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HAEMATINICS FOR ANAEMIA IN THE ELDERLY

SB Khoo FRACGP

Address for correspondence: Dr Khoo Siew Beng, Senior Lecturer & Family Physician, Penang Medical College, No 4, Sepoy Lines Road, 10450 Penang, Malaysia. Tel: 006-012-526 4651, Email: siewbeng@gmail.com

INTRODUCTION

It is not uncommon for a Family Physician to come across elderly patients taking inappropriate haematinics on regular basis for many years with the belief that these supplements are essential to maintain good health. In Malaysia, patients are self-referred to general practitioners and private hospital specialists. They often choose who they want to consult; not who they should consult. There is lack of comprehensive and continuity of care by one specific family doctor and haematinics are easily available over the counter without the need of a prescription.

The main theme for discussion on this paper is the use and misuse of haematinics to treat anaemia in the elderly and in patients with terminal illness. Five general practice cases, each with a specific inappropriate haematinic therapy, are presented to provide topics for discussions. They are followed by questions and answers to highlight these common mistakes and to discuss geriatric issues related to management of anaemias, causes of which are broadly categorised as follows:¹

1. Anaemias due to blood loss and nutritional deficiencies - 34%
2. Anaemias associated with chronic inflammatory diseases - 32%
3. Unexplained and other less common causes of anaemia - 34%

CASE HISTORY 1

Key feature: Routine iron supplements for fatigue and lethargy.

Mr A, a 65-year-old man who is on regular follow up for hypertension and hyperlipidaemia at the Outpatient Department in a general hospital complained of generalised fatigue and lethargy. Clinical examination was normal, with no significant abnormal findings. Laboratory test results were all within normal range. He was prescribed iron tablets, folic acid and vitamin Bco on regular basis to “boost up” his energy as he was told. Mr A has been taking these haematinics for the past five years.

Questions:

1. Are these routine haematinics necessary or helpful to this patient?
2. What are the harmful side effects of long term iron supplements to Mr A?

Commentary:

There is a general misconception that elderly people lack essential vitamins and nutrients vital for maintaining good health. Elderly people take vitamins and iron because they want to prevent anaemia. As clinical presentation of anaemia is often non-specific, iron is prescribed for non-anaemic elderly patients with vague complaints of lethargy and generalized fatigue. It is believed that these haematinics will “strengthen” and improve their well being. The general concept that “if a little heamatinic is good for their health, more must be better,” is certainly not true.²

Results from Framingham Heart Study on a cohort of healthy elderly Americans found that about 3% of the study group had too little iron and about 13% had too much.³ This finding suggests that the use of routine iron supplements in free-living, elderly white Americans is probably unnecessary and could be detrimental.²

Although iron is essential for life, too much iron in the body has been implicated in diseases of all systems. There is epidemiological evidence of a relationship between high body iron stores and liver injury especially haemochromatosis,⁴ coronary artery disease,⁵ non-insulin dependent diabetes mellitus (NIDDM),⁶ Parkinson’s disease,⁷ recurrent infections,⁸ cancer⁹ and Alzheimer disease.¹⁰ Many of the larger studies supported the association of iron with colorectal cancer risk.¹¹ One study found that serum ferritin concentrations >200 mcg/L were strongly associated with a 2.2 fold risk of acute myocardial infarction (MI) in men with elevated serum low-density lipoprotein (LDL) cholesterol concentrations.¹² A review of numerous studies has suggested that iron is an important factor in the development process of atherosclerosis.¹³

CASE HISTORY 2

Key feature: Routine iron therapy for hypochromic microcytic anaemia.

Madam B, a 70-year-old lady, living in a residential home for the elderly, was found to have pallor on routine examination for minor ailments 10 years ago. Her yearly blood test results indicated hypochromic microcytic anaemia with normal platelet and white cell count. Haemoglobin (Hb) level was around 9-10 g/dL, mean corpuscular volume (MCV) of about 58 fL, mean corpuscular haemoglobin concentration (MCHC) of 28 g/dL and reticulocyte index of 1.8%. Liver and renal function tests, serology tests for syphilis (VDRL) and Hepatitis B, urine tests, stool for occult blood, chest X-ray and endoscopy done over the years were all normal. She has been prescribed iron tablets for the past seven years but Hb level and full blood count (FBC) indices remained more or less the same. Other than mild hypertension, she does not have any other medical problems. Clinically she is asymptomatic and there is no significant abnormal physical finding.

Questions:

1. Could Madam B’s anaemia be due to iron deficiency anaemia (IDA)?
2. What are other causes of microcytic anaemia that need to be considered here?
3. What further tests need to be carried out?

Commentary:

Therapy with iron for so many years without any improvement in the blood indices and with no obvious signs of blood loss, suggested that Madam B’s hypochromic microcytic anaemia might not be due to iron deficiency.

IDA typically presents with hypochromic microcytic anaemia. Gastrointestinal (GI) evaluation should be contemplated in all elderly patients with iron deficiency anaemia unless there is an obvious non-GI cause of bleeding.¹⁴ However, microcytosis is also associated with chronic diseases, thalassaemia, sideroblastic anaemia and it may not be seen in combined iron with folate and vitamin B₁₂ deficiency.¹⁵

Madam B does not have other chronic diseases except for mild hypertension, and all other laboratory tests did not suggest any chronic infection, malignancy or organ dysfunction. Peripheral blood film showed hypochromia, microcytosis, and target cells. Iron parameters had to be reviewed, further assessments were necessary to look for other causes of microcytic anaemia.

A low serum iron (<10 µmol/L) with increased total iron binding capacity (TIBC) (>80 µmol/L) and a low percent saturation of transferrin (<15%) may suggest iron deficiency but may be unreliable as serum iron and transferrin levels are often decreased in elderly people.¹⁶ (Table 1).

Table 1: Full Blood Count (FBC) indices
Differentiation of microcytic anaemia due to iron deficiency, chronic disease and thalassaemia¹⁹

	Iron deficiency	Chronic disease	Beta thalassaemia trait
Haemoglobin	↓	↓	↓
MCV	↓ (usually <76 fL)	N or ↓	↓ (usually 55-75 fL)
Serum iron	↓	N or ↓	N
Ferritin	↓	N or ↑	N
TIBC	↑	N or ↓	N
Transferrin saturation	↓	N or ↑	N
Bone marrow	No Fe stores	Fe stores ↑	Normal Fe stores

Serum ferritin is the best non-invasive test for the diagnosis of IDA in patients of all age groups.¹⁷ However, in the elderly population it has to be interpreted with care as serum ferritin tends to rise with ageing. When the serum ferritin is <15 µg/L, iron deficiency is virtually certain. Iron deficiency is unlikely if the serum ferritin level is >100 µg/L. Although ferritin levels between 15 and 100 µg/L are moderately predictive of IDA, patients with levels in this range may have IDA, anaemia of chronic disease, or both.¹⁸

For IDA, oral ferrous iron (ferrous sulphate, ferrous fumarate, ferrous gluconate) is a simple and effective way to restore the body iron store. Hb concentration should rise by 2g/dL after 3-4 weeks. A lack of response implies non-compliance, misdiagnosis, malabsorption or continued blood loss.¹⁴ Iron supplementation should continue for at least 4-6 months after correction of anaemia to replenish the iron stores.¹⁹ Low dose iron therapy (15 mg of elemental iron per day) is an effective therapeutic option with minimal adverse effects and improved compliance for elderly above 80 years of age.²⁰

In this particular case, parameters for nutritional deficiency anaemias were all within normal range. Hb electrophoresis showed elevation of HbA₂, indicating beta thalassaemia trait. It was not certain whether Hb electrophoresis was done before in the past years. Madam B denied being told of such diagnosis or perhaps she was told but had forgotten about it. It could be this test was not done before as she had been healthy all these while and very rarely had she consulted any medical doctor for minor ailments that were relieved with self prescribed traditional medicine.

In beta thalassaemia trait, serum iron may be low as in iron deficiency, but TIBC, transferrin and serum ferritin are usually within normal limits. Compared to IDA, thalassaemia patients have lower MCV (55-75 fL), more normal red blood cell (RBC) count and more abnormal peripheral blood smear (hypochromia, microcytosis, and target cells) at modest levels of anaemia. Reticulocyte count may be normal or slightly raised.²¹ (Table 1).

Clinically, a patient with beta thalassaemia trait is normal and requires no treatment. More important, patients with microcytosis should be identified so that they are not subjected to repeated evaluations for iron deficiency and inappropriately given supplemental iron for years.²¹