leukocytes and platelets is usually not changed. Some patients may experience thrombocytosis, which disappears after correction of anemia.

Morphological examination of the bone marrow for the diagnosis of iron deficiency anemia can only be important with a special stain for iron to count sideroblasts (erythroid bone marrow cells with iron granules), the number of which is significantly reduced in patients with this anemia.

In varying degrees, iron stores in the body can be determined by the following methods:

The study of serum iron;

The study of the total iron-binding capacity of serum with the calculation of the latent iron-binding capacity of serum;

The study of the level of ferritin in the blood;

The study of saturation of transferrin;

Desferal test.

Normal values ​​of iron in blood serum in men are 13 - 30 µmol / l, in women - 12 - 25 µmol / l; with iron deficiency, the value of this indicator is reduced, often significantly. When analyzing the results, one should take into account the susceptibility of serum iron concentration to daily fluctuations (iron levels are higher in the morning), as well as other influences (menstrual cycle, pregnancy, contraceptives, diet, blood transfusion, taking iron supplements, etc.).

When conducting these studies, strict adherence to the methodology is required. When preparing glass tubes for the study of serum iron levels, they must be treated with hydrochloric acid and washed with bidistilled water, since the use of ordinary distilled water for washing, containing a small amount of iron, affects the results of the study. Drying cabinets should not be used to dry test tubes: a small amount of iron gets into the dishes from their walls when heated. Immediately after taking blood, the test tube must be closed with a stopper or cap made of aluminum foil or a special waxed membrane, since fine metal dust gets into it during centrifugation. Plastic tubes can also be used, but the requirements for obtaining and processing blood remain relevant in this case. The exception is vacutainers - disposable test tubes specially adapted for taking such blood samples.

The total iron-binding capacity of serum reflects the degree of "starvation" of the serum and saturation of transferrin with iron. Normally, the total iron-binding capacity of serum is 30-85 µmol/l, with iron deficiency, the value of the indicator increases.

The difference between the total iron-binding capacity of serum and serum iron characterizes the latent iron-binding capacity of serum. The last two tests are rarely used to diagnose iron deficiency anemia. The ratio of the serum iron index to the total iron-binding capacity of the serum, expressed as a percentage, reflects the degree of saturation of transferrin with iron (the norm is 16% - 50%). Iron deficiency anemia is characterized by an increase in the total iron-binding capacity of blood serum, a significant increase in latent iron-binding capacity and a decrease in the percentage of transferrin saturation.

A decrease in serum ferritin is the most sensitive and specific laboratory sign of iron deficiency; the normal content of ferritin is 15 - 20 mcg / l.

Desferal test - normally, after intravenous administration of 500 mg of desferal, from 0.8 to 1.2 mg of iron is excreted in the urine, while in patients with its deficiency, the amount of this microelement excreted in the urine is 0.2 mg or less. At the same time, with an excess of iron, its excretion in the urine after the administration of desferal exceeds the norm. This test is rarely used, more often for the diagnosis of hemosiderosis, and not sideropenia.

Determination of the level of serum transferrin makes it possible to exclude anemia caused by a violation of iron transport (atransferrinemia).

Glycoprotein transferrin is a protein involved in the transport of iron from the place of its absorption (small intestine) to the place of its use or storage (bone marrow, liver, spleen). One transferrin molecule can bind a maximum of two iron atoms. With a lack of iron absorption, transferrin saturation becomes incomplete, i.e., the percentage of saturation decreases, which indicates anemia due to a lack of iron intake. However, this model is valid only in the ideal case. In reality, it must be taken into account that transferrin has the qualities of a “negative” acute phase protein, i.e., acute inflammation contributes to a decrease in the level of transferrin. In addition, the formation of transferrin to a large extent depends on the state of the liver. On the other hand, iron deficiency affects the level of transferrin by induction, i.e. ultimately causes an increase in its production. All of these factors can influence transferrin levels to such an extent that its initial diagnostic value may ultimately be ambiguous. Normally, the level of transferrin ranges from 2.0 to 3.8 g/l.

The transport of iron into the cell occurs when the iron-transferrin complex interacts with the plasma membrane receptor specific for transferrin. The transferrin molecule, carrying up to two iron atoms, "moorings" to the outer (extracellular) end of the receptor, after which it is absorbed by the cell by endocytosis. In the formed vesicle, the pH level changes, iron changes its oxidation state (from Fe +++ to Fe ++) and is subsequently used for hemoglobin synthesis or stored in the form of deposited iron. The protein part of transferrin, freed from iron, together with the receptor comes to the cell surface, where apotransferrin is separated, and the whole cycle is repeated. Normally, the level of transferrin receptors ranges from 8.8 to 28.1 nmol/l.

Schematically, the change in iron metabolism, depending on the degree of its deficiency, is shown in Table B.1 (Appendix B).

To prevent errors, the doctor in determining the pathogenetic variant of anemia should be guided by the following provision: do not prescribe treatment with iron preparations until the level of serum iron and the number of reticulocytes are determined; if the patient receives iron preparations for a short time, they are canceled for 5 to 7 days, after which the iron content in the serum is determined.

To search for the disease underlying iron deficiency in this patient, additional methods of instrumental and laboratory examination are used (X-ray and endoscopic examination of the gastrointestinal tract; ultrasound examination of the abdominal cavity, small pelvis, kidneys). In the process of diagnosing the disease, blood loss from the gastrointestinal tract is assessed, most reliably using one's own erythrocytes labeled with radioactive chromium. The search for the source of bleeding in the small intestine may require a laparotomy, an alternative to it may be a special automated video camera in a video capsule swallowed by the patient.

Determining the cause of iron deficiency is carried out according to the protocols for managing patients with relevant diseases.

Features of diagnosis in patients with iron deficiency anemia in certain age groups and under various conditions are characterized by the following. Patients with newly diagnosed symptoms

See help for case management protocols

See GOST R 52600.0-2006 "Protocols of patient management. General provisions", approved by order of the Federal Agency for Technical Regulation and Metrology dated December 5, 2006 N 288-st

See also the Standard of Medical Care for Patients with Iron Deficiency Anemia, approved by order of the Ministry of Health and Social Development of the Russian Federation of February 28, 2005 N 169

I. Scope

The protocol for the management of patients "Iron deficiency anemia" is intended for use in the healthcare system of the Russian Federation.

Decree of the Government of the Russian Federation of 05.11.97 N 1387 "On measures to stabilize and develop health care and medical science in the Russian Federation" (Sobraniye zakonodatelstva Rossiyskoy Federatsii, 1997, N 46, art. 5312).

III. Designations and abbreviations

The following designations and abbreviations are used in this protocol:

- ÌÊÁ - International Statistical Classification of Diseases and Related Health Problems.

IV. General provisions

The protocol for the management of patients with "Iron deficiency anemia" was developed to solve the following problems:

Determination of the range of diagnostic and therapeutic procedures provided to patients with iron deficiency anemia.

Determination of algorithms for the diagnosis and treatment of iron deficiency anemia.

Establishment of uniform requirements for the procedure for the prevention, diagnosis and treatment of patients with iron deficiency anemia.

Unification of calculations of the cost of medical care, development of basic programs of compulsory medical insurance and tariffs for medical services, and optimization of the system of mutual settlements between territories for medical care provided to patients with iron deficiency anemia.

Formation of licensing requirements and conditions for the implementation of medical activities.

Definition formulary entries drugs used to treat iron deficiency anemia.

Monitoring the volume, availability and quality of medical care provided to a patient in a medical institution within the framework of state guarantees for providing citizens with free medical care.

The scope of this protocol is medical and preventive organizations of all levels, including specialized hematological departments.

The present protocol uses the data evidence strength scale:

A) The evidence is strong: There is strong evidence for the proposed claim.

B) Relative Strength of Evidence: There is sufficient evidence to recommend this proposal.

C) No Sufficient Evidence: The available evidence is not sufficient to make a recommendation, but recommendations may be made in other circumstances.

D) Sufficient negative evidence:

E) Strong negative evidence: There is sufficient evidence to exclude a drug or technique from the recommendations.