Iron Deficiency Anemia

Iron deficiency anemia (and iron deficiency without anemia) is very common in refugees, especially in women and young children. Although an iron deficient diet is a common cause of anemia in refugee patients, potential blood loss (mainly abnormal uterine and gastrointestinal bleeding) should always be considered in these patients as for the rest of the population.

>> Refer to the 2018 Alberta Toward Optimized Practice (TOP) guidelines for a recommended diagnostic approach to iron deficiency anemia in the general population.

 

UNDERLYING ETIOLOGY

Always wait for the complete hemoglobinopathy screen results before interpreting the mean corpuscular volume (MCV) since patients with some traits such as alpha-thalassemia can have lower MCV even in the absence of iron deficiency.

In refugee patients, H. pylori infection and parasitic infections (mainly hookworms and whipworms) are common causes of iron deficiency and should be considered in any anemic patient, especially if gastrointestinal symptoms are present (see Dyspepsia and H. Pylori and Gastrointestinal Parasites). Parasites are especially common in refugee children. Although it is more common in patients of European ancestry, celiac disease should be considered as a cause of iron deficiency in refugee patients. Hematuria should also be ruled out in cases of unexplained iron deficiency anemia.

In asymptomatic adult refugee patients who fit the criteria for assessment of potential occult GI bleeding (see TOP guidelines), but who are at low risk of GI malignancy (<50 years old, no family history), it is reasonable to begin with the following investigations before referring them for GI endoscopy:

  • H. pylori stool antigen test
    ​
  • Stool Ova & Parasites examination (preferably 3)*
     
  • Celiac screen
    ​
  • Urinalysis
* Based on our experience with our refugee patients, it is often difficult to obtain a proper stool sample to perform this test. In these cases, it is reasonable and safe to simply treat empirically for helminth infections with mebendazole (500 mg once, or 100 mg twice daily for 3 days - for patients ≥ 2 years of age).​

 

TREATMENT

If iron deficiency is diagnosed, the underlying cause should be addressed and all patients should be offered treatment with iron supplements. Ferrous sulfate (both the tablets and the oral solution for children) is the only iron formulation that is covered by the Interim Federal Health Program.

Here are the regimens we usually recommend for our asymptomatic refugee patients with iron deficiency:

  • Adults

Ferrous sulfate tablets 300 mg tablets (60 mg elemental iron) twice a day for 3 months

  • Children

Ferrous sulfate drops (15 mg/mL elemental iron) 6 mg/kg/day divided once or twice a day for 3 months

Iron supplements should be taken with orange juice to increase absorption. A repeat CBC and iron studies should be repeated after 3 months of supplements. For patients with symptoms of anemia or significant anemia (<90 g/L), refer to the TOP guidelines for more treatment recommendations.

In addition to prescribing iron supplements, we counsel all our iron deficient refugee patients on iron-rich foods.