Anaemia

Anaemia is a condition where the number of red blood cells or the haemoglobin concentration within them is lower than normal. Haemoglobin is essential for carrying oxygen throughout the body. When there are too few or abnormal red blood cells, or not enough haemoglobin, the blood's capacity to deliver oxygen to the body’s tissues decreases. This condition is also sometimes referred to as a low blood count, low haemoglobin, or colloquially as 'tired blood'. The World Health Organization (WHO) defines anaemia based on specific haemoglobin (Hb) thresholds, which vary by age, sex, and physiological status: Non-pregnant women (15 years and older): Less than 12.0 g/dL Pregnant women: Less than 11.0 g/dL Men (15 years and older): Less than 13.0 g/dL Children (6–59 months): Less than 11.0 g/dL Children (5–11 years): Less than 11.5 g/dL Children (12–14 years): Less than 12.0 g/dL

Symptoms

Fatigue, lethargy, feeling tired
Weakness
Shortness of breath (dyspnoea), particularly on exertion
Pale skin (pallor), especially noticeable in the conjunctiva, nail beds, and palmar creases
Dizziness or light-headedness
Headaches
Cold hands and feet
Pica (craving non-food items like ice, dirt, or paper) - specific to iron deficiency
Restless legs syndrome - associated with iron deficiency
Brittle nails or koilonychia (spoon-shaped nails)
Sore or swollen tongue (glossitis)
Cracks in the corners of the mouth (angular cheilitis)
Tinnitus (ringing in the ears)
Hair loss
Palpitations or noticeable heartbeats
Cognitive impairment ('brain fog'), poor concentration
Mood changes, irritability
Reduced libido
Chest pain (angina)
Severe shortness of breath at rest
Fainting (syncope) or loss of consciousness
Rapid heart rate (tachycardia)
Signs of acute bleeding (e.g., vomiting blood, black tarry stools, heavy rectal bleeding)
Neurological symptoms (e.g., confusion, numbness, difficulty walking) - may indicate severe B12 deficiency

Causes & Risk Factors

Nutritional Deficiencies (Iron Deficiency Anaemia, Vitamin B12 Deficiency Anaemia, Folate Deficiency Anaemia)
Bone Marrow and Stem Cell Problems (Aplastic Anaemia, Leukaemia, Myelodysplastic syndromes)
Anaemia of Chronic Disease/Inflammation (e.g., Chronic kidney disease, cancer, chronic infections, autoimmune diseases)
Hormonal Imbalances (e.g., Erythropoietin deficiency in chronic kidney disease)
Inherited Haemolytic Anaemias (Sickle Cell Anaemia, Thalassaemia, Hereditary Spherocytosis, Glucose-6-phosphate dehydrogenase (G6PD) deficiency)
Acquired Haemolytic Anaemias (Autoimmune Haemolytic Anaemia, mechanical damage, infections like malaria, toxins or drugs)
Acute Blood Loss (Trauma, surgery, childbirth)
Chronic Blood Loss (Gastrointestinal bleeding from peptic ulcers, gastritis, colon polyps, colorectal cancer, NSAID use; Gynaecological bleeding from heavy menstrual bleeding, uterine fibroids; Urinary tract bleeding)
Dietary Insufficiency (low intake of iron, vitamin B12, or folate)
Infections (Malaria, tuberculosis, HIV, parasitic worm infections like hookworm)
Medications (Chronic use of NSAIDs, proton pump inhibitors (PPIs), or anticoagulants)
Alcoholism (contributes to nutritional deficiencies and gastrointestinal bleeding)
Sex (Females of reproductive age due to menstrual blood loss)
Age (Infants, young children, and older adults)
Pregnancy and Postpartum (Increased iron demands and blood loss during delivery)
Chronic Diseases (Chronic kidney disease (CKD), cancer, inflammatory bowel disease, rheumatoid arthritis, heart failure)
Genetic Conditions (Sickle cell disease, thalassaemia, G6PD deficiency)
History of Surgery (Gastric bypass or other surgeries affecting nutrient absorption)
Family History (Inherited anaemias)
Vegetarian or Vegan Diets (if not well-planned, can be low in bioavailable iron and vitamin B12)
Intense Physical Activity (Endurance athletes may have increased iron needs)

Diagnosis

Review of symptoms (fatigue, shortness of breath, etc.)
Dietary history (iron, B12, folate intake)
Menstrual history in women (frequency, duration, volume)
History of bleeding (gastrointestinal, trauma)
Chronic medical conditions
Medication history (NSAIDs, anticoagulants)
Family history of anaemia or bleeding disorders
Surgical history (gastrectomy, bariatric surgery)
Physical examination (assess for pallor, jaundice, tachycardia, postural hypotension, flow murmur, splenomegaly, hepatomegaly, peripheral neuropathy, melaena)
Complete Blood Count (CBC) to measure Haemoglobin (Hb), Haematocrit (Hct), Mean Corpuscular Volume (MCV), Red Cell Distribution Width (RDW), and Reticulocyte Count
Iron Studies (Serum Ferritin, Serum Iron, Total Iron-Binding Capacity (TIBC), Transferrin Saturation)
Vitamin Levels (Serum Vitamin B12, Serum Folate)
Peripheral Blood Smear to examine red blood cell morphology
Tests for Haemolysis (LDH, haptoglobin, bilirubin)
Haemoglobin Electrophoresis to diagnose haemoglobinopathies
Tests for Underlying Cause (Kidney function tests, liver function tests, inflammatory markers like CRP, ESR, stool tests for occult blood)
Diagnosis confirmed by a haemoglobin level below the age- and sex-specific reference range (WHO or local laboratory standards)
Further classification based on MCV and specific test results (e.g., ferritin for iron deficiency)
NICE (UK) recommends a full blood count for initial investigation; if microcytic, check ferritin; if normocytic, consider other causes; if macrocytic, check B12 and folate
ACOG (US) recommends universal anaemia screening with a CBC for all pregnant women at the first prenatal visit and again at 24 to 28 weeks of gestation

Treatment Options

Increase intake of iron-rich foods (heme iron from red meat, poultry, fish; non-heme iron from lentils, beans, tofu, spinach, fortified cereals)
Enhance iron absorption with Vitamin C (e.g., citrus fruits, bell peppers)
Avoid inhibitors of iron absorption at mealtimes (e.g., tea, coffee, calcium supplements)
For B12 Deficiency: Fortified foods, meat, fish, eggs, dairy
For Folate Deficiency: Green leafy vegetables, citrus fruits, beans, fortified foods
Oral Iron Supplementation (first-line for iron deficiency anaemia, e.g., ferrous sulfate, ferrous fumarate, ferrous gluconate; alternate-day dosing may improve absorption and reduce side effects)
Parenteral (IV) Iron (for patients who cannot tolerate oral iron, have severe malabsorption, ongoing blood loss, or need rapid repletion)
Vitamin B12 Injections (for pernicious anaemia or severe B12 deficiency with neurological symptoms; oral high-dose B12 for maintenance)
Folic Acid Supplementation (oral folic acid tablets)
Erythropoiesis-Stimulating Agents (ESAs) (e.g., epoetin alfa, for anaemia of chronic kidney disease or chemotherapy-induced anaemia)
Immunosuppressants (for autoimmune haemolytic anaemia or aplastic anaemia)
Surgical procedures to address underlying causes of blood loss (e.g., endoscopic procedures for GI bleeding, removal of bleeding polyps or tumours, gynaecological procedures for severe menorrhagia)
Red Blood Cell Transfusion (reserved for severe, symptomatic anaemia, haemodynamic instability, or active, significant bleeding)
Monitor CBC and relevant studies (e.g., ferritin) to assess response to treatment; NICE suggests checking Hb after 2-4 weeks of starting iron
Continue treatment for several months after Hb normalizes to replenish iron stores (typically 3 months)
Referral for severe anaemia, failure to respond to treatment, suspicion of underlying malignancy, need for parenteral iron or blood transfusion, suspected haemoglobinopathy or bone marrow disorder, or anaemia with no obvious cause

Frequently Asked Questions

What is the difference between anaemia and iron deficiency?

Anaemia is a condition where you have a lower-than-normal number of red blood cells or a reduced amount of haemoglobin. Iron deficiency is the most common cause of anaemia, meaning your body doesn't have enough iron to produce healthy red blood cells.

How long will it take for my haemoglobin levels to return to normal?

Your healthcare provider will monitor your progress. Guidelines suggest checking your haemoglobin levels 2-4 weeks after starting iron treatment. It typically takes several months of continued treatment for haemoglobin levels to normalize and for iron stores to be replenished.

Do I need to keep taking iron pills after my blood count is normal?

Yes, it is generally recommended to continue iron treatment for several months (typically 3 months) after your haemoglobin levels have returned to normal. This helps to replenish your body's iron stores, which are essential for preventing recurrence of anaemia.

What are the side effects of oral iron supplements, and how can I manage them?

The dossier mentions that alternate-day dosing of oral iron supplements may help improve absorption and reduce side effects. However, specific side effects and detailed management strategies are not provided. It is important to discuss any side effects you experience with your healthcare provider.

Is it better to take iron supplements every day or every other day?

NICE guidelines suggest that taking iron supplements every other day may improve absorption and reduce side effects. However, daily dosing is still a common practice. Your doctor will advise on the best schedule for you.

Can I get enough iron from my diet alone to treat my anaemia?

While increasing iron-rich foods in your diet is very important for managing and preventing anaemia, oral iron supplementation is often the first-line treatment for existing iron deficiency anaemia to effectively raise haemoglobin levels. Diet alone may not be sufficient to correct an established deficiency.

What foods are highest in iron?

Foods high in iron include heme iron sources like red meat, poultry, and fish, which are better absorbed by the body. Non-heme iron sources include lentils, beans, tofu, spinach, and fortified cereals. Consuming these with Vitamin C (like citrus fruits or bell peppers) can enhance absorption.

Does drinking coffee or tea make anaemia worse?

Yes, tea and coffee can inhibit iron absorption. It is advisable to avoid drinking them with meals or when taking iron supplements.

Is my heavy menstrual bleeding causing my anaemia?

Heavy menstrual bleeding (menorrhagia) is a known cause of chronic blood loss, which can lead to anaemia. If you experience heavy periods and have anaemia, it is important to discuss this with your doctor.

Why do I need an IV iron infusion instead of pills?

Intravenous (IV) iron infusions are typically recommended for patients who cannot tolerate oral iron supplements, have severe problems absorbing iron, are experiencing ongoing significant blood loss, or require rapid iron repletion, such as in late-stage pregnancy or before surgery.

Is anaemia dangerous during pregnancy?

Yes, anaemia during pregnancy can increase the risk of several complications, including preterm delivery, low birth weight, perinatal mortality, postpartum depression, maternal cardiac complications, and the need for a blood transfusion at delivery.

Will my baby be born with anaemia if I have it?

Maternal iron deficiency anaemia is associated with iron deficiency in the infant, which can potentially lead to impaired neurodevelopment. Screening and treatment during pregnancy are important for both mother and baby.

Can anaemia cause hair loss?

Yes, hair loss is listed as a less common symptom associated with anaemia.

Why am I still tired even though my anaemia is treated?

While fatigue is a common symptom of anaemia, the dossier does not specifically address reasons for persistent tiredness after treatment. If you continue to feel tired, it is important to discuss this with your healthcare provider, as other factors might be contributing.

Do I need to be screened for colon cancer if I have iron deficiency anaemia?

Iron deficiency anaemia, especially in older males, can be a sign of chronic blood loss from the gastrointestinal tract, which may be caused by conditions like colon polyps or colorectal cancer. Your doctor may recommend screening for underlying malignancy if this is suspected.

What is the difference between vitamin B12 deficiency and pernicious anaemia?

Pernicious anaemia is a specific type of vitamin B12 deficiency. It is often caused by autoimmune gastritis or malabsorption, where the body cannot properly absorb vitamin B12 from food.

Can I take my iron supplement with my other medications?

The dossier advises avoiding certain inhibitors like tea, coffee, and calcium supplements with iron, but does not provide specific guidance on interactions with other medications. It is crucial to discuss all your medications with your healthcare provider to ensure safe and effective treatment.

Is it safe to exercise if I have anaemia?

Anaemia can cause symptoms like shortness of breath, weakness, and impaired physical performance, especially during exertion. The dossier does not provide specific guidance on the safety of exercise with anaemia. It is best to consult your healthcare provider for personalized advice on physical activity levels.

What is the target haemoglobin level I should aim for?

The dossier provides haemoglobin thresholds for diagnosing anaemia based on age, sex, and physiological status. However, it does not specify target haemoglobin levels to aim for during treatment. Your healthcare provider will guide you on appropriate goals for your individual condition.

Can anaemia be a sign of a more serious disease like cancer?

Yes, anaemia can sometimes be a sign of a more serious underlying condition, including certain cancers. For example, chronic blood loss from gastrointestinal cancers can lead to iron deficiency anaemia, and some bone marrow cancers or chronic diseases like cancer can also cause anaemia. If your doctor suspects an underlying malignancy, further investigation will be recommended.

Why do people with kidney disease get anaemia?

People with chronic kidney disease (CKD) can develop anaemia due to several factors, including anaemia of chronic disease/inflammation, which is mediated by hepcidin, and hormonal imbalances, specifically erythropoietin deficiency, as the kidneys produce erythropoietin, a hormone essential for red blood cell production.

Are there different types of iron pills, and is one better than another?

Common oral iron supplements include ferrous sulfate, ferrous fumarate, and ferrous gluconate. The dossier does not indicate that one type is definitively better than another. Your healthcare provider will recommend the most suitable option for you based on your needs and tolerance.