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

1
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.

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

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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

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

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

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

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126 All rights reserved - For personal use only
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Sub-acute anaemia management in the Emergency Department
Whether the onset of anaemia is acute or sub-acute
is another important aspect. In acute anaemia, which
is usually caused by haemorrhage or haemolysis, with
haemodynamic instability, transfusion is frequently
required even at relatively high haemoglobin (Hb)
levels (Hb 9-10 g/dL). Whenever possible, a restrictive
transfusion policy is preferred6. In contrast, sub-acute
anaemia may have developed over time. Depending on a
patient's health status, physiological adaptive mechanisms
may compensate for the decreased circulating red
blood cell (RBC) mass, rendering the administration
of allogeneic RBC unnecessary. However, cardiac,
circulatory or respiratory comorbidity may hamper the
adaptation to sub-acute anaemia, and transfusion may
be required. For patients presenting with well-tolerated
sub-acute anaemia, the anaemia should be classified and
pharmacological treatment attempted; however, such
patients often receive RBC transfusion inappropriately.
According to data from the Pennine Acute Trust, one of
the largest trusts in UK, transfusions in the ED account for
10.5% of an average of 20,000 units of RBC used every
year7. From 2011 to 2013, RBC transfusions in the ED
accounted for 29% (2,498/8,541) of all RBC units used
at a second-level general hospital in Spain8.
We present here the results of a clinical protocol for
management of iron-deficiency anaemia in a fast-track
anaemia clinic in a large tertiary hospital. The protocol
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includes early diagnosis and the use of intravenous
(IV) iron, as a strategy for optimising the use of RBC
units in the ED. The primary study outcome was the
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haematological response, as defined by attaining an
Hb level 12 g/dL and/or a Hb increment (Hb) of
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at least 2 g/dL at 4 weeks after completion of IV iron
dosage. Correction of RBC indices and iron parameters,
transfusion rates and IV iron-related adverse events were
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secondary study outcomes.
Materials and methods
Patients
From November 2010 to January 2014, we
prospectively assessed all patients presenting at the
ED of University Hospital La Paz (Madrid, Spain)
with sub-acute, moderate-to-severe anaemia (Hb<11
g/dL) and suspected or known iron deficiency of any
cause. The cases included anaemia newly detected in
the ED, known untreated anaemia, anaemia refractory
to oral iron, and anaemic patients referred from primary
health care or other specialties for assessment of the
need for transfusion. Those not requiring immediate
transfusion and/or hospitalisation were referred to
the fast-track anaemia clinic for management of iron
deficiency. Exclusion criteria were acute bleeding with
haemodynamic instability, severe anaemic syndromes
(haemodynamic angina, ictus, sepsis, etc.), and known
Blood Transfus 2016; 14: 126-33 DOI 10.2450/2015.0176-15
All rights reserved - For personal use only
No other uses without permission
haematological or oncological pathologies with
appropriate treatment. This study was approved by our
Institutional Review Board, which waived the need for
patients' informed consent.
Blood samples and laboratory work-up
In patients with suspected iron deficiency, three
blood samples were drawn in the ED for assessment
of full blood counts, coagulation, iron profile (serum
iron, transferrin, and ferritin), creatinine, vitamin B12
and folic acid. Transferrin saturation index (TSI) was
derived from serum iron and transferrin levels. A basic
urinalysis was also performed in all patients. Blood
analyses requested up 8 p.m. were performed on the
same day; those requested after 8 p.m. were processed
the next norming. Blood counts and iron profile were
also assessed before the 4-week follow-up visit.
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Anaemia classification
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The type of anaemia was classified within 7 days
in the fast-track anaemia clinic. Anaemia with absolute
iron deficiency was defined by ferritin <30 ng/mL (or
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<100 ng/mL if TSI<20%); functional iron deficiency by
TSI<20% and ferritin >100 ng/mL (anaemia of chronic
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inflammation); vitamin B12 deficiency by a serum level
<200 pg/mL; and folic acid deficiency by a serum level
<5.4 ng/mL.
Iron supplementation
In the fast-track anaemia clinic, all patients received
IV iron to treat iron deficiency, unless there were
contraindications (1st trimester of pregnancy, active
infection, iron overload, hypersensitivity to IV iron
formulations or any of their inactive components). The
total dose of iron to administer was calculated using
a simple formula, taking into account the patient's Hb
concentration and body weight9. Ferric carboxymaltose
(FCM; Ferinject, Vifor, Saint Galene, Switzerland)
was administered by intravenous infusion at doses of
500-1,000 mg in 100-200 mL saline over 15 minutes;
the patient was monitored for 30 minutes after the
infusion. FCM was given weekly, at a maximum dose of
1,000 mg/week. Patients were scheduled for a follow-up
visit 4 weeks after receiving the total dose of iron to check
the haematological response to FCM administration. A
response was defined as attaining a Hb level 12 g/dL
and/or Hb of at least 2 g/dL. Treatment was discontinued
when Hb>13 g/dL, ferritin >500 ng/mL or TSI>50%. Non-
responders were scheduled for further follow-up visits or
referred to another department.
Red blood cell transfusions
During follow-up, RBC transfusion was considered
for normovolaemic patients if: (i) their Hb fell below
127
 Quintana-Daz M et al

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

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

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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

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Paired Student's t-test was used for comparison of
quantitative variables. Linear regression analysis was
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Table II - Patients' demographic and clinical characteristics.
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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,
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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 (%)
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Results Emergency Department 55

Two hundred and two anaemic patients with Primary health care 36
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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
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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
characteristics.
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.

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

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Sub-acute anaemia management in the Emergency Department

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

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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.
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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.

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

All rights reserved - For personal use only 129
No other uses without permission
 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
Implementation

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

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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

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*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.
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management of anaemia in an ED which need to be
overcome14. The management of patients in a fast-
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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
not-assessed.
consulting room and dedicated health-care personnel),
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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
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(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),
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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
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(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).
Nine (4.5%), self-limited adverse drug events were
witnessed during FCM infusion or the subsequent
monitoring period: eight were mild (1 headache and
flu-like syndrome, 2 urticaria, 2 heartburn, 2 diarrhoea,
1 superficial phlebitis; 4.0%) and one was moderate
(bronchospasm; 0.5%).
Discussion
In this article we present the results of a clinical
protocol for management of anaemic patients with iron
deficiency (absolute or functional) in the ED of a large
tertiary hospital. The protocol includes early diagnosis
and classification of anaemia and the use of IV FCM
in a fast-track anaemia clinic. We observed that the
administration of IV FCM (at a median dose of 1,500
mg) resulted in a significant increase of Hb levels
was offered to health professionals in the ED in order
to refresh and update knowledge on blood transfusions
and alternatives15,16. It is also necessary to intensify
communication between ED and primary health care to
improve patients' referral and follow-up14.
Costs
In our series, 73 out 183 analysed patients were
older than 65 years (mean: 836 years), presented with
Hb levels <9 g/dL (mean: 7.61.0 g/L), and might have
needed transfusion of RBC, depending on individual Hb
level and co-morbidity. These patients received a mean of
1,500 mg FCM, only six had a Hb<9 g/dL (7.71.0 g/dL)
at the last follow-up visit, and only 20 needed transfusion
(40 RBC units) during follow-up. Taking into account
that, in Europe, the estimated population-weighted mean
cost of transfusing two RBC units is close to 90017,

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130 All rights reserved - For personal use only
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Sub-acute anaemia management in the Emergency Department
whereas that of administering 1,000 mg FCM is around
30018,19, the potential saving of a significant number
of RBC units could contribute to outweigh the cost of
IV iron administration. In this regard, at the Pennine
Acute Trust (UK), it has been estimated that if anaemic
patients with iron deficiency were stabilised with one
unit of RBC and then supported with IV iron infusion,
this could potentially save 4.5% of RBC units with
a potential total cost saving of about 60,000/year7.
To get more benefit from the logistic effort of setting
up this clinical pathway, we are now considering the
possibility of extending anaemia management in the
fast-track anaemia clinic to patients requiring immediate
transfusion but not hospitalisation, as well as increasing
the follow-up period.
IV iron supplementation may be costly, especially
when using the newer formulations, such as FCM.
In Spain, FCM costs more ( 19.2/100 mg) than iron
sucrose ( 11.2/100 mg), which is the most commonly
used IV formulation for managing iron deficiency,
having been used in millions of patients20. However,
FCM is at least as effective9,21 and more convenient than
iron sucrose, both for the patient (fewer venepunctures,
less time away from work and family), and for the
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health system (fewer day-hospital visits and ambulance
transfers) 18,19,22,23. These advantages of FCM may
outweigh its higher acquisition cost, suggesting that
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FCM is a valuable option for efficient and cost-effective
treatment of iron deficiency in various therapeutic
areas13,14. Unfortunately, this study lacks a control group
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(patients treated with iron sucrose or oral iron), thus
precluding a comparative assessment of the effects of
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different iron formulations on erythropoiesis. A formal
cost-efficacy evaluation of our anaemia management
protocol in the ED is certainly needed.
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Safety
Nine self-limited IV iron-related adverse drug
events were witnessed. This is in agreement with the
European Medicines Agency's Committee for Medicinal
Products for Human Use (CHMP) report concluding
that the benefits of IV exceed the risks, provided that
adequate measures are taken to minimise the risk of
allergic reactions, and issuing recommendations for
health care professionals on the administration of IV
iron24. Essentially all interpretable evidence supports
the equivalent efficacy and safety of all of the current
IV formulations25-27, but healthcare staff should be
familiar with recently published recommendations on
the management and prevention of hypersensitivity
reactions to IV iron28.
It is also important to stress that iron administration
does not stimulate erythropoiesis; that is the main role
of erythropoietin. Thus, administration of IV iron alone
Blood Transfus 2016; 14: 126-33 DOI 10.2450/2015.0176-15
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No other uses without permission
will never result in supra-physiological Hb levels and/or
thrombocytosis and will not, therefore, increase the risk
of thromboembolic complications. In fact, in our series,
FCM administration resulted in a significant reduction
of iron deficiency-induced thrombocytosis (Table III),
as previously described for patients with inflammatory
bowel disease or cancer-associated anaemia29,30.
Hypophosphataemia is frequent after parenteral
FCM injection and may have clinical consequences,
including persistent fatigue 31-33. Phosphate experts
recommend that patients with a likelihood of baseline
hypophosphataemia have serum phosphate measured on
the day of FCM infusion and take appropriate dietary
supplements if the level of phosphate is low34. Phosphate
levels were not assessed either before or after FMC
administration, and this should also be considered as
another limitation of the study.
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Conclusions
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In summary, although some of the anaemic patients
attending an ED may need RBC transfusion for
conditions such as acute anaemia with haemodynamic
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instability, most of them present with chronic
iron deficiency anaemia and could benefit from
optimisation of their Hb level and iron stores with IV
iron. Unfortunately, they still receive RBC transfusion
because it is readily available and erroneously
considered a safe and inexpensive therapeutic option.
Our data seem to support - to the best of our knowledge,
for the first time - the implementation of a fast-track
anaemia clinic in the ED for management of patients
presenting with sub-acute, moderate-to-severe
anaemia, and the administration of FCM as a safe,
durable and probably cost-effective option for iron
supplementation in such patients. Early diagnosis and
treatment of iron deficiency anaemia in the ED will
most probably result in improved use of blood products
in this hospital healthcare area.
Acknowledgements
The Authors acknowledge the invaluable help
from hospital managers and healthcare personnel
in implementing this anaemia care pathway in the
Emergency Department of the University Hospital La
Paz, Madrid (Spain).
Authorship contributions
MQD and JAGE designed the fast-track anaemia
clinic protocol and reviewed the manuscript; SFC and
AMV, were responsible for active management of
patients and data entry, and reviewed the manuscript.
SGR performed the data review and reviewed the
manuscript. MM performed the statistical analysis and
wrote the manuscript.
131

Disclosure of conflicts of interest
MQD has received honoraria for consultancy or
lectures and/or travel support from Octapharma
(Spain & Switzerland) and Vifor Pharma (Spain),
but not for this work. JAGE has received honoraria
for consultancy or lectures and/or travel support
from Wellspect HealthCare (Sweden), Roche (Spain),
Vifor Pharma (Spain & Switzerland), Amgen (Spain),
Janssen-Cilag (Spain) and Novartis (Spain), but not for
this work. MM has received honoraria for consultancy
or lectures and/or travel support from Wellspect
HealthCare (Sweden), Roche (Spain), Vifor Pharma
(Spain and Switzerland), PharmaCosmos (Denmark)
and Zambon (Spain) but not for this work. SFC, SGR
and AMV have nothing to declare.
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Arrived: 7 July 2015 - Revision accepted: 29 July 2015
Correspondence: Manuel Muoz
Medicina Transfusional Perioperatoria
Facultad de Medicina, Universidad de Mlaga
Campus de Teatinos
29071 Mlaga, Spain
e-mail: mmunoz@uma.es

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

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