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Original Article

A fast-track anaemia clinic in the Emergency Department:

feasibility and efficacy of intravenous iron administration for treating
sub-acute iron deficiency anaemia

Manuel Quintana-Daz1,2,3, Sara Fabra-Cadenas1,3, Susana Gmez-Ramrez4, Ana Martnez-Virto1,3,

Jos A. Garca-Erce3,5, Manuel Muoz4

Emergency Department; 2Intensive Care Unit, University Hospital La Paz, Madrid; 3Emergency Medicine
Research Group, Research Institute University Hospital La Paz (IdiPAZ), Madrid; 4Transfusion Medicine, School
of Medicine, University of Mlaga, Mlaga; 5Haematology and Haemotherapy Service, General Hospital San
Jorge, Huesca, Spain

Background. Clinically significant anaemia, requiring red blood cell transfusions, is frequently
observed in Emergency Departments (ED). To optimise blood product use, we developed a clinical
protocol for the management of iron-deficiency anaemia in a fast-track anaemia clinic within the ED.

Materials and methods. From November 2010 to January 2014, patients presenting with sub-

acute, moderate-to-severe anaemia (haemoglobin [Hb] <11 g/dL) and confirmed or suspected iron
deficiency were referred to the fast-track anaemia clinic. Those with absolute or functional iron
deficiency were given intravenous (IV) ferric carboxymaltose 500-1,000 mg/week and were reassessed

4 weeks after receiving the total iron dose. The primary study outcome was the haematological response

(Hb12 g/dL and/or Hb increment 2 g/dL). Changes in blood and iron parameters, transfusion rates
and IV iron-related adverse drug effects were secondary outcomes.
Results. Two hundred and two anaemic patients with iron deficiency (150 women/52 men; mean
age, 64 years) were managed in the fast-track anaemia clinic, and received a median IV iron dose of

1,500 mg (1,000-2,000 mg). Gastro-intestinal (44%) or gynaecological (26%) bleeding was the most
frequent cause of the anaemia. At follow-up (183 patients), the mean Hb increment was 3.92.2 g/dL;
84% of patients were classified as responders and blood and iron parameters normalised in 90%.

During follow-up, 35 (17%) patients needed transfusions (2 [range: 1-3] units per patient) because
they had low Hb levels, symptoms of anaemia and/or were at risk. Eight mild and one moderate,
self-limited adverse drug effects were witnessed.

Discussion. Our data support the feasibility of a clinical protocol for management of sub-acute
anaemia with IV iron in the ED. IV iron was efficacious, safe and well tolerated. Early management

of anaemia will improve the use of blood products in the ED.

Keywords: hospital emergency department, sub-acute anaemia, fast-track anaemia clinic,

intravenous iron, transfusion.

Introduction these anaemic individuals, 65% had mild anaemia

According to data from 187 countries worldwide and and 35% had moderate-to-severe anaemia 3. In a
using World Health Organization (WHO) definitions cohort investigation of non-cardiac surgery patients
of anaemia, the global prevalence of anaemia in 2010 (n=227,425), pre-operative anaemia was present
was 32.9%1. In most cases, anaemia was mild (50%) or in 69,229, of whom 11,359 (16.4%) had moderate-
moderate (45%), while severe anaemia accounted for a to-severe anaemia4. Another retrospective study of
smaller proportion of cases (5%)1. Iron deficiency was patients of any age hospitalised for medical disorders
the leading cause of anaemia (50%)1. (n=2,234; September-October 2010) found an anaemia
In Western countries, the prevalence of anaemia prevalence of 50%, with severe anaemia accounting for
increases with age2. A meta-analysis of 34 studies 8% of all cases5. Thus, it is reasonable to assume that
(85,409 elderly individuals) found that the prevalence among patients presenting with anaemia at a hospital
of anaemia increased with age, and also in those Emergency Department (ED), in 20-30% of cases the
hospitalised or living in nursing homes (40%)3. Among anaemia will be moderate-to-severe.

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Sub-acute anaemia management in the Emergency Department

Whether the onset of anaemia is acute or sub-acute haematological or oncological pathologies with
is another important aspect. In acute anaemia, which appropriate treatment. This study was approved by our
is usually caused by haemorrhage or haemolysis, with Institutional Review Board, which waived the need for
haemodynamic instability, transfusion is frequently patients' informed consent.
required even at relatively high haemoglobin (Hb)
levels (Hb 9-10 g/dL). Whenever possible, a restrictive Blood samples and laboratory work-up
transfusion policy is preferred6. In contrast, sub-acute In patients with suspected iron deficiency, three
anaemia may have developed over time. Depending on a blood samples were drawn in the ED for assessment
patient's health status, physiological adaptive mechanisms of full blood counts, coagulation, iron profile (serum
may compensate for the decreased circulating red iron, transferrin, and ferritin), creatinine, vitamin B12
blood cell (RBC) mass, rendering the administration and folic acid. Transferrin saturation index (TSI) was
of allogeneic RBC unnecessary. However, cardiac, derived from serum iron and transferrin levels. A basic
circulatory or respiratory comorbidity may hamper the urinalysis was also performed in all patients. Blood
adaptation to sub-acute anaemia, and transfusion may analyses requested up 8 p.m. were performed on the
be required. For patients presenting with well-tolerated same day; those requested after 8 p.m. were processed
sub-acute anaemia, the anaemia should be classified and the next norming. Blood counts and iron profile were
pharmacological treatment attempted; however, such also assessed before the 4-week follow-up visit.
patients often receive RBC transfusion inappropriately.

According to data from the Pennine Acute Trust, one of Anaemia classification

the largest trusts in UK, transfusions in the ED account for The type of anaemia was classified within 7 days
10.5% of an average of 20,000 units of RBC used every in the fast-track anaemia clinic. Anaemia with absolute
year7. From 2011 to 2013, RBC transfusions in the ED iron deficiency was defined by ferritin <30 ng/mL (or

accounted for 29% (2,498/8,541) of all RBC units used
at a second-level general hospital in Spain8.
<100 ng/mL if TSI<20%); functional iron deficiency by
TSI<20% and ferritin >100 ng/mL (anaemia of chronic
We present here the results of a clinical protocol for inflammation); vitamin B12 deficiency by a serum level
management of iron-deficiency anaemia in a fast-track <200 pg/mL; and folic acid deficiency by a serum level
anaemia clinic in a large tertiary hospital. The protocol <5.4 ng/mL.

includes early diagnosis and the use of intravenous

(IV) iron, as a strategy for optimising the use of RBC Iron supplementation
units in the ED. The primary study outcome was the In the fast-track anaemia clinic, all patients received

haematological response, as defined by attaining an IV iron to treat iron deficiency, unless there were
Hb level 12 g/dL and/or a Hb increment (Hb) of contraindications (1st trimester of pregnancy, active

at least 2 g/dL at 4 weeks after completion of IV iron infection, iron overload, hypersensitivity to IV iron
dosage. Correction of RBC indices and iron parameters, formulations or any of their inactive components). The
transfusion rates and IV iron-related adverse events were total dose of iron to administer was calculated using

secondary study outcomes. a simple formula, taking into account the patient's Hb
concentration and body weight9. Ferric carboxymaltose
Materials and methods (FCM; Ferinject, Vifor, Saint Galene, Switzerland)

Patients was administered by intravenous infusion at doses of

From November 2010 to January 2014, we 500-1,000 mg in 100-200 mL saline over 15 minutes;
prospectively assessed all patients presenting at the the patient was monitored for 30 minutes after the
ED of University Hospital La Paz (Madrid, Spain) infusion. FCM was given weekly, at a maximum dose of
with sub-acute, moderate-to-severe anaemia (Hb<11 1,000 mg/week. Patients were scheduled for a follow-up
g/dL) and suspected or known iron deficiency of any visit 4 weeks after receiving the total dose of iron to check
cause. The cases included anaemia newly detected in the haematological response to FCM administration. A
the ED, known untreated anaemia, anaemia refractory response was defined as attaining a Hb level 12 g/dL
to oral iron, and anaemic patients referred from primary and/or Hb of at least 2 g/dL. Treatment was discontinued
health care or other specialties for assessment of the when Hb>13 g/dL, ferritin >500 ng/mL or TSI>50%. Non-
need for transfusion. Those not requiring immediate responders were scheduled for further follow-up visits or
transfusion and/or hospitalisation were referred to referred to another department.
the fast-track anaemia clinic for management of iron
deficiency. Exclusion criteria were acute bleeding with Red blood cell transfusions
haemodynamic instability, severe anaemic syndromes During follow-up, RBC transfusion was considered
(haemodynamic angina, ictus, sepsis, etc.), and known for normovolaemic patients if: (i) their Hb fell below

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Quintana-Daz M et al

a predefined transfusion trigger; (ii) they presented severe in 82 (41%; Hb<8 g/dL). Patients were referred
with clinical signs/symptoms of anaemia/hypoxaemia, from the ED (55%) or primary health care (36%), and
such as hypotension, tachycardia, tachypnoea, chronic upper or lower gastro-intestinal blood loss (44%)
dizziness, or fatigue; or (iii) they met risk criteria, and gynaecological bleeding (26%; mostly heavy uterine
such as coronary/valve heart disease, cardiac failure, bleeding) were the most frequent causes of anaemia (Table
cerebro-vascular disease or obstructive pulmonary II). Seventy-eight (39%) patients were referred to other
disease (Table I). hospital departments or primary care for investigation of
the cause of the anaemia in an out-patient manner (Table
Data collection II). Most patients were referred back to the fast-track
Various demographic and clinical data were anaemia clinic for the 4-week follow-up visit, but some
collected for all patients, including age, gender, did not attend (9.4%).
underlying pathology, patient's provenance and Twenty-one patients presented with a previous
referral, Hb concentration at baseline and at the 4-week diagnosis of iron-deficiency anaemia, 164 were
follow-up visit, total IV iron dose, number of treatment classified as having absolute iron deficiency, and 16
sessions, FCM-related adverse drug effects, and RBC as having functional iron deficiency. In addition, three
transfusion rate. patients had mild vitamin B12 deficiency (184, 187, and
199 pg/mL), but none had folic acid deficiency. All
Statistical analysis patients were offered supplementation with IV iron,

Data are expressed as percentages (%) or as but two refused. The median IV iron dose was 1,500

meansstandard deviations, or medians with interquartile mg (range: 1,000-2,000 mg), and the median number of
ranges. Pearson's chi-square test or Fisher's exact test visits to the anaemia clinic for IV iron administration or
was used for the comparison of qualitative variables. follow-up was three (range: 2-4) (Table II). Prophylactic

Paired Student's t-test was used for comparison of
quantitative variables. Linear regression analysis was
Table II - Patients' demographic and clinical characteristics.
performed to obtain correlations between baseline Hb
Patients (n) 202
and ferritin or Hb. All statistical computations were
Gender (female/male) 150/52
performed with IBM-SPSS statistics ver. 22 (Chicago,

Age (years) 6422

IL, USA), licensed to the University of Mlaga, and a
p-value <0.05 was considered statistically significant. Weight (kg) 6915
Provenance (%)

Results Emergency Department 55

Two hundred and two anaemic patients with Primary health care 36

iron deficiency (150 women/52 men; mean age, 64 Other 9

years) were managed in the fast-track anaemia clinic. Underlying pathology (%)
According to WHO definitions10, the anaemia was

Gynaecological 26
moderate in 120 cases (59%; Hb 8<11 g/dL) and
Digestive tract 44
Anaemia with ID 12

Table I - Indications for transfusion according to patients'

Haematological 5
Other 13
Patients' characteristics Transfusion
trigger* Referral to (%)

Sub-acute anaemia in asymptomatic patients Hb<5 g/dL Gynaecological care 7

Digestive tract care 9
Sub-acute anaemia in young patients with clinical
signs/symptoms and without risk criteria** Hb<6 g/dL
Internal Medicine 6
Sub-acute anaemia in elderly patients with clinical Primary health care 12
signs/symptoms and without risk criteria Hb<7 g/dL
Others 5
Sub-acute anaemia in patients with risk criteria IV iron dose (mg) 1,500 [1,000-2,000]
and without clinical signs/symptoms Hb<8 g/dL
Transfusion, n (%) 35 (17)
Sub-acute anaemia in patients with clinical signs/
symptoms and risk criteria Hb<9 g/dL RBC concentrates (unit/patient) 2 [1-3]
FTAC visits (n) 3 [2-4]
*Adapted from recommendations of the Spanish Society of Blood
Transfusion and Cellular Therapy35; **Risk criteria: coronary artery disease/ Data are expressed as incidence (n) and percentage (%), meanstandard
cardiac valve disease, heart failure, cerebrovascular disease or obstructive deviation, or median [interquartile range].
pulmonary disease. Hb: haemoglobin. FTAC: fast-track anaemia clinic; ID: iron deficiency; RBC: red blood cell.

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Sub-acute anaemia management in the Emergency Department

supplementation with vitamin B12 and folic acid was not analysed according to the underlying disease, with a
given routinely. trend to a higher percentage of responders among those
Nineteen patients (9.4%) were lost during follow-up. with heavy uterine bleeding. Non-responders were older
The analysis of treatment effect was, therefore, restricted (74 years vs 62 years; p=0.008), presented with higher
to 183 patients. As presented in Table II, mean Hb was baseline Hb (9.1 g/dL vs 8.2 g/dL; p=0.001), ferritin (61
3.92.2 g/dL at the 4-week follow-up visit. There was a ng/mL vs 23 ng/mL; p=0.01) and TSI (9.8% vs 5.4%;
moderate inverse correlation between Hb and baseline p=0.011), and received a lower dose of IV iron (1,360
Hb (r=0.518; p<0.01; Figure 1A) and a weak inverse mg vs 1,610 mg; p=0.058). The most frequent underlying
correlation between Hb and baseline ferritin (r=0.261; pathology among non-responders were digestive tract
p<0.01; Figure 1B). disorders (58%).
At the 4-week follow-up visit, Hb response (Hb2 There were also significant improvements in RBC
g/dL) had been attained in 149 out of 183 patients (81%), indices and significant decreases in platelet counts
and a partial Hb response (Hb: 1.0-1.9 g/dL) in 22 (12%). (90109/L; n=183) (Table III). Additionally, IV iron
A Hb level 12 g/dL was attained by 108 out of 183 supplementation led to normalisation of iron parameters
patients (59%). Overall, 153 out 183 patients (84%) in most patients, with significant increases in TSI
were classified as responders. As depicted in Figure 2, (+20%; n=131) and serum ferritin (+293 ng/mL; n=145)
there were slight differences in these parameters when (Table III).

i Sr

Figure 1 - Correlation between the increment of haemoglobin (Hb) 4 weeks after administration of the total dose of iron and
(A) baseline haemoglobin (Hb) or (B) baseline ferritin.

Figure 2 - Percentage of patients showing a haematological response (responders), as defined by a haemoglobin increment
(Hb) 2 g/dL and/or a haemoglobin level 12 g/dL, at 4 weeks after administration of the total dose of iron.

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Quintana-Daz M et al

Table III - Haematological and biochemical parameters (Hb2 g/dL in 79% of patients) and/or correction of
before (baseline) and after treatment (4-week anaemia (Hb12 g/dL in 57%), with a low transfusion
follow-up visit).
rate (17%). IV Iron supplementation also replenished
Parameter N* Baseline 4 week p iron stores in most patients (ferritin 100 ng/mL in 90%),
follow-up visit which may help in delaying recurrence of anaemia,
Haemoglobin (g/dL) 183 8.31.4 12.21.8 0.001 although a 4-week follow-up period is probably too
short to evaluate this outcome. Our data strongly suggest
Haematocrit (L/L) 183 282 396 0.001
benefits, beyond avoidance of RBC transfusion, from
MCV (fL) 183 7611 898 0.001 IV FCM administration in patients with sub-acute,
MCH (pg) 183 225 283 0.001 moderate-to-severe anaemia.
These data support the administration of FCM, which
RDW 183 183 215 0.001 has been proven efficacious in raising Hb levels and/or
Platelets (109/L) 183 344138 254100 0.001 correcting anaemia, as well as in replenishing iron stores,
in a host of clinical settings11-13. However, there are a
Creatinine (mg/dL) 171 1.00.4 1.00.4 0.409
number of issues regarding implementation, costs and
Serum iron (mg/dL) 144 2849 7636 0.001 safety of this clinical protocol that need to be addressed.
TSI (%) 131 68 2612 0.001

Ferritin (ng/mL) 145 2755 320287 0.001 The suggested benefits of running a fast-track

Vitamin B12 (pg/L) 140 441263 NA -- anaemia clinic in the ED for both patients and
health-care system seemed evident. However, as
Folic acid (ng/L) 134 108 NA --
for pre-operative anaemia, there are barriers to the

*Some patients did not have a full set of parameters assessed at the
follow-up visit (4 weeks after the administration of the total iron dose),
thus precluding paired-data comparison.
management of anaemia in an ED which need to be
overcome14. The management of patients in a fast-
MCV: mean corpuscular volume; MCH: mean corpuscular haemoglobin; track anaemia clinic requires support from hospital
RDW: red cell distribution width; TSI: transferrin saturation index; NA: administrators (to allocate physical space for the
consulting room and dedicated health-care personnel),

the clinical laboratory (to perform those tests not

Thirty-five patients (17%) needed RBC transfusions included in the routine request form from the ED, such as
during the follow-up period, with a median of two iron profile and vitamin assays), the hospital pharmacy

(range: 1-3) units per patient. Transfusions were most (to facilitate access to FCM, which is restricted to
commonly administered to woman with digestive tract medical day-care facilities in most institutions in Spain),

diseases. Compared to non-transfused patients, the and medical and surgical departments (to investigate the
transfused patients were older (76 years vs 62 years; cause of anaemia promptly and schedule patients for
p=0.001), presented with lower Hb concentrations follow-up visits in the fast-track anaemia clinic). In our

(7.6 g/dL vs 8.5 g/dL), achieved a lower Hb (2.5 g/dL experience, this was attained by reaching a consensus
vs 3.7 g/dL; p=0.005) and had a lower Hb response rate among disciplines on the set of diagnostic, therapeutic
(65% vs 80%; p=0.071), when the effect of transfusion and logistic interventions. Continuing medical education

was subtracted (1 RBC unit = 1 g/dL Hb). was offered to health professionals in the ED in order
Nine (4.5%), self-limited adverse drug events were to refresh and update knowledge on blood transfusions
witnessed during FCM infusion or the subsequent and alternatives15,16. It is also necessary to intensify
monitoring period: eight were mild (1 headache and communication between ED and primary health care to
flu-like syndrome, 2 urticaria, 2 heartburn, 2 diarrhoea, improve patients' referral and follow-up14.
1 superficial phlebitis; 4.0%) and one was moderate
(bronchospasm; 0.5%). Costs
In our series, 73 out 183 analysed patients were
Discussion older than 65 years (mean: 836 years), presented with
In this article we present the results of a clinical Hb levels <9 g/dL (mean: 7.61.0 g/L), and might have
protocol for management of anaemic patients with iron needed transfusion of RBC, depending on individual Hb
deficiency (absolute or functional) in the ED of a large level and co-morbidity. These patients received a mean of
tertiary hospital. The protocol includes early diagnosis 1,500 mg FCM, only six had a Hb<9 g/dL (7.71.0 g/dL)
and classification of anaemia and the use of IV FCM at the last follow-up visit, and only 20 needed transfusion
in a fast-track anaemia clinic. We observed that the (40 RBC units) during follow-up. Taking into account
administration of IV FCM (at a median dose of 1,500 that, in Europe, the estimated population-weighted mean
mg) resulted in a significant increase of Hb levels cost of transfusing two RBC units is close to 90017,

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Sub-acute anaemia management in the Emergency Department

whereas that of administering 1,000 mg FCM is around will never result in supra-physiological Hb levels and/or
30018,19, the potential saving of a significant number thrombocytosis and will not, therefore, increase the risk
of RBC units could contribute to outweigh the cost of of thromboembolic complications. In fact, in our series,
IV iron administration. In this regard, at the Pennine FCM administration resulted in a significant reduction
Acute Trust (UK), it has been estimated that if anaemic of iron deficiency-induced thrombocytosis (Table III),
patients with iron deficiency were stabilised with one as previously described for patients with inflammatory
unit of RBC and then supported with IV iron infusion, bowel disease or cancer-associated anaemia29,30.
this could potentially save 4.5% of RBC units with Hypophosphataemia is frequent after parenteral
a potential total cost saving of about 60,000/year7. FCM injection and may have clinical consequences,
To get more benefit from the logistic effort of setting including persistent fatigue 31-33. Phosphate experts
up this clinical pathway, we are now considering the recommend that patients with a likelihood of baseline
possibility of extending anaemia management in the hypophosphataemia have serum phosphate measured on
fast-track anaemia clinic to patients requiring immediate the day of FCM infusion and take appropriate dietary
transfusion but not hospitalisation, as well as increasing supplements if the level of phosphate is low34. Phosphate
the follow-up period. levels were not assessed either before or after FMC
IV iron supplementation may be costly, especially administration, and this should also be considered as
when using the newer formulations, such as FCM. another limitation of the study.
In Spain, FCM costs more ( 19.2/100 mg) than iron

sucrose ( 11.2/100 mg), which is the most commonly Conclusions

used IV formulation for managing iron deficiency, In summary, although some of the anaemic patients
having been used in millions of patients20. However, attending an ED may need RBC transfusion for
FCM is at least as effective9,21 and more convenient than conditions such as acute anaemia with haemodynamic

iron sucrose, both for the patient (fewer venepunctures,
less time away from work and family), and for the
instability, most of them present with chronic
iron deficiency anaemia and could benefit from
health system (fewer day-hospital visits and ambulance optimisation of their Hb level and iron stores with IV
transfers) 18,19,22,23. These advantages of FCM may iron. Unfortunately, they still receive RBC transfusion
outweigh its higher acquisition cost, suggesting that because it is readily available and erroneously

FCM is a valuable option for efficient and cost-effective considered a safe and inexpensive therapeutic option.
treatment of iron deficiency in various therapeutic Our data seem to support - to the best of our knowledge,
areas13,14. Unfortunately, this study lacks a control group for the first time - the implementation of a fast-track

(patients treated with iron sucrose or oral iron), thus anaemia clinic in the ED for management of patients
precluding a comparative assessment of the effects of presenting with sub-acute, moderate-to-severe

different iron formulations on erythropoiesis. A formal anaemia, and the administration of FCM as a safe,
cost-efficacy evaluation of our anaemia management durable and probably cost-effective option for iron
protocol in the ED is certainly needed. supplementation in such patients. Early diagnosis and

treatment of iron deficiency anaemia in the ED will

Safety most probably result in improved use of blood products
Nine self-limited IV iron-related adverse drug in this hospital healthcare area.

events were witnessed. This is in agreement with the

European Medicines Agency's Committee for Medicinal Acknowledgements
Products for Human Use (CHMP) report concluding The Authors acknowledge the invaluable help
that the benefits of IV exceed the risks, provided that from hospital managers and healthcare personnel
adequate measures are taken to minimise the risk of in implementing this anaemia care pathway in the
allergic reactions, and issuing recommendations for Emergency Department of the University Hospital La
health care professionals on the administration of IV Paz, Madrid (Spain).
iron24. Essentially all interpretable evidence supports
the equivalent efficacy and safety of all of the current Authorship contributions
IV formulations25-27, but healthcare staff should be MQD and JAGE designed the fast-track anaemia
familiar with recently published recommendations on clinic protocol and reviewed the manuscript; SFC and
the management and prevention of hypersensitivity AMV, were responsible for active management of
reactions to IV iron28. patients and data entry, and reviewed the manuscript.
It is also important to stress that iron administration SGR performed the data review and reviewed the
does not stimulate erythropoiesis; that is the main role manuscript. MM performed the statistical analysis and
of erythropoietin. Thus, administration of IV iron alone wrote the manuscript.

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Quintana-Daz M et al

Disclosure of conflicts of interest optimization in surgical patients. Br J Anaesth 2015; 115:

MQD has received honoraria for consultancy or 15-24.
15) Cancellere N, Fabra S, Martinez-Virto AM, et al. Evaluation
lectures and/or travel support from Octapharma of an educational intervention in transfusion medicine for
(Spain & Switzerland) and Vifor Pharma (Spain), medical students and postgraduate trainees. Transfus Med
but not for this work. JAGE has received honoraria 2015; 25 (Suppl 1): 26.
for consultancy or lectures and/or travel support 16) Quintana M, Borobia AM, Medrano M, et al. Impact of an
from Wellspect HealthCare (Sweden), Roche (Spain), educational intervention on red blood cell transfusion practice.
Transfus Med 2014; 24 (Suppl 1): 27-8.
Vifor Pharma (Spain & Switzerland), Amgen (Spain), 17) Abraham I, Sun D. The cost of blood transfusion in Western
Janssen-Cilag (Spain) and Novartis (Spain), but not for Europe as estimated from six studies. Transfusion 2012; 52:
this work. MM has received honoraria for consultancy 1983-8.
or lectures and/or travel support from Wellspect 18) Calvet X, Ruz M, Dosal A, et al. Cost-minimization analysis
HealthCare (Sweden), Roche (Spain), Vifor Pharma favours intravenous ferric carboxymaltose over ferric sucrose
for the ambulatory treatment of severe iron deficiency. PLoS
(Spain and Switzerland), PharmaCosmos (Denmark) One 2012; 7: e45604.
and Zambon (Spain) but not for this work. SFC, SGR 19) Bhandari S. A hospital-based cost minimization study of the
and AMV have nothing to declare. potential financial impact on the UK health care system of
introduction of iron isomaltoside 1000. Ther Clin Risk Manag
References 2011; 7: 103-13.
1) Kassebaum NJ, Jasrasaria R, Naghavi M, et al. A systematic 20) Beguin Y, Jaspers A. Iron sucrose - characteristics, efficacy

analysis of global anemia burden from 1990 to 2010. Blood and regulatory aspects of an established treatment of iron

2014; 123: 615-24. deficiency and iron-deficiency anemia in a broad range
2) Guralnik JM, Eisenstaedt RS, Ferrucci L, et al. The prevalence of therapeutic areas. Expert Opin Pharmacother 2014; 15:
of anemia in persons aged 65 and older in the United States: 2087-103.
evidence for a high rate of unexplained anemia. Blood 2004; 21) Bisbe E, Garca-Erce JA, Dez-Lobo AI, Muoz M; Anaemia

Working Group Espaa. A multicentre comparative study

104: 2263-8.
3) Gaskell H, Derry S, Andrew Moore R, McQuay HJ. Prevalence on the efficacy of intravenous ferric carboxymaltose and
of anaemia in older persons: systematic review. BMC Geriatr iron sucrose for correcting preoperative anaemia in patients
2008; 8: 1. undergoing major elective surgery. Br J Anaesth 2011; 107:
4) Musallam KM, Tamim HM, Richards T, et al. Preoperative 477-8.
22) Wilson PD, Hutchings A, Jeans A, Macdougall IC. An analysis
anaemia and postoperative outcomes in non-cardiac surgery:
a retrospective cohort study. Lancet 2011; 378: 1396-407. of the health service efficiency and patient experience with
5) Muoz M, Gmez-Ramrez S, Cobos A, Enguix A. Prevalence two different intravenous iron preparations in a UK anaemia
and severity of anaemia among medical patients from different clinic. J Med Econ 2013; 16: 108-14.
23) Reinisch W, Staun M, Bhandari S, Muoz M. State of the iron:

hospital departments. Transfus Altern Transfus Med 2011; 12: 30.

6) Hogshire L, Carson JL. Red blood cell transfusion: what is how to diagnose and efficiently treat iron deficiency anemia in
the evidence when to transfuse? Curr Opin Hematol 2013; inflammatory bowel disease. J Crohns Colitis 2013; 7: 429-40.
24) European Medicines Agency. New recommendations to

20: 546-51.
7) Allameddine A, Heaton M, Jenkins H, et al. Inappropriate use manage risk of allergic reactions with intravenous iron-
of blood transfusion in emergency department in a tertiary care containing medicines. Available at:

hospital and potential saving with patient blood management. ema/index.jsp?curl=pages/news_and_events/news/2013/06/

Transfus Med 2014; 24 (Suppl 1): 25. newsdetail_001833.jsp&mid=WC0b01ac058004d5c1.
8) Tirado-Angls G, Gangutia-Hernndez S, Rodrguez-Chacn Accessed on 20/06/2015.
L, et al. Influence of a transfusion pocket guide on physicians' 25) Auerbach M, Adamson J, Bircher A, et al. On the safety of

transfusion practices, 2010-2013. Transfus Med 2014; 24 intravenous iron, evidence trumps conjecture. Haematologica
(Suppl 1): 27. 2015; 100: e214-5.
9) Evstatiev R, Marteau P, Iqbal T, et al; FERGI Study 26) Auerbach M, Macdougall IC. Safety of intravenous iron
Group. FERGIcor, a randomized controlled trial on ferric formulations: facts and folklore. Blood Transfus 2014; 12:
carboxymaltose for iron deficiency anemia in inflammatory 296-300.
bowel disease. Gastroenterology 2011; 141: 846-53.e1-2. 27) Leal-Noval SR, Muoz M, Asuero M, et al. Spanish Consensus
10) World Health Organization. Haemoglobin concentrations for Statement on alternatives to allogeneic blood transfusion:
the diagnosis of anaemia and assessment of severity. WHO/ the 2013 update of the "Seville Document". Blood Transfus
NMH/NHD/MNM/11.1. Available at: 2013; 11: 585-610.
vmnis/indicators/haemoglobin.pdf. Accessed on 20/06/2015. 28) Rampton D, Folkersen J, Fishbane S, et al. Hypersensitivity
11) Keating GM. Ferric carboxymaltose: a review of its use in reactions to intravenous iron: guidance for risk minimization
iron deficiency. Drugs 2015; 75: 101-27. and management. Haematologica 2014; 99: 1671-6.
12) Bregman DB, Goodnough LT. Experience with intravenous 29) Kulnigg-Dabsch S, Evstatiev R, Dejaco C, Gasche C. Effect of
ferric carboxymaltose in patients with iron deficiency anemia. iron therapy on platelet counts in patients with inflammatory
Ther Adv Hematol 2014; 5: 48-60. bowel disease-associated anemia. PLoS One 2012; 7: e34520.
13) Muoz M, Martn-Montaez E. Ferric carboxymaltose for the 30) Henry DH, Dahl NV, Auerbach MA. Thrombocytosis
treatment of iron-deficiency anemia [corrected]. Expert Opin and venous thromboembolism in cancer patients with
Pharmacother 2012; 13: 907-21. chemotherapy induced anemia may be related to ESA induced
14) Muoz M, Gmez-Ramrez S, Kozek-Langeneker S, et al. iron restricted erythropoiesis and reversed by administration
'Fit to fly': overcoming barriers to preoperative haemoglobin of IV iron. Am J Hematol 2012; 87: 308-10.

Blood Transfus 2016; 14: 126-33 DOI 10.2450/2015.0176-15

132 All rights reserved - For personal use only
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Sub-acute anaemia management in the Emergency Department

31) Hardy S, Vandemergel X. Intravenous iron administration 35) Sociedad Espaola de Transfusin Sangunea y Terapia
and hypophosphatemia in clinical practice. Int J Rheumatol Celular. Gua sobre la transfusion de components sanguneos
2015; 2015: 468675. y derivados plasmticos, 4 th ed. Sociedad Espaola de
32) Snchez Gonzlez R, Ternavasio-de la Vega HG, Moralejo Transfusin Sangunea y Terapia Celular: Barcelona; 2010.
Alonso L, et al. [Intravenous ferric carboxymaltose-associated p. 43-53.
hypophosphatemia in patients with iron deficiency anemia.
A common side effect.] Med Clin (Barc) 2015; 145: 108-11.
[In Spanish.]
33) Blazevic A, Hunze J, Boots JM. Severe hypophosphataemia
after intravenous iron administration. Neth J Med 2014; 72:
49-53. Arrived: 7 July 2015 - Revision accepted: 29 July 2015
34) Food and Drug Administration Center for Drug Evaluation Correspondence: Manuel Muoz
Medicina Transfusional Perioperatoria
and Research. Summary minutes of the drug safety and risk
Facultad de Medicina, Universidad de Mlaga
management advisory committee, February 1, 2008. Available Campus de Teatinos
at: http:// 29071 Mlaga, Spain
4337m1-Final.pdf. Accessed on 20/06/2015. e-mail:

i Sr

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