Iron Deficiency Anaemia

This guideline applies to adults aged 16 years and over.

 

Scope

In scope:

Iron deficiency anaemia

 

Outside scope:

Non-iron deficient anaemia; Iron deficiency without anaemia

 

Examinations and investigations required prior to referral

• DRE
   
• Urine dip – 1% have renal tract carcinoma
   
• qFIT
   
• Blood tests:
  • FBC (anaemia confirmed by local lab values)
  • Ferritin
  • CRP (ferritin may be falsely raised in inflammatory states or chronic disease)
  • Coeliac serology (anti-TTG antibodies) *
  • eGFR
• Response to trial of iron (if appropriate)

*Don’t delay an urgent referral awaiting coeliac serology.

 

Management optimisation

A diagnostic trial of iron replacement therapy for 2-4 weeks can be considered in certain low-risk patient groups i.e. premenopausal with menorrhagia, pregnancy (if no suspicion of coeliac disease)¹.

Those with red flag features, male patients and post-menopausal women typically require further investigation to have sources of bleeding excluded. A diagnostic trial should not be offered, but iron replacement therapy can be considered whilst awaiting investigation (unless imminent colonoscopy¹).

• Hb is expected to increase by about 20g/L over 3-4 weeks on iron replacement therapy, if due to iron deficiency, therefore re-check FBC within first 4 weeks¹. If there is a:
  • response, check FBC at 2-4 months to ensure Hb level has returned to normal¹.
  • lack of response, refer; if already had a normal OGD and colonoscopy, consider testing for H. Pylori, and eradicate if present¹.
• Give iron until Hb normalises and for 3 months thereafter to ensure iron stores are replenished, then stop¹. Ongoing treatment may be beneficial in select patient groups (see NICE CKS IDA Management).
• Monitor FBC periodically i.e. 3, 6, 12 and 24 months¹ as clinically indicated.
• In the event of recurrent iron deficiency after investigation, give a further trial of iron as above. Further GI investigation is only necessary if Hb cannot be maintained on iron therapy.
• See guideline on Patient Blood Management.

 

Advice and Guidance

• Unexplained anaemia in the absence of new or change in bowel symptoms with a negative qFIT - seek Haematology Advice and Guidance.
   
• Hypoferritinaemia with normal Hb (iron deficiency without anaemia) – consider seeking Gastroenterology Advice and Guidance if not able to manage in primary care.

 

Referral

Same-day Assessment:

Suspected Upper GI bleed – see Acute GP: Upper GI bleed and Urgent Endoscopy

 

Fast Track Suspected Colorectal Cancer Criteria:

qFIT is not required in rectal mass, abdominal mass, anal mass or ulceration, or following an investigation that suggests or confirms colorectal cancer.

 

*Negative qFIT (less than 10): These patient groups will be booked to have a scope within 6 weeks, rather than 2 weeks. Their pathway and tests will still be managed by the suspected bowel cancer team.

 

Urgent Gastroenterology Referral Criteria:

• Iron deficiency anaemia with a negative qFIT (<10) in a patient with NO new or change in bowel symptoms.

 

Fast Track Suspected Upper GI Cancer Referral Criteria²:

Refer via Fast Track Direct Access Gastroscopy (ODG): 

• Dysphagia below suprasternal notch
• Aged 55 and over with Weight loss AND either Reflux / Upper abdominal pain / Dyspepsia

Refer via Fast Track Upper GI pathway:

• Dysphagia above suprasternal notch (barium swallow)
• Upper abdominal mass consistent with stomach cancer

See Fast Track Suspected Upper GI Cancer referral form for other criteria for referral.

 

Gynaecology Referral Criteria:

• Menorrhagia unresponsive to medical management – see Heavy Menstrual Bleeding guideline.
• Postmenopausal bleeding – see Post Menopausal Bleeding guideline.

 

Urology Referral Criteria:

• Haematuria - see Haematuria guideline.

 

Supporting Information

For professionals:          

• NICE CKS: Anaemia – iron deficiency 
• British Society of Gastroenterology: Management of Iron Deficiency Anaemia in Adults

 

For patients:

• NHS: Iron deficiency anaemia

 

References

1. NICE CKS: Anaemia – iron deficiency (August 2024) 
2. RCHT Fast Track Suspected Cancer Referral Forms: Colorectal Cancer, Direct Access Gastroscopy, Upper GI

Page Review Information

Review date	15 May 2025
Next review date	15 May 2027
GP speciality lead	Dr Laura Vines, GP, RMS
Contributors	Karen Cock, Consultant Colorectal Nurse RCHT & Honorary Clinical Fellow UHP Mr Will Faux, Colorectal Consultant RCHT