In your attached reports (attachments are hidden to protect the patient's identity) ferritin level is low, and TIBC (total-iron binding capacity) increased, which is suggestive of mild iron deficiency anemia. Other analytical methods utilizing mass spectrometry are not feasible for routine use in a hospital or outpatient setting [23]. Infused iron is captured by Kupffer cells, which become overloaded and gradually shuttle the iron to hepatocytes. official website and that any information you provide is encrypted Moreover, i.v. Baseline characteristic summary was described using counts for categorical variables and median and range for continuous variables. The concentration of C-reactive protein in sera from healthy individuals. The results of this study are indicative of a significant biological effect of systemic inflammation on iron uptake, but patient numbers were relatively small. Shortness of breath and nausea. Our results suggest that CRP may be useful to identify IBD patients who can benefit from first-line treatment with i.v. Free Online Library: Ready-to-Use Therapeutic Foods Fail to Improve Vitamin A and Iron Status Meaningfully during Treatment for Severe Acute Malnutrition in 6-59-Month-old Cambodian Children. Iron Deficiency Anemia: Evaluation and Management | AAFP 1e, f). Chest pain. The diagnosis of iron deficiency anemia is confirmed by the findings of low iron stores and a hemoglobin level two standard deviations below normal. It affects 3% of adults and is slightly more common in women younger than 50 years. In ID, iron stores are progressively exhausted before red cell morphology of hemoglobin levels are affected, and patients may experience early symptoms such as fatigue, reduced cognitive performance, and exercise intolerance. Iron saturation in ACD is typically >5% but <15%, and reduced TIBC is also suggestive of ACD. Anemia of chronic disease. Evidence also exists that iron deficiency anemia . Outcome measures included Hb and iron status variables (serum ferritin and TSAT), with available assessments at baseline and weeks 2, 4, 8, and 12 [15]. As a library, NLM provides access to scientific literature. Differences were less pronounced with stratification according to baseline IL-6. by "Nutrients"; Food/cooking/nutrition C-reactive protein Health aspects EDTA Ethylenediaminetetraacetic acid Ferritin Functional foods Hemoglobin Hemoglobins Iron deficiency anemia Care and treatment . iron-treated patients, no significant differences between the high- and low-IL-6 groups were observed (overall population and CD/UC subpopulations; Fig. ?accessibility.screen-reader.external-link_en_US?. When you have anemia, you don't have enough hemoglobin, and so your cells aren't getting enough oxygen to function well. Impaired intestinal iron absorption in Crohns disease correlates with disease activity and markers of inflammation. is of special relevance to Fe biofortifcation as it provides the population with a regular high consumption of contaminant soil Fe due to the traditional threshing procedure under the hooves of the cattle. Diagnosis and management of iron deficiency anemia in patients with IBD. IV iron was indicated because the use of a proton pump inhibitor precludes adequate oral iron absorption, and the patients concerns about side effects of parenteral iron were addressed. for 12weeks) [15]. . Guidelines on the diagnosis and management of iron deficiency and anemia in inflammatory bowel diseases. Cells of the immune system release pro-inflammatory cytokines, predominantly interleukin-6 (IL-6), which in turn up-regulate the expression of hepcidin, a key regulator of iron homeostasis. Men and postmenopausal women should not be screened, but should be evaluated with gastrointestinal endoscopy if diagnosed with iron deficiency anemia. The predictive value of baseline CRP in terms of Hb response was assessed after retrospective stratification of the study population into a high-CRP and a low-CRP population. 1-10%: hypophosphatemia, skin rash, nausea; Previously iron isomaltoside; verification of phosphate levels is recommended for repeated infusions. Confusion or changes in speech. Data include patients with HF, dialytic CKD or ndCKD, HIV infection, IBDs,36 and data from a systematic review of 38 studies in nonhealthy patients, including blood disorders, liver conditions, rheumatoid arthritis, among others.19 The area in red represents the thresholds for absolute ID recommended by WHO (ferritin >30 g/L and TSAT >16%). Normal values for CRP range between 0.20 and 6.10 mg/L [8]. All pregnant women should be screened for iron deficiency anemia. Patients were stratified by baseline IL-6 levels into a high-IL-6 (>6pg/mL; n=95) and a low-IL-6 (6pg/mL; n=95) groups, and responsiveness to iron supplementation (Hb change from baseline) was compared. The results of this study suggest that patients with IBD and IDA, who have elevated CRP at initiation of treatment, may benefit from first-line treatment with i.v. Fever (p<0.0001), arthritis (p<0.03) were significantly related and CRP was elevated (p<0.04) in cases with high SLEDAI (severe flare). A pragmatic way of understanding the implications of a certain ferritin threshold is to examine studies comparing ferritin levels with BM iron, the gold-standard test for determination of iron stores. ID is defined as a health-related condition in which iron availability is insufficient to meet the bodys needs and which can be present with or without anemia,3(p1069) and it is fundamentally recognized that IDA is simply the most advanced stage of ID. Iron-deficiency anemia is usually discovered during a medical examination through a blood test that measures . Supplemental iron may be given initially, followed by further workup if the patient is not responsive to therapy. It may reflect delayed release of iron from reticuloendothelial stores in active disease. This should also be considered in the selection of diagnostic markers for assessment of iron status. See permissionsforcopyrightquestions and/or permission requests. It binds to ferroportin, the only iron exporter found on the membrane of mammalian cells and reduces iron export, lowering iron in circulation. Patients with BMID have ferritin <160 g/L and TSAT <20%. Iron deficiency anemia (IDA) is the most common acquired anemia and should be the first consideration in a patient with unexplained anemia. Parenteral iron is often used because numerous systematic reviews have identified the superiority of parenteral iron over oral iron for patients with IBD, HF, CKD, or perioperative anemia. iron-treated patients (at week 8) needs to be evaluated. Mild (1.8-2.5 mg/dL or 0.6-0.8 mmol/L) to moderate (1.0-1.8 mg/dL or 0.3-0.6 mmol/L) decreases in phosphate levels can be managed with dietary changes to increase ingestion of phosphate-rich food (eg, dairy, poultry) and/or oral potassium phosphate. The study population consisted of patients with Crohns disease or ulcerative colitis and IDA (Hb110g/L and TSAT<20% or serum ferritin<100ng/mL), randomized to either oral (ferrous sulfate) or i.v. Clinical significance of C-reactive protein levels in predicting In patients with CD, the risk of folate deficiency is high, reaching up to 20-30% at CD diagnosis [13,18,19]. Despite a ferritin level of 89 g/L (considered normal for healthy individuals), the presence of ferritin <200 g/L, a TSAT <20% in the presence of several CICs (liver disease, controlled rheumatoid arthritis, and stage 3 ndCKD), and hypoproliferative normochromic, normocytic anemia supported a diagnosis of IDA. A week later, she called the office to report that she was still feeling weak and wondered whether her anemia was getting worse. Diagnosis of iron deficiency anemia requires laboratory-confirmed evidence of anemia, as well as evidence of low iron stores.4 Anemia is defined as a hemoglobin level two standard deviations below normal for age and sex (Table 1).5, A complete blood count can be helpful to determine the mean corpuscular volume or red blood cell size. Patients should always be investigated for blood loss, such as uterine and GI bleeding. Diagnosis of hemolytic anemia in adults - UpToDate The diagnosis of iron deficiency anemia is confirmed by the. Least-squares meansstandard errors, adjusted for gender and baseline Hb. Statistical presentation includes least-squares means (LS means), standard errors (SE) split by baseline CRP or IL-6 (high vs. low) group, and associated level of significance. Baseline measurements of CRP and IL-6 were available [15]. Vermeire S, Van AG, Rutgeerts P. Laboratory markers in IBD: useful, magic, or unnecessary toys? Bone marrow iron deficiency (BMID) is ID confirmed by the absence of granules of hemosiderin in macrophages and erythroblasts and requires an invasive procedure to obtain an adequate BM sample stained with Prussian blue (or Perls stain). CICs caused by CKD, HF, and other disorders make the diagnosis of ID more difficult, but knowledge of how ferritin and TSAT measurements behave in concurrent CICs and ID helps identify patients who are more likely to benefit from iron supplementation. Patients can also call 8-1-1 to speak . Published data suggest that IL-6 levels may be more relevant in CD than those in UC patients [29]. Hide glossary Glossary. This content is owned by the AAFP. Prevalence and management of cancer-related anaemia, iron deficiency and the specific role of intravenous iron. Women should be screened during pregnancy, and children screened at one year of age. The diagnosis of ID in this population can be complicated by the coexistence of systemic inflammation or other nutritional deficiencies which may mimic ID. 1b, p<0.05) and tended to be smaller until week 8 compared to the low-CRP group. Another common symptom is restless leg syndrome (RLS), which is an unpleasant urge to move the legs during periods of inactivity. iron-treated patients (all patients, LS means: 26.3 vs. 29.7, p=0.105; CD patients: 24.0 vs. 25.9, p=0.671; UC patients: 27.7 vs. 30.8, p=0.189). . Our current findings are in line with the established link between inflammation and iron sequestration. Subpopulation analysis showed a significantly smaller Hb increase (p<0.05) in the high- versus low-CRP group at weeks 2, 4, and 8 among UC patients treated with oral iron (n=44; Fig. iron-treated patients, there were no significant differences between the high- and low-CRP groups at weeks 1, 4, and 12 (Fig. Iron deficiency and biomarkers of inflammation: a 3-year - Springer Based on the available evidence from BMID studies, the map in Figure 4 has been designed to help estimate the adequacy of iron stores and to aid in interpreting ferritin and TSAT in patients with CIC. Cytokines such as IL-6 are prone to degradation, and proper handling and storage of the samples are critical for the accuracy of the measurements. Kulnigg S, Stoinov S, Simanenkov V, Dudar LV, et al. The route of administration in CICs may shift back to oral with the ongoing success of trials of novel iron formulations that have better absorption and tolerance, such as ferric citrate (a phosphate binder approved for use in ndCKD) and ferric maltol, or those that do not depend on ferroportin (eg, Sucrosomial iron) and are currently in clinical trials.30. The median baseline CRP value of the study population was applied as the cutoff value. C-reactive protein (CRP) is widely used as a routine marker of chronic or acute inflammation [7]. Theurl I, Schroll A, Nairz M, et al. Low transferrin saturation (TSAT), calculated by serum iron divided by total iron-binding capacity (TIBC), indicates iron deficiency. In patients with HF who undergo coronary artery bypass graft, TSAT <19.8% and serum iron <13 mol/L were independently associated with mortality and were most accurate for BMID. Wiesenthal M, Dignass A, Hartmann F, Stein J. Relationship of functional and antigenic interleukin 6 to disease activity in inflammatory bowel disease. iron (CD: n=40; UC: n=96). Among i.v. However, vere anemia, 70 g/L; iron deficiency, plasma ferritin <12 the prevalence of anemia was significantly lower in those g/L or TfR >8.5 mg/L; iron deficiency anemia, the pres- with subclinical infection (29%) in comparison to those ence of anemia and iron deficiency; and, subclinical in- without (59%) (p=0.03). The guideline may not apply to all patients with chronic inflammatory conditions (CICs), such as obesity, chronic kidney disease (CKD), liver disease, and heart failure (HF), in whom an increase in CRP is frequently absent, or where AGP measurements are not routinely available. In clinical practice, CRP levels 5mg/L are usually considered elevated. The study lacked longer follow-up with prolonged iron administration and assessment of hematological response. Current recommendations support upper and lower endoscopy; however, there are no clear guidelines about which procedure should be performed first or if the second procedure is necessary if a source is found on the first study.18 Lesions that occur simultaneously in the upper and lower tracts are rare, occurring in only 1 to 9 percent of patients.18 However, one study showed that 12.2 percent of patients diagnosed with celiac disease and iron deficiency anemia had a secondary source of anemia, including three cases of colon cancer.26 A study of patients with iron deficiency anemia of unknown etiology in the primary care setting found that 11 percent had newly diagnosed GI cancer.27 Additionally, a cohort study found that 6 percent of patients older than 50 years and 9 percent of those older than 65 years will be diagnosed with a GI malignancy within two years of a diagnosis of iron deficiency anemia.28 Celiac serology should also be considered for all adults presenting with iron deficiency anemia.18 Upper endoscopy with duodenal biopsies should be performed to confirm the diagnosis after positive serologic testing and to evaluate for additional etiologies.29. A potential relation of baseline CRP and IL-6 values with baseline Hb and iron status was investigated to assess whether these markers would be independent. iron: n=136). Naveen Sharma, Email: moc.liamg@1142amrahsvan. A linear relationship between serum high-sensitive C-reactive protein Liver iron overload has been diagnosed by MRI in up to 84% of patients with dialytic CKD and is associated with the infusion of more than 250 mg of iron per month.32 Kidney Disease Improving Global Outcomes 2012 guidelines33 warn against iron supplementation in patients with CKD with ferritin >500 g/L, but MRIs have shown that patients with ferritin in that range may have significant iron overload. Hepcidin is a predominantly liver-derived regulator of iron trafficking. Fe, elemental iron; LR, label recommendation. Ferrous fumarate (Ferretts, Ferrimin, Hemocyte), 1 tablet every other day (>100 mg Fe per dose). PDF Multiple Myeloma Early Detection, Diagnosis, and Staging A small number of patients (n=11) only had categorized CRP measurements that are available (e.g., <5, <10mg/mL). Prominent anisocytosis and poikilocytosis, including pencil-shaped RBC forms, on the peripheral smear, tend to favor iron deficiency over ACD. Patients with iron deficiency anemia are often asymptomatic and have limited findings on examination. Hepcidin immunoassays may detect inactive forms as well as the biologically active form, hepcidin-25, and measurements can vary up to tenfold between different assays, making it difficult to determine reference values [22]. IV iron preparations: test dose, dosage, side effects, and average wholesale pricing. Ferritin and TSAT ranges reported by studies that evaluated BM iron in patients with CICs. Iron deficiency anemia signs and symptoms may include: Extreme fatigue Weakness Pale skin Chest pain, fast heartbeat or shortness of breath Headache, dizziness or lightheadedness Cold hands and feet Inflammation or soreness of your tongue Brittle nails Unusual cravings for non-nutritive substances, such as ice, dirt or starch Low serum iron is associated with anemia in CKD stage 1-4 - Nature Hematology Am Soc Hematol Educ Program 2020; 2020 (1): 478486. In patients in whom endoscopy may be contraindicated because of procedural risk, radiographic imaging may offer sufficient screening. Further evaluation should be based on risk factors (Figure 2).10,15,1721, Excessive menstruation is a common cause of iron deficiency anemia in premenopausal women in developed countries; however, a GI source (particularly erosive lesions in the stomach or esophagus) is present in 6 to 30 percent of cases.20,22,23 If the gynecologic workup is negative and the patient does not respond to iron therapy, endoscopy should be performed to exclude an occult GI source.20,22,23, Excessive or irregular menstrual bleeding affects 9 to 14 percent of all women and can lead to varying degrees of iron deficiency anemia.24 Etiologies include thyroid disease, uncontrolled diabetes mellitus, polycystic ovary syndrome, coagulopathies, uterine fibroids, endometrial hyperplasia, hyperprolactinemia, and use of antipsychotics or antiepileptics. iron supplementation is often preferable. Contrary to IDA, AI is moderate anemia characterized by normochromic and normocytic erythrocytes [5,21,24]. iron treatment appears to be independent of inflammatory status in IBD patients. Schematic representation of the regulation of iron metabolism in absolute ID. Adequate iron stores are expected in the green areas, but caution is recommended for patients in the dark green area (TSAT >20% and ferritin >500 g/L) if they are receiving parenteral iron, because they may be at risk of iatrogenic iron overload. Statistical support and medical writing support were funded by Vifor Pharma Ltd. TI received lecture fees from Vifor Pharma Ltd and Shire Pharmaceuticals Inc. JS has received consulting fees and been a member of advisory committees or review panels of Abbott Laboratories, Falk Pharma, Ferring Pharmaceuticals Inc, Fresenius Kabi Ltd, Immundiagnostik AG, MSD, Nycomed, Shire Pharmaceuticals Inc, and Vifor Pharma Ltd. NS has no conflicts of interest to disclose. Conclusion: Thus, in SLE, anaemia is the most frequent hematological alteration; iron deficiencies supercede in contrast to ACD and further autoimmune haemolytic anaemia. She eventually completed her treatment with hemoglobin of 10.4 g/dL, ferritin of 359 g/L, and TSAT of 35%. Can iron deficiency cause high CRP? Patients with iron stores estimated to be low (in black and red) should be considered for iron supplementation. Hepcidin expression results in a reduction in the uptake of iron from the duodenum and a reduction in the ability of the body to utilize sufficient iron for effective erythropoiesisalso called functional iron deficiency [5, 6]. Anemia can have many different causes. iron was mainly independent of baseline CRP. Various ferritin cutoff values have been recommended to help detect ID in different patient populations, such as in those with CKD, HF, and IBD.3 There is a general consensus that the usual ferritin cutoff of 30 g/L is inappropriate in the presence of a CIC but the recommended ferritin values range between 50 and 500 g/L across guidelines. In addition, high hepcidin levels also block the release of ferritin-bound iron from cells of the reticuloendothelial system (e.g., macrophages) [6, 17]. Insufficient dietary intake of iron . Christoph Gasche, Email: ta.ca.neiwinudem@ehcsag.hpotsirhc. A total of 196 patients were evaluated (oral iron: n=60; i.v. Previously recommended, but currently not on label; >20%: hypotension, vomiting, nausea, headache, diarrhea, injection site reaction, muscle cramps; 1-10%: hypotension, edema, chest pain, hypertension, dizziness, headache, pruritus, rash, diarrhea, nausea, constipation, vomiting, abdominal pain, hypersensitivity reaction, cough, dyspnea, fever. Tumour necrosis factor alpha causes hypoferraemia and reduced intestinal iron absorption in mice. Low-grade inflammation in a CIC is enough to disrupt iron metabolism by increasing hepcidin, but does not necessarily correlate with inflammatory markers. and transmitted securely. iron was mainly independent of inflammation. Copyright 2023 by American Society of Hematology, Out of Balance: Anemias Due to Disordered Iron Homeostasis, Ferritin in CIC: making the best of an imperfect tool, Transferrin saturation in CIC: a helping hand, Adverse events with IV iron supplementation and management, https://doi.org/10.1182/hematology.2020000132, http://www.who.int/vmnis/indicators/haemoglobin, https://www.who.int/publications/i/item/9789240000124, Anorexia/GI tract edema; frequent use of proton pump inhibitors; use of phosphate chelators; high hepcidin with blockade of duodenal absorption, Uremic platelet dysfunction; antiplatelet therapy and anticoagulation; blood loss from hemodialysis, Anorexia/GI tract edema; high hepcidin with blockade of duodenal absorption, High hepcidin with blockade of duodenal absorption; small bowel resection, Chronic diarrhea with high epithelial turnover; GI tract bleeding; use of corticosteroids, High hepcidin due to adipose tissue inflammation; bariatric surgery, Increased uterine bleeding (when associated with polycystic ovarian syndrome), Anorexia/GI tract edema; diarrhea caused by laxatives, Variceal bleeding; thrombocytopenia; coagulopathy, High hepcidin with blockade of duodenal absorption. Evaluation and Management of Iron Deficiency in Children Und Once iron deficiency anemia is identified, the goal is to determine the underlying etiology. This test is a second-line technique for evaluating the small bowel because it is complicated by the level of sedation and duration of procedure.13 Magnetic resonance imaging enteroclysis, computed tomographic enterography, or barium studies may also be considered, but have a limited ability to identify most small bowel lesions, which are mucosal and flat.7. iron to improve their IDA and obtain a more rapid response. Its indication in clinical practice by itself has become rare with the ease of the use of ferritin, but it may occasionally prove useful in patients who undergo BM sampling for other reasons. Patients were randomized in a 2:1 ratio to receive either i.v. In CICs, polypharmacy is the rule, and chronic use of some medications can predispose patients to GI bleeding (eg, corticosteroids, nonsteroidal anti-inflammatory drugs, aspirin, and anticoagulants), and use of other medications can impair iron absorption (eg, proton pump inhibitors and laxatives). Not to be confused with high-molecular-weight dextran (discontinued); 4-wk interval recommended before MRI. While iron deficiency remains the most common cause of anemia worldwide, low iron stores are associated with symptoms regardless of the presence of typical microcytic, hypochromic anemia and may be hard to recognize in patients with concurrent inflammation. For children at low risk for acute inflammation, concurrent measurement of CRP may not be necessary. Mean baseline Hb and laboratory measures of inflammatory markers were similar between treatment groups [15]. The sensitivity of computed tomographic colonography for lesions larger than 1 cm is greater than 90 percent.7 The use of barium enema is less reliable, but may be of use if colonoscopy or computed tomographic colonography is not available. Iron-Deficiency Anemia: Symptoms, Treatments & Causes - Cleveland Clinic Jrgen Stein, Email: ed.trufknarf-inu.me@niets.j. A ferritin test helps your doctor understand how much iron your body stores. Choose one of the access methods below or take a look at our subscribe or free trial options. TSAT 20% to 25% is still associated with BMID in CKD, and TSAT <20% may still predict BMID in patients with ferritin up to 500 g/L with HF or CKD treated with ESAs, with or without hemodialysis. The study was conducted in accordance with good clinical practice guidelines and the Declaration of Helsinki, and was approved by the ethics committee at each site. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity, Iron deficiency across chronic inflammatory conditions: International expert opinion on definition, diagnosis, and management, Plasma ferritin determination as a diagnostic tool, Ferritin is secreted via 2 distinct nonclassical vesicular pathways, Serum ferritin is derived primarily from macrophages through a nonclassical secretory pathway, Vitamin and Mineral Nutrition Information System (WHO/NMH/NHD/MNM/11.2). Intravenous iron sucrose versus oral iron supplementation for the treatment of iron deficiency anemia in patients with inflammatory bowel diseasea randomized, controlled, open-label, multicenter study. Because there is a significant overlap in ferritin levels between samples with BMID and normal BM iron (range, 50-500 g/L), TSAT helps identify patients who are more likely to benefit from iron supplementation. Oral treatment is cost effective, easily available, and should always be considered. iron therapy. Erichsen K, Hausken T, Ulvik RJ, Svardal A, Berstad A, Berge RK. Patients with high baseline CRP achieved a lower Hb response with oral iron therapy. Testing should be performed in patients with signs and symptoms of anemia, and a complete evaluation should be performed if iron deficiency is confirmed.13, The American Academy of Family Physicians, U.S. Preventive Services Task Force, and Centers for Disease Control and Prevention recommend routine screening of asymptomatic pregnant women for iron deficiency anemia.4,11,14 The American College of Obstetricians and Gynecologists recommends screening for anemia and implementing iron therapy if iron deficiency anemia is confirmed.15 The defined values consistent with anemia in pregnancy are hemoglobin levels less than 11 g per dL (110 g per L) in the first or third trimester, or less than 10.5 g per dL (105 g per L) in the second trimester.16 A maternal hemoglobin level of less than 6 g per dL (60 g per L) has been associated with poor fetal outcomes, including death.15. One of the functions of an acute-phase reaction is to prevent iron from being scavenged by pathogens. Iron supplementation is recommended in all types of IBD-associated anemia where iron deficiency is present [2, 3, 9]. Hepcidin-mediated ferroportin blockade traps iron inside cells, such as hepatocytes and macrophages, which in turn produce ferritin to store iron safely. CRP . de Silva AD, Tsironi E, Feakins RM, Rampton DS. That mechanism underlies functional iron deficiency (FID; pathogenesis and management are reviewed elsewhere10). Koilonychia DR P. MARAZZI/SCIENCE PHOTO LIBRARY Occasionally, it can cause chest pain, a fast heartbeat and shortness of breath. ? Ready-to-Use Therapeutic Foods Fail to Improve Vitamin A and Iron Iron deficiency anemia was confirmed by percent transferrin saturation < 20 %. MATTHEW W. SHORT, LTC, MC, USA, AND JASON E. DOMAGALSKI, MAJ, MC, USA. Nevertheless, in clinical practice a course of oral iron therapy is often used as first-line treatment for anemic patients with IBD. Anaemia is defined by the World Health Organization as a Hb level below 120 g/L in non-pregnant females and 130 g/L in males, which is consistent with the definition of anaemia in the National Blood Authority Patient Blood Management Guidelines. Ferritin reflects iron stores and is the most accurate test to diagnose iron deficiency anemia.7 Although levels below 15 ng per mL (33.70 pmol per L) are consistent with a diagnosis of iron deficiency anemia, using a cutoff of 30 ng per mL (67.41 pmol per L) improves sensitivity from 25 to 92 percent, and specificity remains high at 98 percent.8,12 Ferritin is also an acute phase reactant and can be elevated in patients with chronic inflammation or infection. A comparison between absolute ID (Figure 1) and FID (Figure 2) shows that both have low serum iron and elevated ferritin, and low TIBC characterizes FID. Weakness. Current guidelines recommend empiric treatment in children up to two years of age and in pregnant women with iron deficiency anemia; however, if the hemoglobin level does not increase by 1 g per dL (10 g per L) after one month of therapy in children or does not improve in pregnant women, further evaluation may be indicated.4,15,16 In pregnant patients, poor compliance or intolerance should be considered, and parenteral iron may produce a better response.15, The evaluation should begin with a thorough history and physical examination to help identify the cause of iron deficiency.