This is a really useful, practical guideline.
There are 2 excellent flow-charts, which I personally am going to print out and carry around, summarising who should be investigated and also how to treat.
In summary of the most important bits:
Any degree of anaemia warrants investigation. The worse the anaemia, the more likely that there is an underlying serious cause. Current 2ww cut-offs will miss a lot of cancers, so they suggest referring men with Hb < 12 and post-menopausal women with Hb < 10 urgently (if not 2ww). If they have symptoms, refer appropriately.
- FOB – in the investigation of IDA they are neither specific nor sensitive enough.
- PR unless there are rectal symptoms (eg tenesmus / bleeding) as it rarely shows anything up.
- Assume it is due to warfarin or aspirin – studies show the same rates of malignancy in these patients with IDA.
Who and how to investigate
- All people (including pre-menopausal and pregnant women):
- Coeliac screen
- Dipstix for haematuria (1% will have urological malignancy)
- All males and postmenopausal women:
- OGD and colonoscopy – unless there is marked overt non-GI loss. Consider even if coeliac screen is positive, especially if they are > 50, have marked anaemia, or have a significant family history (eg 1 1st deg relative < 50 or 2 1st deg relatives at any age).
- Pre-menopausal women:
- Only need further investigation considering if they are > 50, have GI symptoms, have a significant family history OR if they have persistent IDA despite adequate Fe supplementation, correction of menorrhagia, adequate diet and are not donating blood.
- Certain ethnic groups:
- Do electrophoresis if appropriate before other investigations
How to treat:
Fe supplementation with monthly FBC until corrected. Then continue for a further 3 months to build up stores. After this, check every 3m for 1 yr, then again a year later. Use further Fe supplementation if needed. Only need to refer back for further investigations if you can’t maintain their levels.