For citation:Dvoretsky L.I. Algorithms for the diagnosis and treatment of anemias // BC. 2003. No. 8. P. 427

MMA named after I.M. Sechenov

Sh A wide range of a wide variety of diseases leading to anemia, along with various mechanisms of the development of anemic syndrome, makes it advisable to carry out a diagnostic search in a certain sequence with the solution of a specific diagnostic problem at each stage of the search.

At the initial stage of the diagnostic search, the main goal is to determine the so-called pathogenetic variant of anemia (AN), i.e. the main mechanism causing a decrease in the level of hemoglobin in a particular patient.

Based on the prevailing mechanism (not the cause!) Of the formation of various types of anemias, several pathogenetic variants can be conditionally distinguished:

- iron deficient AN

Sideroachrestic (iron-saturated) AN

Iron redistributing AN

B 12 - deficient and folate deficient AN

Hemolytic AN

Anemia with bone marrow failure

Anemia with a decrease in the volume of circulating blood

Anemias with a mixed development mechanism.

At this stage, in fact, we are talking about syndromic diagnosis, since each of the pathogenetic variants is only a separate anemic syndrome (iron deficiency syndrome, hemolytic anemia syndrome, etc.). These variants reflect only the leading pathogenetic mechanism, while the reasons for the development of AN in each pathogenetic variant may be different. For example, the cause of iron deficiency anemia can be chronic blood loss from the gastrointestinal tract, intestinal pathology with malabsorption, alimentary insufficiency, etc. Sideroachrestic anemia can develop in patients with chronic lead intoxication, against the background of treatment with certain drugs (isoniazid, etc.).

At the next stage of the diagnostic search, after determining the pathogenetic variant of anemia, the task of the doctor is to recognize the disease or pathological process underlying the existing anemic syndrome, i.e. identifying the cause of anemia in a particular patient. This stage of the diagnostic search can be conditionally designated as nosological diagnosis. The latter becomes important, since in many cases it allows not only pathogenetic therapy of anemia, for example, with iron preparations, but also to influence the underlying disease (elimination of chronic blood loss in iron deficiency anemia, relief of an infectious-inflammatory process, etc.).

Iron deficiency anemias

The main pathogenetic mechanism for the development of iron deficiency anemia (IDA) is the lack of iron in the body - the main building material for the construction of the hemoglobin molecule, in particular, its iron-containing part - heme. The main criteria for IDA are the following:

Low color index

Erythrocyte hypochromia, microcytosis

Decreased serum iron levels

Increasing the total iron binding capacity of serum

Decreased serum ferritin.

At the stage of nosological diagnostics, the search for the cause of IDA should be carried out using the most informative research methods for a specific clinical situation (data from anamnesis, physical examination, additional methods, etc.) (Fig. 1).

Figure: 1. Algorithm of diagnostic search for hypochromic and normo- / hyperchromic anemia

The main reasons for the development of IDA:

1. Chronic blood loss of various localization:

1. Chronic blood loss of various localization:

Gastrointestinal (gastroesophageal reflux disease, erosive and ulcerative lesions of the stomach, tumors of the stomach and colon, terminal ileitis, ulcerative colitis, diverticulitis, bleeding hemorrhoids, etc.);

Uterine (menorrhagias of various etiologies, fibroids, endometriosis, intrauterine contraceptives;

Nasal (hereditary hemorrhagic telangiectasia and other hemorrhagic diathesis);

Renal (IgA nephropathy, hemorrhagic nephritis, renal tumors, permanent intravascular hemolysis);

Iatrogenic and artificial blood loss (frequent bloodletting and blood sampling for research, hemodialysis treatment, donation, etc.).

2. Violation of iron absorption (enteritis of various origins, malabsorption syndrome, resection of the small intestine, resection of the stomach with switching off the duodenum 12).

3. Increased need for iron (pregnancy, lactation, intensive growth and puberty, B 12 - deficiency anemia, treated with cyanocobalamin).

4. Violation of iron transport (hypoproteinemia of various origins).

5. Alimentary insufficiency.

Treatment ... When identifying the cause of IDA, the main treatment should be aimed at eliminating it (surgical treatment of tumors of the stomach, intestines, treatment of enteritis, correction of nutritional deficiency, etc.). In a number of cases (menorrhagia, etc.) pathogenetic therapy iron medications (RV).

In clinical practice, the pancreas is administered orally or parenterally. The route of administration of the drug in patients with IDA is determined by the specific clinical situation. In most cases, to correct iron deficiency in the absence of specific indications, the prostate should be administered orally. On the Russian pharmaceutical market there is a wide selection of pancreas for oral administration. They differ in the amount of iron salts contained in them, including ferrous iron, the presence of additional components (ascorbic and succinic acids, vitamins, fructose, etc.), dosage forms (tablets, dragees, syrups, solutions), tolerance, cost (table. 1)

Clinical guidelines for the treatment of the prostate for oral administration:

The appointment of the pancreas in the form of salts inside with a sufficient content of ferrous iron;

The appointment of the pancreas in the form of salts inside with a sufficient content of ferrous iron;

Appointment of pancreas containing substances that enhance iron absorption;

Undesirability of simultaneous intake of nutrients and drugsthat reduce iron absorption;

Feasibility of prescribing iron preparations containing folic acid, cyanocobalamin in the presence of a mixed nature of anemia;

Prescribing parenteral iron preparations for intestinal absorption disorders;

Sufficient duration of a saturating course of therapy (at least 1-1.5 months);

The need for maintenance therapy of the pancreas in appropriate situations.

When choosing a medicinal pancreas, one should focus on the content of ferrous iron in it, which is only absorbed in the intestine. Ascorbic acid, cysteine, fructose, which are part of many dosage forms of the pancreas, enhance iron absorption. The appointment of iron preparations in high doses (300 mg per day) does not lead to an increase in the absorption of iron ions, however, it causes a significant increase in the number side effects... Taking this into account, combined preparations containing folic acid as a necessary component for the normal synthesis and maturation of erythrocytes, and cyanocobalamin, which is necessary for the normal metabolism of folic acid, which is the main factor in the formation of an active form from it, lead to a significant increase in the rate of hemoglobin synthesis and increase the effectiveness of therapy for iron deficiency anemia. All these criteria are met by a complex antianemic drug Ferro-foil containing in its composition, in addition to ferrous sulfate, 100 mg of ascorbic acid, 10 μg of cyanocobalamin, 5 mg of folic acid. So, for example, when prescribing a drug with a low content of ferrous iron, the number of tablets taken should be at least 8-10 per day, while drugs with a high content of ferrous iron (Ferro-foil) can be taken in an amount of 1-2 tablets per day ... It should be borne in mind that the absorption of iron may decrease under the influence of certain substances contained in food (phosphoric acid, calcium salts, etc.), as well as with the simultaneous use of a number of medications (tetracyclines, magnesium salts). To avoid this, in the Ferro-foil gamma preparation, all active components are in a special neutral shell, which ensures their absorption mainly in the upper part of the small intestine. The absence of local irritating effect on the gastric mucosa contributes to good tolerance.

Among the side effects against the background of the use of the pancreas inside, the most common are nausea, anorexia, a metallic taste in the mouth, constipation, less often diarrhea.

Indications for the use of the pancreas parenterally can be the following clinical situations:

Impaired absorption;

Intolerance of the pancreas for oral administration, which does not allow further continuation of treatment;

The need for faster saturation of the body with iron, for example, before surgery (uterine fibroids, hemorrhoids, etc.).

The algorithm for maintaining large IDA is shown in Figure 2.

Figure: 2. Algorithm for the management of patients with iron deficiency anemia

Sideroachrestic anemias

There is a group of hypochromic anemias, in which the iron content in the body and its reserves in the depot are within normal limits or even increased, however, the inclusion of iron in the hemoglobin molecule (for various reasons) is disturbed, and therefore iron is not used for heme synthesis. Such anemias are referred to as sideroachrestic ("achresia" - non-use). Their share in the structure of hypochromic anemias is small. Nevertheless, the verification of sideroachrestic ("iron-saturated") anemia and its differential diagnosis with IDA are of great practical importance. Erroneous diagnosis of IDA in patients with sideroachrestic anemia usually entails an unjustified prescription of iron preparations, which in this situation not only have no effect, but even more “overload” the iron stores in the depot. The criteria for sideroachrestic anemias are the following:

There is a group of hypochromic anemias, in which the iron content in the body and its reserves in the depot are within normal limits or even increased, however, the inclusion of iron in the hemoglobin molecule (for various reasons) is disturbed, and therefore iron is not used for heme synthesis. Such anemias are referred to as sideroachrestic ("achresia" - non-use). Their share in the structure of hypochromic anemias is small. Nevertheless, the verification of sideroachrestic ("iron-saturated") anemia and its differential diagnosis with IDA are of great practical importance. Erroneous diagnosis of IDA in patients with sideroachrestic anemias usually entails unjustified prescription of iron preparations, which in this situation not only have no effect, but even more "overload" the iron stores in the depot. the following:

- low color index;

Hypochromia of erythrocytes;

Increased (less often normal) serum iron;

Normal or decreased serum iron-binding capacity;

Normal or elevated serum ferritin

Increased number of sideroblasts in the bone marrow;

Increased urinary iron excretion after administration of desferal;

Lack of effect from iron preparations.

Sideroachrestic anemias are a heterogeneous group and result from various causes. Therefore, the nosological stage of the diagnostic search for sideroachrestic anemias should be carried out taking into account both the clinical situation and knowledge of the underlying diseases and pathological processes accompanied by the development of this anemic syndrome. Several forms of sideroachrestic anemias are known:

Hereditary forms (autosomal and recessive, sensitive and refractory to the use of pyridoxine);

Associated with a deficiency of the enzyme hemsynthetase (providing the inclusion of iron in the heme molecule);

Associated with a violation of the synthesis of hemoglobin due to the pathology of its globin part (thalassemia). This disease is usually seen in the group of hemolytic anemias;

Acquired forms ( alcohol intoxication, chronic lead intoxication, exposure to certain medications, myeloproliferative diseases, cutaneous porphyria, idiopathic forms).

Correction of the main pathological process (cancellation of the suspected medication, EDTA for lead intoxication, etc.);

The appointment of pyridoxine in some forms (hereditary);

Prescribing desferioxyamine for high serum iron levels;

Transfusion of erythrocytes for strict indications (severe anemia in patients with concomitant pathology);

Contraindication to the appointment of iron preparations.

Iron redistribution anemias

Among hypochromic anemias, a certain place is occupied by anemias in various inflammatory diseases of both infectious and non-infectious origin. With all the variety of pathogenetic mechanisms of anemias in these situations, one of the main ones is the redistribution of iron into the cells of the macrophage system, which is activated during various inflammatory (infectious and non-infectious) or tumor processes. Since true iron deficiency is not observed in these anemias, it is more justified to talk about iron redistribution anemias.

Criteria for iron redistribution ANs:

• moderately hypochromic nature of anemia;
• normal or moderately reduced serum iron;
• normal or decreased serum iron-binding capacity;
• increased serum ferritin;
• an increase in the number of sideroblasts in the bone marrow;
• clinical and laboratory signs of an active process (inflammatory, tumor);
• lack of effect from iron preparations.

Isolation of this pathogenetic variant and awareness of practitioners about it is important due to the similarity of iron redistribution anemias with IDA and some sideroachrestic anemias (Table 2), although the essence and therapeutic approaches for these anemias are different.

The most frequent infectious and inflammatory diseases in which iron-redistributing anemias occur are active tuberculosis of various localization, infective endocarditis, suppurative diseases (abscesses of the abdominal cavity, lungs, kidneys, empyema, etc.), urinary tract infections, cholangitis. Among non-infectious diseases, a similar variant of anemia can develop in rheumatic diseases ( rheumatoid arthritis and infectious arthritis with high activity), chronic hepatitis, tumors of various localization in the absence of chronic and acute blood loss. The appointment of iron preparations, cyanocobalamin in these situations is usually ineffective and only delays the timely identification of the main cause of anemia and appropriate therapy. The main way to correct anemia in this category of patients is to treat an active inflammatory process.

B 12 - deficiency and folate deficiency anemias

This pathogenetic variant is based on a deficiency of vitamin B 12, less often folic acid, which occurs due to various reasons. As a result of the deficiency, there is a violation of DNA synthesis in hematopoietic cells, ineffective megaloblastic erythropoiesis develops (normally exists only in the fetus) with the production of unstable megalocytes and macrocytes.

Criteria for B 12 - deficient AN:

- high color index;

Macrocytosis, megalocytosis;

Erythrocytes with remnants of nuclei (Jolly's little bodies, Cabot's rings);

Reticulocytopenia;

Hypersegmentation of neutrophils;

Leukopenia (neutropenia);

Thrombocytopenia;

Megaloblastic hematopoiesis in the bone marrow;

Neurological disorders and mental disorders.

At the stage of syndromic diagnosis, the main method is the study of the bone marrow, in which megaloblastic erythropoiesis is detected. This study should be carried out before the appointment of cyanocobalamin, which is widely and often unreasonably prescribed for unclear AN or various neurological symptoms. If it is impossible to perform a diagnostic study of the bone marrow (refusal of patients, etc.), a trial administration of cyanocobalamin is permissible, followed by a mandatory study of the number of reticulocytes after 3-5 days (no later), which acquires diagnostic value. If AN is associated with a deficiency of vitamin B 12, then under the influence of several injections of the drug, the transformation of megaloblastic hematopoiesis into normoblastic occurs, which is reflected in the peripheral blood by a significant increase in the number of reticulocytes compared to the initial one (reticulocytic crisis).

The main reasons for the development of B 12 -deficiency anemia , the exclusion of which the doctor should focus on at the stage of nosological diagnosis, are the following:

Impaired absorption of vitamin B 12 (atrophic gastritis, stomach cancer, gastrectomy, resection of the small intestine, intestinal anastomoses with the formation of a "blind loop", enteritis with malabsorption, sprue, celiac disease, selective defect (autosomal recessive) absorption in combination with proteinuria manifested in early childhood (Imerslund syndrome);

Increased need for vitamin B 12 (invasion by a wide tapeworm, colon diverticulosis, intestinal dysbiosis, rapid growth in children, hyperthyroidism, chronic liver disease);

Impaired transport of vitamin B 12 (transcobalamin II deficiency (an autosomal recessively inherited defect that manifests itself in early childhood);

Violation of use when taking certain medications (PASK, neomycin, metformin);

Alimentary insufficiency (a rare cause) mainly in childhood, with prolonged parenteral nutrition without additional administration of vitamins.

Folate-deficient ANs by their hematological characteristics (macrocytosis, megaloblastic erythropoiesis) resemble B 12 - deficient ANs, but they are much less common and have a slightly different spectrum of diseases causing these ANs. Among the causes of folate deficiency anemia, the main ones should be considered :

Alimentary insufficiency ( common reason in the elderly);

Enteritis with malabsorption;

Taking some medications that inhibit the synthesis of folic acid (methotrexate, triamterene, anticonvulsants, barbiturates, metformin);

Chronic alcohol intoxication;

Increased need for folic acid (malignant tumors, hemolysis, exfoliative dermatitis, pregnancy).

The algorithm for managing patients with macrocytic anemia of unknown origin is shown in Figure 3.

Figure: 3. Algorithm of management of patients with macrocytic anemia of unknown cause

Hemolytic anemias

The main pathogenetic mechanism of the development of hemolytic AN (HAN) is the shortening of the life span of erythrocytes (normally 100-120 days) and their premature decay under the influence of various reasons.

The main pathogenetic mechanism of the development of hemolytic AN (HAN) is the shortening of the life span of erythrocytes (normally 100-120 days) and their premature decay under the influence of various reasons.

The GAN criteria are as follows:

- normal color index (low in thalassemia);

Reticulocytosis;

The presence of nucleated erythroid cells (erythrokaryocytes) in the blood;

Increase in the number of erythrokaryocytes in the bone marrow (over 25%);

Increased serum indirect bilirubin with or without jaundice;

Increased serum iron;

The presence of hemosiderin in the urine (in some forms with intravascular hemolysis);

An increase in the content of free hemoglobin in plasma (with intravascular hemolysis);

Enlargement of the spleen (in some forms).

Most HANs are normo- or hyperchromic, with the exception of HANs associated with globin synthesis disorders (thalassemia), which are hypochromic.

The direction of the diagnostic search at the nasological stage is determined by the peculiarities of the clinical situation (the patient's age, the presence and nature of the background pathology, medication intake, family cases, acute or chronic hemolysis, etc.). It is necessary to distinguish between hereditary and acquired HAN.

Hereditary GAN associated with various genetic defects, in particular, with a defect in the membrane of erythrocytes (hereditary microspherocytosis, ovalocytosis), a deficiency of certain enzymes in erythrocytes (glucose-6-phosphate dehydrogenase, pyruvate kinase, etc.), a violation of the synthesis of globin chains (thalassemia), the presence of unstable hemoglobin.

Thalassemia should be suspected in patients with hypochromic anemia with normal or high serum iron levels in combination with signs of hemolysis, as well as in the absence of an effect from iron preparations, often mistakenly prescribed to such patients. To confirm the diagnosis and determine the form of thalassemia, an electrophoretic study of hemoglobin is necessary.

Among acquired by GAN the most common are autoimmune HANs (symptomatic and idiopathic). Symptomatic autoimmune HAN occur against the background of lymphoproliferative diseases (chronic lymphocytic leukemia, lymphogranulomatosis, etc.), systemic vasculitis (systemic lupus erythematosus, rheumatoid arthritis), chronic active hepatitis, some infections, in particular; viral, when taking a number of medications. If the cause of autoimmune hemolysis is not identified, then one speaks of idiopathic HAN. Acquired HANs include Markiafava's disease (permanent intravascular hemolysis), microangiopathic HANs (hemolysis due to disseminated intravascular coagulation with various diseases), mechanical hemolysis with prosthetic vessels and heart valves, marching hemoglobinuria, HAN when exposed to various toxic substances (acetic acid, arsenic, etc.) etc.).

The management of patients with autoimmune HAN is determined by the variant of HAN (symptomatic or idiopathic). Figure 4 shows an algorithm for the management of patients with autoimmune HAN.

Figure: 4. Algorithm for the treatment of autoimmune hemolytic anemia

Anemia with bone marrow failure

This pathogenetic variant of AN is based on a violation of the normal production of erythroid cells in the bone marrow. At the same time, often simultaneously with the inhibition of erythropoiesis, there is a violation of the production of cells of granulocyte and platelet sprouts, which affects the composition of peripheral blood (pancytopenia) and serves as a guideline in recognizing the possible mechanism of development of AN.

This pathogenetic variant of AN is based on a violation of the normal production of erythroid cells in the bone marrow. At the same time, often simultaneously with the inhibition of erythropoiesis, there is a violation of the production of cells of granulocyte and platelet sprouts, which affects the composition of peripheral blood (pancytopenia) and serves as a guideline in recognizing the possible mechanism of development of AN.

AN criteria for bone marrow failure:

- normochromic (less often hyperchromic) AN;

Reticulocytopenia (up to the complete absence of reticulocytes in some forms);

Leukopenia due to a decrease in the content of neutrophilic granulocytes (granulocytopenia);

Thrombocytopenia varying degrees severity;

Fever, infectious complications, ulcerative necrotic lesions of the mucous membranes;

Hemorrhagic syndrome;

Changes in the picture of bone marrow hematopoiesis in accordance with the nature of the main pathological process (replacement by adipose tissue, infiltration by blast cells, etc.).

Figure 5 shows a diagnostic algorithm in patients with various types of cytopenic syndrome (pancytopenia, bicytopenia). Figure 6 shows an algorithm for the management of patients with aplastic anemia.

Figure: 5. Algorithm for diagnostic search in patients with pancytopenia

Figure: 6. Algorithm of management of patients with aplastic anemia

Clinical guidelines for the management of patients with aplastic anemia:

• elimination of the identified cause (withdrawal of the drug, removal of thymoma, treatment viral infections etc.);
• HLA-typing of siblings of patients in order to select a bone marrow donor;
• platelet transfusion with a platelet count below 10x10 9 / L or with less deep thrombocytopenia, but severe hemorrhagic syndrome;
• platelet transfusion from HLA-matched donors for profuse bleeding;
• transfusion of erythrocytes with a decrease in HB below 70 g / l or with less severe anemia in the elderly and the elderly;
• inappropriate transfusion of blood components from relatives-potential bone marrow donors;
• the effectiveness of antithymocyte globulin and cyclosporin is assessed after 3-6 months;
• the appointment of glucocorticoids as monotherapy is impractical;
• unproven efficacy of recombinant preparations of germ factors (G-CSF, GM-CSF, IL-1, IL-3);
• providing conditions that prevent infectious complications.

Anemias with combined pathogenetic mechanisms

In clinical practice, AN is often encountered, in the development of which two or more pathogenetic mechanisms may be important. The combined pathogenetic variant can occur in elderly and senile patients (for example, iron deficiency anemia in combination with folic acid deficiency anemia). In such situations, the prescription of preparations containing iron and folic acid is justified.

See Help for patient management protocols

See GOST R 52600.0-2006 "Protocols for the management of patients. General provisions", approved by order of the Federal Agency for Technical Regulation and Metrology of December 5, 2006 N 288-st

See also the Standard of medical care for patients with iron deficiency anemia, approved by order of the Ministry of Health and Social Development of the Russian Federation of February 28, 2005 N 169

I. Scope

The protocol for the management of patients "Iron deficiency anemia" is intended for use in the healthcare system of the Russian Federation.

Decree of the Government of the Russian Federation of 05.11.97 N 1387 "On measures to stabilize and develop healthcare and medical science in the Russian Federation" (Collected Legislation of the Russian Federation, 1997, N 46, Art. 5312).

III. Designations and abbreviations

The following symbols and abbreviations are used in this protocol:

- ÌÊÁ - International Statistical Classification of Diseases and Related Health Problems.

IV. General Provisions

The protocol for the management of patients "Iron deficiency anemia" was developed to solve the following problems:

Determination of the range of diagnostic and therapeutic procedures provided to patients with iron deficiency anemia.

Determination of algorithms for the diagnosis and treatment of iron deficiency anemia.

Establishment of uniform requirements for the procedure for prevention, diagnosis and treatment of patients with iron deficiency anemia.

Unification of calculations of the cost of medical care, development of basic programs of compulsory medical insurance and tariffs for medical services and optimization of the system of mutual settlements between territories for medical care provided to patients with iron deficiency anemia.

Formation of licensing requirements and conditions for the implementation of medical activities.

Definition form articles medicines used to treat iron deficiency anemia.

Monitoring the volume, availability and quality of medical care provided to a patient in a medical institution within the framework of state guarantees for providing citizens with free medical care.

The scope of this protocol is medical and prophylactic organizations of all levels, including specialized hematology departments.

This protocol uses the Evidence Strength Scale:

A) The evidence is strong: There is strong evidence for the proposed claim.

B) Relative Strength of Evidence: There is sufficient evidence to recommend this proposal.

C) No sufficient evidence: the available evidence is insufficient to make a recommendation, but recommendations may be made taking into account other circumstances.

D) Sufficient negative evidence:

E) Strong negative evidence: There is sufficient evidence to exclude a drug or method from the recommendation.

Anemia of pregnancy - anemia that develops during pregnancy (mainly starting in the II or III trimester) due to insufficient satisfaction of the increased needs of the mother and fetus in substances necessary for hematopoiesis (M.M. Shekhtman, 2011).

Protocol code:

Abbreviations used in the protocol:
J - iron deficiency
DNA - deoxyribonucleic acid
IDA - iron deficiency anemia
WDS - iron deficiency state
PONRP - premature detachment of a normally located placenta
PN - placental insufficiency
CPU - color index

Protocol development date:2013

Protocol users: therapist, general practitioner, hematologist, obstetrician-gynecologist, surgeon.

Classification

Clinical classification
There are anemias that develop during pregnancy (due to a deficiency of iron, protein, folic acid) that existed before its onset. The latter can be both acquired and congenital (for example, sickle cell).

The severity of the anemia determined according to laboratory research data:

- Light: Hb 120-110 g / l,
- Moderate (moderate): Hb 109–70 g / l, erythrocyte count 3.9–2.5 × 1012 / l, Ht

37–24%;
- Heavy: Hb 69–40 g / l; the number of erythrocytes is 2.5–1.5 × 1012 / l, Ht 23–13%;
- Very heavy: Hb ≤40 g / l; the number of erythrocytes is less than 1.5 × 1012 / l, Ht ≤13%.

Iron deficiency anemia (IDA) is most common in clinical practice in pregnant women.

Clinical classification of anemia in pregnant women:
1. Pathogenetic variant:

 iron deficiency;

 sideroachrestic (iron-saturated);

 iron redistribution;

 B12-deficient and folate deficient;

 hemolytic;

 anemia with bone marrow failure;

 anemia caused by a decrease in the volume of circulating blood;

 anemia with a mixed development mechanism.

2. The severity of IDA:
Light (Hb content 90-120 g / l)
Medium (Hb content 70-89 g / l)
Heavy (Hb content below 70 g / l)
For example: Pregnancy 22 weeks. Iron deficiency anemia, moderate severity, with increased consumption.
Pregnancy 32 weeks. Moderate aplastic anemia.

Factors and risk groups

Risk factors for anemia:
poor living conditions: unbalanced nutrition and insufficient intake of iron, proteins, vitamins, folic acid, trace elements; chronic intoxication, including heavy metal salts (hazardous production, living in an ecologically unfavorable region);
chronic diseases: rheumatism, diabetes, gastritis, kidney disease, chronic foci of infection;
a history of anemia;
blood loss during pregnancy;
multiple pregnancy;
frequent childbirth with a long lactation period;
unfavorable heredity;
short intervals between births.

Clinical picture

Symptoms, course

Diagnostic criteria ***

1) Complaints and anamnesis:

a. Unfavorable medical history - anemia preceding the onset of pregnancy, hyperpolymenorrhea, frequent pregnancies, the presence of concomitant diseases leading to anemia, multiple pregnancies, a region endemic in terms of the incidence of anemia, patients with heavy and prolonged menstruation prior to pregnancy, malnutrition, vegetarianism, impaired absorption in the intestine for account of diseases of the gastrointestinal tract, helminthiasis;

b. General anemic syndrome: weakness, increased fatigue, dizziness, headaches (more often in the evening), shortness of breath on exertion, palpitations, syncope, flashing "flies" before the eyes at a low level blood pressure, Often there is a moderate increase in temperature, often drowsiness during the day and poor sleep at night, irritability, nervousness, conflict, tearfulness, loss of memory and attention, loss of appetite.

c. Sideropenic syndrome:

• changes in the skin and its appendages (dryness, peeling, slight cracking, pallor). Hair is dull, brittle, "splits", turns gray early, falls out intensely, changes in nails: thinning, brittleness, transverse striation, sometimes spoon-shaped concavity (koilonychia).

• Changes in the mucous membranes (glossitis with papillary atrophy, cracks in the corners of the mouth, angular stomatitis).

 Changes in the gastrointestinal tract (atrophic gastritis, atrophy of the esophageal mucosa, dysphagia). Difficulty swallowing dry and solid food.

 The muscular system. Dysfunction of the muscular apparatus: imperative urge to urinate, incontinence of urine when laughing, coughing, sometimes urinary incontinence in girls).

• Addiction to unusual smells.

 Perversion of taste (the desire to eat something that is hardly edible).

 Sideropenic myocardial dystrophy - tendency to tachycardia, hypotension.

 Violations in the immune system (the level of lysozyme, B-lysines, complement, some immunoglobulins decreases, the level of T- and B-lymphocytes decreases, which contributes to a high infectious morbidity in IDA and the appearance of secondary immunodeficiency of a combined nature).

Anamnesis (according to literature data):

The total need for iron during pregnancy is 1300 mg (300 mg for the fetus). With insufficient intake of iron in the body or incomplete absorption of it due to protein deficiency, a pregnant woman develops iron deficiency anemia, Hb below 110 g / l. There are the following main mechanisms that contribute to the development of anemia in pregnant women:

Gynecological diseases accompanied by external or internal bleeding (endometriosis, uterine fibroids, etc.)

Diseases manifested by chronic nosebleeds: idiopathic thrombocytopenic purpura, thrombocytopathy, Randu-Osler disease (angiomatosis of the vessels of the nasal cavity)

Glomerulonephritis, urolithiasis.

Chronic infectious diseases.

Previous iron deficiency (even in countries with high level only 20% of menstruating women have enough iron stores to avoid developing iron deficiency during pregnancy);

Frequent pregnancies and childbirth, multiple pregnancies contribute to the depletion of iron stores in the body;

Chronic blood loss of various localization (gastrointestinal, uterine, nasal, renal) due to various diseases;

Impaired absorption of dietary iron in the intestine (enteritis, resection small intestine, syndrome of insufficient absorption, “blind loop” syndrome);

Alimentary iron deficiency (malnutrition, anorexia of various origins, vegetarianism, etc.).

2) physical examination:
pallor of the skin and mucous membranes;
"Blue" of the sclera due to their dystrophic changes, slight yellowness of the area of \u200b\u200bthe nasolabial triangle, palms as a result of impaired carotene metabolism;
koilonychia;
cheilitis (seizures);
indistinct symptoms of gastritis;
involuntary urination (due to weakness of the sphincters);
symptoms of damage to the cardiovascular system: palpitations, shortness of breath, chest pain and sometimes swelling in the legs.

Diagnostics

List of basic and additional diagnostic measures

List of main diagnostic measures:
1. General blood test (12 parameters)
2. Biochemical analysis blood (total protein, urea, creatinine, ALT, AST, total bilirubin and fractions)
3. General urine analysis
4. In order to assess the effectiveness of treatment of anemia, it is necessary to control the level of hemoglobin and hematocrit once a month.

List of additional diagnostic measures:
1. Serum iron, ferritin, folic acid, vitamin B12 in serum according to indications.
2. Sternal puncture and trepanobiopsy if indicated
3. Esophagogastroduodenoscopy according to indications,
4. Ultrasound of the abdominal cavity, kidneys, spleen in severe anemia.
5. After childbirth, UAC - once a week (with moderate severity)

instrumental research
In order to identify sources of blood loss, pathology of other organs and systems:

• X-ray examination of the gastrointestinal tract according to indications, depends on the duration of pregnancy (1 trimester study is strictly contraindicated, only for health reasons),

 X-ray examination of the chest organs according to indications, depends on the line of pregnancy (1 trimester study is strictly contraindicated, only for health reasons),

Fibrocolonoscopy strictly according to indications,

 sigmoidoscopy strictly according to indications,

 ultrasound thyroid gland according to indications.

 Sternal puncture for hyporegenerative type of anemia, after consulting a hematologist

 Trepanobiopsy for hyporegenerative type of anemia, after consulting a hematologist

indications for specialist consultation
gastroenterologist - pathology of the organs of the gastrointestinal tract, leading to anemia;

dentist - dental problems, accompanied by bleeding from the gums, chewing disorders, etc., ENT - problems of the nasal mucosa, accompanied by bleeding,
oncologist - a malignant lesion that causes bleeding,
nephrologist - exclusion of kidney disease,
phthisiatrician - bleeding and secondary anemia against the background of tuberculosis,
pulmonologist - blood loss due to diseases of the bronchopulmonary system,
gynecologist - bleeding from the genital tract,
endocrinologist - decreased thyroid function, the presence of diabetic nephropathy,
hematologist - to exclude diseases of the blood system of the proctologist - rectal bleeding,
an infectious disease specialist - if there are signs of helminthiasis.

Differential diagnosis

Differential diagnosis
The differential diagnosis of iron deficiency anemia is carried out with other hypochromic anemias caused by a violation of hemoglobin synthesis. These include anemias associated with impaired synthesis of porphyrins (anemia with lead poisoning, with congenital disorders of porphyrin synthesis), as well as thalassemia. Hypochromic anemias, in contrast to iron deficiency anemias, occur with a high content of iron in the blood and depot, which is not used for the formation of heme (sideroachresia); in these diseases there are no signs of tissue iron deficiency.
A differential sign of anemia caused by impaired synthesis of porphyrins is hypochromic anemia with basophilic puncture of erythrocytes, reticulocytes, enhanced erythropoiesis in the bone marrow with a large number of sideroblasts. Thalassemia is characterized by a target-like shape and basophilic puncture of erythrocytes, reticulocytosis and the presence of signs of increased hemolysis

Treatment

Treatment goals

 Correction of deficiency of iron, protein, trace elements, vitamins (B12).

 Complex treatment of anemia and complications associated with it.

 Elimination of hypoxic conditions, prevention and treatment of early placental insufficiency.

 Normalization of hemodynamics, systemic, metabolic and organ disorders.

 Prevention of complications of pregnancy and childbirth, correction of biocenosis.

 Early rehabilitation in the postpartum period.

Treatment tactics ***:
non-drug treatment
Non-drug treatment includes a diet rich in iron and protein. But it is impossible to achieve normalization of the Hb level with the help of diet alone, since a small percentage of iron is absorbed from food (from meat - 20%, from plant products - 0.2%). Recommend to use health food for replenishing protein deficiency: special medical food products containing iron.

drug treatment ***
in these sections, it is necessary to cite a source with a good evidence base, indicating the level of reliability. References should be indicated in the form of square brackets with numbering as they occur. This source should be indicated in the list of references under the appropriate number.

IDA treatment should include the following steps:

A. Relief of anemia.

B. Saturation therapy (restoring iron stores in the body).
B. Supportive care.

When drug treatment and the prevention of IDA during pregnancy should be guided by the WHO principles, which are as follows: all pregnant women from the very beginning of pregnancy (but no later than the 3rd month) and then within 3 months of lactation should receive 50-60 mg of elemental iron per day for prevention WAIT. If IDA is detected in a pregnant woman daily dose increases by 2 times.
The daily dose for the prevention of anemia and the treatment of mild forms of the disease is 60-100 mg of iron, and for the treatment of severe anemia - 100-120 mg of iron (for iron sulfate).
The inclusion of ascorbic acid in salt preparations of iron improves its absorption. For iron (III) hydroxide polymaltose, the doses can be higher, about 1.5 times in relation to the latter, because the drug is non-ionic, it is much better tolerated than iron salts, while only the amount of iron that the body needs and only in an active way is absorbed.
WHO experts also recommend daily intake of folic acid. Iron preparations are taken in combination with ascorbic and folic acid at a dose of 400 mcg.
Treatment should be long-term. With adequate prescription of iron preparations in a sufficient dose, an increase in reticulocytes is noted on the 8-12th day, the Hb content increases by the end of the 3rd week. Normalization of red blood counts occurs only after 5–8 weeks of treatment.

All iron preparations are divided into two groups:
1. Ionic iron-containing preparations (salt, bivalent polysaccharide compounds.
2. Non-ionic compounds, which include ferric iron preparations, represented by an iron-protein complex and a hydroxide-polymaltose complex, iron (III) -hydroxide sucrose complex.

For relief of mild IDA:
Salt, polysaccharide compounds of ferrous iron, ferric iron (iron III hydroxide-polymaltose complex) 1 tab. x 2 p. in d. 2-3 weeks;
Moderate severity: Salt, polysaccharide compounds of ferrous iron, ferric iron (iron III hydroxide-polymaltose complex) 1 tab. x 2 p. in the village 1-2 months;

Severe severity: Salt, polysaccharide compounds of ferrous iron, ferric iron (iron III hydroxide-polymaltose complex) 1 tab. x 2 p. in the village 2-3 months.
During pregnancy, the drug should be taken during the entire pregnancy period and for at least 3 months of lactation.
Of course, the duration of therapy is influenced by the level of hemoglobin against the background of ferrotherapy, as well as a positive clinical picture!

Indications for parenteral administration of iron preparations:
Intolerance to iron preparations for oral administration;
Violation of iron absorption (enteritis, malabsorption syndrome, resection of the small intestine, resection of the stomach according to Billroth-II with the inclusion of the duodenum 12);
Peptic ulcer of the stomach and duodenum during an exacerbation;
Severe anemia and the vital need for rapid replenishment of iron deficiency, for example, preparation for surgery (refusal of hemocomponent therapy).
For parenteral administration, ferric preparations are used. The course dose of iron preparations for parenteral administration is calculated by the formula: A \u003d 0.066 M (100 - 6 Hb), where A is the course dose, mg; M is the patient's body weight, kg; Нb - content of Нb in blood, g / l.

In case of moderate and severe anemia, targeted correction of metabolic disorders characteristic of chronic placental insufficiency is carried out.

Treatment regimen for IDA complicating pregnancy, childbirth and the postpartum period:

1. If the hemoglobin level is over 110 g / l, therapy is carried out according to the section on prevention of anemia (outpatient stage);
2. At a hemoglobin level of 109-90 g / l, a hematocrit of 27-32%, prescribe a combination of drugs:

• A diet that includes iron-rich foods - beef tongue, rabbit, chicken, porcini mushrooms, buckwheat or oatmeal, legumes, cocoa, chocolate, prunes, apples;

• Salt, polysaccharide compounds of ferrous iron, iron III hydroxide polymaltose complex in a total daily dose of 100 mg (oral administration) for 1.5 months with a complete blood count control once a month, if necessary, prolongation of the course of treatment up to 3 months;

 ascorbic acid 2 dr. X 3 r. in d. 2 weeks

3. When the hemoglobin level is below Hb 69 g / l; erythrocyte level less than 1.5 × 1012 / l, Ht less than 23%; consult a hematologist.

• Salt or polysaccharide compounds of ferrous iron or iron (III) -hydroxide polymaltose complex in a standard dosage. In addition to previous therapy, prescribe iron III hydroxide sucrose complex (200 mg / 10 ml) intravenously every other day, the amount of iron administered should be calculated according to the formula given in the manufacturer's instructions or iron III dextran (100 mg / 2 ml) once a day, intramuscularly (calculation according to the formula), with an individual selection of the course depending on hematological parameters, at this moment the intake of oral iron preparations is temporarily stopped; UAC control once every 5 days; The tactics will vary depending on the severity of the anemia during treatment.

4. When the hemoglobin level is normalized over 110 g / l and the hematocrit is more than 33%, prescribe a combination of preparations of salt or polysaccharide compounds of ferrous iron or iron III hydroxide polymaltose complex 100 mg once a week for 1 month, under the control of the hemoglobin level (1 time month), ascorbic acid 2 dr. x 3 r. in d. 2 weeks (not applicable for pathology from the gastrointestinal tract - erosion and ulcers of the esophagus, stomach), folic acid 1 tab. x 2 p. in d. 2 weeks. 5. If the hemoglobin level is less than 70 g / l, inpatient treatment in the hematology department (up to 30 weeks), in case of exclusion of acute gynecological or surgical pathology, after 30 weeks, the pathology department (maternity hospitals, obstetrics and perinatology centers). Mandatory preliminary examination by a gynecologist and surgeon.

 In case of severe anemic and circulatory-hypoxic syndromes, leukofiltered erythrocyte suspension, further transfusions are strictly according to absolute indications, according to the Order of the Minister of Health of the Republic of Kazakhstan dated July 26, 2012 No. 501. On amendments to the order of the acting Minister of Health of the Republic of Kazakhstan dated November 6, 2009 No. 666 "On approval of the Nomenclature, Rules for the procurement, processing, storage, sale of blood and its components, as well as the Rules for storage, transfusion of blood, its components and preparations"

• In the preoperative period, in order to speed up the normalization of hematological parameters, transfusion of leukofiltered erythrocyte suspension, according to order No. 501;

• Iron III hydroxide sucrose complex (100 mg / 5 ml) intravenously every other day according to the calculations according to the instructions and under the control of hematological parameters.

 In the 1st and 2nd trimesters - in case of a threat to the life of the fetus and mother, transfusion of leukofiltered erythrocyte suspension, further transfusions strictly according to absolute indications;

 In the 3rd trimester, prenatal period, in order to speed up the normalization of hematological parameters, transfusion of leukofiltered erythrocyte suspension, it is desirable to increase the hemoglobin level for childbirth over 90 g / l;

 In the early postpartum period, iron III hydroxide sucrose complex (100 mg / 5 ml) or iron III carboxymaltosate (100 mg / 2 ml) intravenously every other day No. 7 (the duration of the course depends on the level of hemoglobin, ferritin data, individual characteristics) under the control of hematological parameters ... Control for 7 days of therapy, 2 times a week.

6. In the postpartum period, in case of bleeding and a drop in hemoglobin level less than 70 g / l, pronounced circulatory-hypoxic syndrome, replacement therapy with blood components as mentioned above.
Prevention of anemia:
1.admission of drugs - iron (III) -hydroxide polymaltose complex or ferrous sulfate at a dose of 60 mg per day, in the case of latent iron deficiency, multiple pregnancies, aggravated by anemic history;
2. taking folic acid at a dose of 400-500 mg daily in case of revealed deficiency of folic acid, preceding folic acid deficiency anemia.

other treatments - no

surgical intervention
Indications for surgical treatment are ongoing bleeding, an increase in anemia, due to reasons that cannot be eliminated by drug therapy.

Indicators of the effectiveness of treatment and the safety of diagnostic and treatment methods described in the protocol.

 Increasing trophological insufficiency;

Prevention

Preventive actions

Prevention of iron deficiency anemia in pregnant women.
All pregnant women with a gestational age of 8 weeks are divided into the following groups:

O (zero) - pregnant women with a normal pregnancy. These women are prescribed prophylactic iron supplementation at a dose of 30-40 mg (for elemental iron) from the 31st week of pregnancy for 8 weeks. This is necessary due to the fact that in the indicated time frame there is an intensive accumulation of iron by the fetus. The best drug for prophylaxis, iron salt preparations should be considered, 1 tablet 3-4 times a day (such a dose of the drug will provide 30-40 mg of iron).

Group 1 - pregnant women with a normal blood test, but with factors predisposing to the development of anemia:
profuse, prolonged menstruation before pregnancy;
pathology of the gastrointestinal tract, in which blood loss or impaired absorption of iron is possible (ulcerative colitis, erosive gastritis, peptic ulcer stomach and duodenal ulcer, chronic enteritis, etc.);
multiple births (more than three with an interval of less than two years);
insufficient intake of iron from food;
the presence of infectious and inflammatory foci;
early toxicosis of pregnant women with frequent vomiting.
Preventive therapy begins from 12-13 weeks and is carried out until the 15th week (30-40 mg of iron per day is prescribed), then from 21st to 25th weeks, from 31-32 weeks to 37 weeks.

Group 2 - women who developed anemia during pregnancy, more often anemia develops after the 20th week. A thorough examination of the pregnant woman is necessary (to exclude bleeding of various etiologies), and then treatment of iron deficiency anemia should be carried out as described above, using therapeutic doses of drugs. Treatment must be carried out as anemia of the expectant mother leads to fetal anemia.

Group 3 - women with pregnancy that has already occurred against the background of existing iron deficiency anemia. After clarifying the genesis of anemia, iron deficiency anemia is treated with the appointment of therapeutic doses of drugs, followed by replenishment of iron stores (saturation therapy) and courses of preventive therapy (2 courses of 8 weeks).

Treatment with iron-containing drugs is useful to combine with the intake of antioxidants (vitamin E, vitamin C), a complex of multivitamins, calcium preparations.

Prevention of complications of gestation
Prevention of maternal and perinatal complications in anemia - balanced nutrition for a pregnant woman in terms of quantity and quality.
According to the WHO recommendation, all pregnant women during the II and III trimesters of pregnancy and in the first 6 months of lactation should receive iron supplements in a prophylactic dose (60 mg per day). Serum iron and ferritin levels should be tested prior to ferrotherapy to avoid iron overload.
For pregnant women with Hb levels ≤115 g / l, iron supplementation is necessary from the earliest stages of pregnancy, almost from the moment of registration.
Measures aimed at improving the health of the woman and the fetus after 17-18 weeks of pregnancy (completion of the formation of the uteroplacental-fetal circulation) do not give much effect. That is why early attendance and quick examination of the pregnant woman are so necessary.
Prevention of iron deficiency anemia is indicated for pregnant women:
living in populations where iron deficiency is a common problem in the population;
with profuse and prolonged menstruation before pregnancy;
with a short intergenetic interval;
with multiple pregnancies;
with prolonged lactation.

Further management
With a moderate degree of anemia, regular visits to the antenatal clinic are prescribed at the usual time according to the standard of monitoring the pregnant woman.
Clinical blood tests should be performed monthly, biochemical studies (serum iron, transferrin, ferritin) are prescribed 1 time per trimester, as well as with dynamic laboratory control of therapy.
In case of severe anemia, laboratory control is carried out every week, in the absence of positive dynamics of hematological parameters, an in-depth hematological and general clinical examination of the pregnant woman is indicated.

page 1

page 2

page 3

p. 4

p. 5

page 6

page 7

page 8

page 9

page 10

page 11

p. 12

p. 13

page 14

p. 15

page 16

p. 17

p. 18

page 19

page 20

p. 21

page 22

p. 23

page 24

p. 25

p. 26

page 27

page 28

p. 29

page 30

FEDERAL AGENCY FOR TECHNICAL REGULATION AND METROLOGY

NATIONAL

STANDARD

RUSSIAN

FEDERATIONS

Official edition

Standardinform

Foreword

The goals and principles of standardization in the Russian Federation are established Federal law of December 27, 2002 No. 184-FZ "On technical regulation", and the rules for the application of national standards of the Russian Federation - GOST R 1.0-2004 "Standardization in the Russian Federation. Basic provisions "

Information about the standard

1 DEVELOPED by the Interregional Public Organization for the Promotion of Standardization and Improvement of the Quality of Medical Care

2 INTRODUCED by the Technical Committee for Standardization TC 466 "Medical Technologies"

3 APPROVED AND PUT INTO EFFECT by the Order of the Federal Agency for Technical Regulation and Metrology dated December 18, 2008 No. 498-st

By order of the Federal Agency for Technical Regulation and Metrology dated December 31, 2008 No. 4196, the introduction date was postponed to January 1, 2010.

4 INTRODUCED FOR THE FIRST TIME

Information on changes to this standard is published in the annually published information index "National Standards", and the text of changes and amendments - in the monthly published information indexes "National Standards". In case of revision (replacement) or cancellation of this standard, the corresponding notice will be published in the monthly published information index "National standards". Relevant information, notice and texts are also posted in the public information system - on the official website of the Federal Agency for Technical Regulation and Metrology on the Internet

© Standartinform, 2009

This standard may not be reproduced in whole or in part, replicated and distributed as an official publication without permission from the Federal Agency for Technical Regulation and Metrology.

GOST R 52600.4-2008

for iron deficiency anemia without an obvious source of blood loss, a thorough laboratory and instrumental examination is carried out: X-ray and endoscopic studies

gastrointestinal tract, etc., aimed at determining the cause of iron deficiency anemia in accordance with the requirements of the diagnostic sections of other protocols for the management of patients.

Iron deficiency anemia in children is characterized by the following features. Anemia in newborns and infants is a consequence of maternal iron deficiency not so much during pregnancy, but especially during lactation. In children with a high level of risk of iron deficiency anemia (high risk is implied in the low socio-economic status of the child's family, low birth weight (less than 2500 g), feeding only with cow's milk during the first year of life), repeated blood hemoglobin determinations are required at 6 and 12 month

Iron deficiency anemia in pregnant women is characterized by the following features. Differential diagnosis excludes "false anemia", which in pregnant women may be a consequence of hydremia (blood dilution). In this case, to clarify the diagnosis, it is necessary:

Examine the volume of circulating blood;

Assess the ratio of the volume of circulating plasma to the volume of circulating erythrocytes;

Determine the hypochromia of erythrocytes (an important sign);

To establish the content of serum iron (an important sign);

Establish the content of ferritin in the blood;

Establish the content of soluble transferrin receptors.

Anemia in pregnant women is also observed with nephropathy of pregnant women (preeclampsia), with chronic urinary tract infections, but in these cases refers to anemia of chronic diseases.

Iron deficiency anemia in the elderly is characterized by the following features. Diagnostic studies are aimed at excluding (detecting) microbleeding from the gastrointestinal tract (erosion and stomach ulcers, polyposis, hemorrhoids, etc.), oncological pathology in the intestine, dysbiosis, diverticulosis (competitive iron intake by bacteria), alimentary iron deficiency, malabsorption ( for example when chronic pancreatitis), blood loss from oral cavity due to problems with dentures. Differential diagnosis excludes B 12 deficiency anemia and anemia of chronic diseases.

Iron deficiency anemia, which is not amenable to correction for a long time with adequate treatment, has the following features. In case of persistent anemia, especially in combination with subfebrile condition, lymphadenopathy, unreasonable sweating, it is necessary to diagnose the absence of tuberculosis.

Diagnostic errors:

Incomplete history taking, physical examination;

The cause of iron deficiency anemia has not been established;

Baseline study of serum iron and ferritin has not been performed;

The initial determination of peripheral blood reticulocytes has not been carried out;

Serum iron studies were performed after taking iron supplements.

3.3 General approaches to the treatment of iron deficiency anemia

Treatment principles for iron deficiency anemia:

Iron deficiency anemia cannot be cured by diet.

The use of drugs that strictly correspond to a specific pathogenetic variant of anemia, i.e., the use of only iron preparations.

The use of predominantly oral preparations.

Treatment with adequate high daily doses of one drug with good tolerance.

Appointment of erythrocyte transfusion only for life-long indications, including for patients of older age groups with progressive angina pectoris, circulatory decompensation and cerebral hypoxic disorders.

Evaluation of the effect of treatment by clinical and laboratory signs, including reticulocytic crisis.

The use of drugs with an optimal cost / effectiveness ratio allows you to minimize treatment costs.

Rational therapeutic tactics implies the beginning of treatment from the moment of detection of iron deficiency anemia until complete clinical and hematological remission is achieved; if necessary - carrying out supportive (preventive) therapy.

Elimination of the causes (diseases) of iron deficiency anemia.

Iron supplements are the mainstay of replacement therapy for iron deficiency in the treatment of iron deficiency anemia. Currently, two groups of iron preparations are used - the content

containing ferrous and ferric iron. Due to the fact that iron from most modern iron-containing preparations is well absorbed by the intestine, in the vast majority of cases it is possible to use iron medications inside. Parenteral iron preparations are prescribed only for special indications, which include:

The presence of intestinal pathology with malabsorption (severe enteritis, malabsorption syndrome, resection of the small intestine, etc.);

Absolute intolerance to iron preparations when taken orally (nausea, vomiting), even with the use of drugs of different groups, which does not allow further treatment to be continued;

The need to quickly saturate the body with iron, for example, when patients with iron deficiency anemia are planning surgical interventions;

Treatment of patients with erythropoietin, in which the limiting factor of effectiveness is an insufficient amount of reserves and circulating iron.

Of dosage form not more than 10% - 12% of the iron contained in it is absorbed. With severe iron deficiency, the rate of iron absorption can increase threefold. An increase in the bioavailability of iron is facilitated by the presence of ascorbic and succinic acids, fructose, cysteine \u200b\u200band other accelerators, as well as the use of special matrices in a number of drugs that slow down the release of iron in the intestine (level of evidence B). Iron absorption can be reduced under the influence of certain substances contained in food (tea tannin, phosphoric acid, phytin, calcium salts, milk), as well as with the simultaneous use of a number of medications (tetracycline drugs, almagel, phosphalugel, calcium preparations, chloramphenicol, penicillamine, etc. .). These substances do not affect the absorption of iron from the polymaltose complex of iron hydroxide. To reduce the likelihood of side effects, iron salts are taken before meals.

The calculation of the daily amount of the drug (SD) for oral iron preparations is performed according to the following formula

where NSD is the required daily dose of bivalent or trivalent (non-elementary) iron (in adults - 200 mg per day, in children - 30 - 100 mg per day);

The calculation of the approximate course dose of iron A, mg, administered parenterally, can be carried out according to the formula taking into account the patient's body weight and the hemoglobin level, reflecting the degree of iron deficiency

A \u003d M (Hbi - Hb 2) 0.24 + D, (5)

where M is body weight, kg;

Hbi - the normative level of hemoglobin for body weight less than 35 kg 130 g / l, more than 35 kg - 150 g / l;

Hb 2 - the patient's hemoglobin level, g / l;

D - the calculated value of iron depot for body weight less than 35 kg - 15 mg / kg, for body weight over 35 kg - 500 mg.

The optimal daily dose for iron supplements in the treatment of iron deficiency anemia should correspond to the required daily dose and is calculated:

Iron in the composition of iron salts is for children under 3 years old - 5 - 8 mg of bivalent iron per kg of body weight per day, over 3 years - 100 - 120 mg of ferrous iron per day, for adults - 200 mg of ferrous iron per day;

Iron in preparations of the polymaltose complex of iron hydroxide (ferric iron) for premature infants 2.5 - 5 mg per kg of body weight, children under one year old - 25 - 50 mg, 1-12 years old 50 - 100 mg, over 12 years old 100 - 300 mg , adults - 200 - 300 mg.

The use of smaller doses of drugs does not give an adequate clinical effect. With latent iron deficiency or to saturate the depot after the end of the course of therapy, half of the therapeutic doses of drugs are used.

For adult patients, no more than 200 mg of iron per day is parenterally administered, according to special indications, by drop, up to 500 mg per day. In children, a daily dose of 25-50 mg, depending on age, the drug

GOST R 52600.4-2008

enter in a stream, slowly - at least 10 minutes. Maximum allowable single dose - 7 mg of iron per kg of body weight is administered once a week.

Monitoring the effectiveness of therapy is an essential component of the rational use of iron-containing drugs. In the first days of treatment, an assessment of subjective sensations is carried out, on the 5-8th day, it is necessary to determine the reticulocytic crisis (2-10-fold increase in the number of reticulocytes compared to the initial value). At the 3rd week, the increase in hemoglobin and the number of erythrocytes is assessed. The absence of a reticulocytic crisis indicates either an erroneous prescription of the drug, or the appointment of an inadequately small dose.

Normalization of hemoglobin levels, the disappearance of hypochromia usually occurs by the end of the first month of treatment (with adequate doses of drugs). However, to saturate the depot, it is recommended to use a half dose of iron-containing preparations for another 4 to 8 weeks. Depot saturation is determined using a comprehensive biochemical study. In the absence of these methods, treatment is carried out empirically.

Among the side effects against the background of oral administration of iron preparations, dyspeptic disorders (anorexia, metallic taste in the mouth, a feeling of fullness in the stomach, pressure in the epigastric region, nausea, vomiting), constipation, and sometimes diarrhea occur most often. The development of constipation is associated with the formation of iron sulfide in the intestine, which is an active inhibitor of the function of the large intestine. In some patients, especially in children, when using preparations of iron salts, a brownish staining of the enamel of the teeth occurs. Of no clinical significance, the often appearing dark staining of the stool.

With parenteral administration of iron preparations, reactions may occur: local - phlebitis, venous spasm, darkening of the skin at the injection site, post-injection abscesses and general - hypotension, chest pain, paresthesia, muscle pain, arthralgia, fever. In case of an overdose, iron overload with the development of hemosiderosis is possible. Malignancy is possible at the injection site.

Ferrous iron is very often included in complex vitamin preparations... However, the dose of iron in them in this case is insignificant, and therefore they cannot be used for the treatment of iron deficiency conditions (level of evidence A).

The most common treatment errors have the following main reasons:

Iron preparations are prescribed in inadequate (small) doses;

Treatment is short-term, adequate patient adherence to therapy has not been achieved;

Unreasonably prescribed vitamins, dietary supplements or drugs with a low iron content.

Treatment of iron deficiency anemia in some age groups and in various conditions has the following features.

Iron deficiency anemia in children of puberty (juvenile chlorosis) is characterized by the following features. Iron deficiency during the period of rapid growth is a consequence of an uncompensated low iron reserve in the first years of life. An abrupt increase in iron consumption by a fast-growing body, the appearance of menstrual blood loss aggravate the relative deficit. Therefore, in puberty, it is advisable to use dietary prophylaxis for iron deficiency, and when signs of hyposiderosis appear, prescribe iron supplements.

Iron deficiency anemia in menstruating women is characterized by the following features. A simple calculation of the approximate amount of iron lost in menstrual blood can help determine the source of the blood loss. On average, a woman during menstruation loses about 50 ml of blood (25 mg of iron), which determines twice the loss of iron compared to men (if distributed over all days of the month, then in addition about 1 mg per day). At the same time, it is known that in women suffering from menorrhagia, the amount of blood lost reaches 200 ml and more (100 mg of iron or more), and, therefore, additional average daily iron losses are 4 mg or more. In such situations, the loss of iron in 1 month exceeds its possible intake with food by 30 mg, and in one year the deficit reaches 360 mg.

The rate of progression of anemia in uterine blood loss, in addition to the severity of menorrhagias, is influenced by the initial value of iron stores, dietary habits, previous pregnancy and lactation, etc. To assess the volume of blood lost during menstruation, it is necessary to clarify the number of linings changed by a woman daily and their characteristics (recently, pads with different absorbent properties have been used, a woman chooses pads for herself depending on the amount of blood loss), the presence of a large number of large clots. Relatively small, "normal" blood loss is considered to be the use of two pads per day, the presence of small (1 - 2 mm across) and a small number of clots.

In the case when menstrual blood loss is the cause of iron deficiency, a single course of replacement therapy is insufficient, since a relapse will occur in a few months. Therefore, supportive prophylactic therapy is carried out, usually by individually selecting the dose of the drug by titration. It is recommended to take iron-containing preparations with a high iron content from the first day of menstruation for 7 to 10 days. For some women, it is sufficient to carry out such supportive therapy once a quarter or once every six months. It is imperative that a consensus be reached between the doctor and the patient about the essence of anemia, methods of therapy, and the importance of prevention. All this significantly improves treatment compliance.

Iron deficiency anemia in women during pregnancy and lactation is characterized by the following features. For the prevention of anemia in this group of patients, combined preparations with a relatively low iron content (30-50 mg) are often used, including vitamins, including folic acid and vitamin B12. This prophylaxis has been shown to be ineffective (level of evidence A). Pregnant women with diagnosed iron deficiency anemia are prescribed preparations containing a large amount of iron (100 mg, 2 times a day) for the entire remaining period of pregnancy, during lactation (in the absence of large blood loss during childbirth and menstrual losses and with full compensation of anemia), you can switch to drugs with a lower iron content (50 - 100 mg per day). In the absence of the effect of the therapy, first of all, the adequacy of the prescribed doses is analyzed (perhaps they should be increased), the correctness of the woman's execution of the prescribed appointments (compliance). In addition, there may be "false anemia" as a consequence of hydremia (blood dilution), which is often observed in pregnant women (for confirmation, it is necessary to examine the volume of circulating blood, assess the ratio of the volume of circulating plasma to the volume of circulating erythrocytes, erythrocyte hypochromia and serum iron content). Anemia is also observed with nephropathy (gestosis), with chronic infections (more often the urinary tract); in the case of persistent anemia, especially in combination with subfebrile condition, lymphadenopathy, unreasonable sweating, it is necessary to exclude the presence of tuberculosis. In these cases, we are talking about anemia of chronic diseases. There are no direct contraindications for the use of parenteral iron preparations in pregnant women, however, large-scale studies in this group have not been performed.

Iron deficiency anemia in old age is characterized by the following features. The main forms of anemia in this group of patients are iron deficiency and B 12 deficiency. No specific treatment regimens are required for anemia, and patients usually respond quickly to prescribed therapy. The ineffectiveness of therapy for iron deficiency anemia is often associated with constipation caused by dysbiosis, disturbances of peristalsis. In such cases, lactulose can be added to therapy in an adequate dose of up to 50 - 100 ml, after a stable effect is obtained, the dose of lactulose is halved.

4 Description of requirements

4.1 Patient model

Nosological form: iron deficiency anemia Stage: any Phase: any

Complication: regardless of complications ICD-10 code: 050.0

4.1.1 Criteria and features defining the patient model

The patient's condition must meet the following criteria and signs:

Decrease in hemoglobin levels below 120 g / l;

Decrease in the level of erythrocytes below 4.2 10 12 / l;

Hypochromia of erythrocytes;

Decrease in one of the indicators of saturation of erythrocytes with hemoglobin (color index (CP) is below 0.85, the average corpuscular hemoglobin content (MCH) is below 24 pg, the average concentration of hemoglobin in erythrocytes (MCHC) is below 30 - 38 g / dL);

Decrease in serum iron levels below 13 μmol / L in men and below 12 μmol / L in women.

4.1.2 Requirements for the diagnosis of outpatient

The list of medical services (MU) for outpatient-polyclinic diagnostics according to the "Nomenclature of works and services in health care" is presented in Table 1.

Table 1 - Outpatient diagnostics

MU name Delivery frequency Multiplicity fulfillment Study of the level of leukocytes in the blood Study of the level of platelets in the blood The ratio of leukocytes in the blood (blood count) Viewing a blood smear to analyze abnormalities in the morphology of red blood cells, platelets and leukocytes Taking blood from a finger Determination of the average content and average concentration of hemoglobin in erythrocytes Cytological examination of a bone marrow smear (calculation of the bone marrow formula) Histological examination of bone marrow preparations Assessment of hematocrit Obtaining a cytological preparation of bone marrow by puncture Obtaining a histological preparation of bone marrow Determination of sideroblasts and siderocytes Study of the osmotic resistance of erythrocytes Study of acid resistance of erythrocytes Desferal test Determination of the volume of blood loss through the gastrointestinal tract using radioactive chromium

4.1.3 Characteristics of algorithms and features of the implementation of non-drug care

Diagnostics for iron deficiency anemia:

1st stage - determination (confirmation) of the iron deficiency nature of anemia;

2nd stage - determining the cause of iron deficiency.

The collection of anamnesis and complaints in diseases of the hematopoietic and blood organs is carried out as follows: first of all, signs of sideropenia are detected, including the clarification of the diet (exclusion of vegetarianism and other diets with a low content of iron-containing food); also specify the possible source of blood loss or increased iron consumption.

An objective study in diseases of the hematopoietic and blood organs is aimed at identifying in a patient the signs characterizing hyposiderosis, and determining diseases (conditions) with increased iron consumption.

The study of the level of erythrocytes, leukocytes, platelets, reticulocytes of the color index, the ratio of leukocytes in the blood (blood formula), the study of the level of total hemoglobin is aimed at identifying signs of blood diseases that may be accompanied by anemia (see the 2nd stage of diagnosis). A decrease in the color index is decisive in the diagnosis of iron deficiency anemia. The results of all studies are analyzed by the physician in the aggregate, no sign in isolation is specific for iron deficiency.

Viewing a blood smear to analyze abnormalities in the morphology of erythrocytes, platelets and leukocytes - the most accurate method for determining the hemoglobin content in erythrocytes remains a morphological study of erythrocytes. With iron deficiency anemia, a distinct hypochromia is revealed, characterized by the presence of a wide enlightenment in the center of the erythrocyte, which resembles a donut or ring (anulocyte).

Serum iron testing is a mandatory diagnostic test for the diagnosis of iron deficiency anemia. It is necessary to pay attention to the reasons for false positive results: in case of non-observance of the technology of the study; the study is carried out soon after taking (even a single dose) iron supplements; after hemo- and plasma transfusion.

When determining the average hemoglobin content in erythrocytes, the technique used in automatic analyzers is used.

Studies of the level of transferrin, serum ferritin are necessary studies in case of doubt about the form of anemia. Research is carried out in a complex of studies of iron metabolism. Determination of serum transferrin level allows to exclude forms of anemia caused by impaired iron transport (atransferrinemia).

Decreased serum ferritin levels are the most sensitive and specific laboratory finding of iron deficiency.

The total iron binding capacity of serum reflects the degree of serum starvation and iron saturation of transferrin. Iron deficiency anemia is characterized by an increase in the total iron-binding capacity of serum.

Counting sideroblasts (erythroid cells of the bone marrow with iron granules) confirms the iron-deficiency nature of anemia (their number in patients with iron-deficiency anemia is significantly reduced). The study is rarely performed, only in complex differential diagnostic cases.

The study of osmotic and acid resistance of erythrocytes is carried out for differential diagnosis with erythrocyte membranopathies.

Taking blood from a finger and from a peripheral vein is performed strictly on an empty stomach. Taking blood for the study of hemostasis is carried out without using a syringe and with a loose tourniquet; it is better to use vacuum tubes.

Determining the cause of iron deficiency.

2nd stage - determination of the cause of iron deficiency is carried out in accordance with the requirements provided for by other protocols for the management of patients (stomach ulcer, uterine leiomyoma, etc.). In particular, with the help of erythrocytes labeled with radioactive chromium, the fact of blood loss through the gastrointestinal tract is confirmed.

If necessary, a cytological and histological examination of a bone marrow smear, a study of the acid resistance of erythrocytes, a desferal test are performed.

4.1.4 Requirements for outpatient treatment

The list of medical services (MH) for outpatient-polyclinic treatment according to the "Nomenclature of works and services in health care" is presented in Table 2.

Table 2 - Outpatient-polyclinic treatment

MU name Delivery frequency Multiplicity of execution Collection of anamnesis and complaints in diseases of the hematopoiesis and blood organs Visual examination in diseases of the hematopoietic and blood organs Study of the level of reticulocytes in the blood Determination of color index Study of the level of total hemoglobin in the blood Taking blood from a finger Palpation for diseases of the hematopoietic and blood organs Percussion for diseases of the hematopoietic and blood organs General therapeutic auscultation Determination of the average hemoglobin content in erythrocytes Assessment of hematocrit Study of the level of iron in blood serum Study of the level of ferritin in the blood Serum transferrin test Taking blood from a peripheral vein Study of the iron binding capacity of serum Study of the level of erythrocytes in the blood

4.1.5 Characteristics of algorithms and features of the implementation of non-drug care

Collection of anamnesis and complaints in diseases of the hematopoietic and blood organs, physical examination is carried out twice to assess the dynamics in general condition (well-being) of patients. "Small signs" of effectiveness are very important from the point of view of early assessment of the effectiveness of therapy.

The first objective effect of taking therapy should be a reticulocytic crisis, which manifests itself as a significant - 2-10 times increase in the number of reticulocytes compared to the initial value by the end of the first week of therapy. The absence of a reticulocytic crisis indicates either an erroneous prescription of the drug, or the appointment of an inadequately small dose.

An increase in the level of hemoglobin, the number of erythrocytes is usually noted in the 3rd week of therapy, later hypochromia and microcytosis disappear. By 21-22 days of treatment, hemoglobin is usually normalized (with adequate doses), but the depot is not saturated.

If necessary, the level of the color index, the average content of hemoglobin in erythrocytes, the study of the level of serum iron, the level of ferritin, serum transferrin, assessment of the hematocrit and iron-binding capacity of serum are carried out.

You can check the saturation of the depot only with the help of a comprehensive biochemical study. Thus, monitoring the effectiveness of therapy is an essential component of the rational use of iron-containing drugs.

Taking blood from a finger and from a peripheral vein is carried out strictly on an empty stomach. Blood sampling for the study of hemostasis is carried out without using a syringe and with a loose tourniquet; it is better to use vacuum tubes.

4.1.6 Requirements for outpatient drug care

Requirements for outpatient medical care are presented in Table 3.

Table 3 - Outpatient drug care

Pharmacotherapeutic group Anatomical Therapeutic Chemical Group International generic name destination Estimated daily dose, mg Equivalent course dose, mg Drugs affecting blood Antianemic agents Iron (III) hydroxide sucrose complex Iron (III) hydroxide polymaltose complex

4.1.7 Characteristics of algorithms and characteristics of the use of medicines

Iron replacement therapy is performed with iron preparations. Currently, two groups of iron preparations are used - containing ferrous and trivalent iron, in the overwhelming majority of cases used internally.

One of the drugs is used: iron sulfate (oral), iron (III) hydroxide sucrose complex (intravenously), iron (III) hydroxide polymaltose complex (oral and parenteral).

Some drugs are available in the form of syrups and suspensions, which makes them easier to administer to children. However, here, too, the recalculation of the daily dose should be carried out taking into account the iron content per unit volume.

For better tolerance, iron supplements are taken with meals. It should be borne in mind that under the influence of certain foods and substances contained in food (tea tannin, phosphoric acid, phytin, calcium salts, milk), as well as with the simultaneous use of a number of medications (tetracycpin drugs, almagel, phospholugel, calcium preparations, chloramphenicol , penicillamine, etc.), the absorption of iron from iron salt preparations may decrease. These substances do not affect the absorption of iron from iron III hydroxide of the polymaltose complex.

Prescribing iron supplements without recalculating the daily dose is ineffective and leads to the development of a false "refractory" (level of evidence C).

Iron preparations are prescribed for 3 weeks, after receiving the effect, the dose of the drug is reduced by 2 times and is prescribed for another 3 weeks.

Iron sulfate: the optimal daily dose for iron preparations should correspond to the required daily dose of ferrous iron, which for children under 3 years old is 5-8 mg / kg per day, over 3 years old - 100-120 mg / day, for adults - 200 mg / day ( 100 mg 2 times a day 1 hour before sludge and 2 hours after meals). Duration of treatment is 3 weeks, followed by maintenance therapy (1/2 dose) for at least 3 weeks (level of evidence A).

Iron (III) hydroxide polymaltose complex is a new group of iron preparations containing trivalent iron as part of the polymaltose complex. They have no less pronounced effect in terms of the speed of saturation of the body with iron than ferrous iron... Ferric iron preparations have virtually no side effects. They are used in the form of a solution for intramuscular injection, solution and tablets according to the requirements of the formulary articles for drugs.

Iron (III) hydroxide sucrose complex - for parenteral administration, 2.5 ml are injected on the 1st day, 5 ml - on the 2nd and 10 ml on the 3rd days, then 10 ml 2 times a week. The dose of the drug is calculated taking into account the degree of anemia, body weight and iron stores.

Parenteral administration of iron preparations should be used only in the following exceptional cases:

1 area of \u200b\u200buse............................................... ....1

3 General ............................................... .....1

3.1 Classification of iron deficiency anemia ................................. 4

3.2 General approaches to the diagnosis of iron deficiency anemia ........................ 4

3.3 General approaches to the treatment of iron deficiency anemia .......................... 7

4 Description of requirements ............................................. 10

4.1 Patient model ............................................... ..ten

4.1.1 Criteria and features defining the patient model ..................... 10

4.1.2 Requirements for outpatient-polyclinic diagnostics ................... 10

4.1.3 Characteristics of algorithms and features of the implementation of non-drug care. 12

4.1.4 Requirements for outpatient-polyclinic treatment ..................... 12

4.1.5 Characteristics of algorithms and features of the implementation of non-drug care. thirteen

4.1.6 Requirements for outpatient drug care ............ 14

4.1.7 Characteristics of algorithms and features of the use of medicines .......... 14

4.1.8 Requirements for the regime of work, rest, treatment or rehabilitation ............... 15

4.1.9 Requirements for patient care and ancillary procedures ... 15

4.1.10 Requirements for dietary prescriptions and restrictions ................... 15

4.1.11 Features of informed voluntary consent of the patient when performing

patient management protocols and additional information for the patient and his family ...................................... ..............sixteen

4.1.12 Rules for changing requirements during protocol execution and termination

protocol requirements .......................................... 16

4.1.13 Possible outcomes and their characteristics ............................... 16

5 Graphical, schematic and tabular presentation of the protocol ................... 16

5.1 Evaluation of the effectiveness of therapy with iron-containing drugs ................. 16

5.2 Some characteristics of tablet forms of iron-containing preparations ....... 17

5.3 Some characteristics of syrups and other liquid forms of iron-containing preparations. ... 17

6 Monitoring ................................................ ....eighteen

6.1 Criteria and methodology for monitoring and evaluating the effectiveness of protocol implementation ... 18

6.2 Principles of randomization ............................................ 18

6.3 Procedure for assessing and documenting side effects and the development of complications ........ 18

6.4 Interim assessment and changes to the protocol ... 18

6.5 Procedure for including and excluding a patient from monitoring ...................... 19

6.6 Parameters for assessing the quality of life during the implementation of the protocol .................... 19

6.7 Estimation of the cost of the protocol and the price of quality ....................... 19

6.8 Comparison of results ............................................. 19

6.9 Procedure for generating a report ........................................ 19

5.2 Some characteristics of tablet forms of iron-containing preparations

The characteristics of the tableted forms of iron-containing preparations are shown in table 6.

Table 6 - Tableted forms of iron-containing preparations

Commercial name Composition, release form Special indications for use Aktiferrin Iron sulfate + serine Pills Hemofer pro-longatum Iron sulfate Maltofer Foul Iron polmalto-zat + folic acid Chewable tablets, 100 mg / 0.35 mg Pregnant and lactating women Maltofer Iron polymaltose Chewable tablets, 100 mg Pregnant and lactating women Sorbifer-Duru- Iron sulfate + ascorbic acid Tablets, 320/60 mg Tardiferon Iron sulfate + mucoprotheose + ascorbic acid Pills Iron sulfate + ascorbic acid + riboflavin + nicotinamide + pyridoxine + calcium pantatenate Pills Pregnant and lactating women Ferretab Ferrous fumarate Ferroplex Iron sulfate + ascorbic acid Tablets, 50 mg / 30 mg Children and adolescents Ferrous fumarate Capsules, 350 mg

5.3 Some characteristics of syrups and other liquid forms of iron-containing preparations

The characteristics of syrups and other liquid forms containing iron are shown in table 7.

Table 7 - Syrups and other liquid forms of iron-containing preparations

Commercial name International non-proprietary name Composition, release form Aktiferrin Iron sulfate + serine Drops, 30 ml Aktiferrin Iron sulfate + serine Syrup, 100 ml Iron chloride Drops (vials), 10 and 30 ml Iron gluconate, manganese gluconate, copper gluconate Mix for solution preparation in ampoules 50 in 1 ampoule Maltofer Iron polymaltose Solution for internal use (drops), 30 ml 50 in 1 ml Fe * ++ Maltofer Iron polymaltose Syrup, 150 ml 10 in 1 ml Fe ~ + Ferrum Lek Iron polymaltose Syrup, 100 ml 10 in 1 ml Fe ~ +

Annex A (informative) Unified scale for assessing the strength of evidence

expediency of using medical technologies ................... 20

Appendix B (reference) Some indicators of iron metabolism, depending on the degree of its

deficit ................................................. 20

Appendix B (informative) EQ-5D Questionnaire ... 21

Appendix D (reference) Patient record form ............................... 27

Bibliography................................................. ....... 29

GOST R 52600.4-2008

NATIONAL STANDARD OF THE RUSSIAN FEDERATION

Patient management protocol IRON DEFICIENCY ANEMIA

Protocol for patient’s management. Iron deficiency anaemia

Date of introduction - 2010-01-01

1 area of \u200b\u200buse

This standard specifies the types, volume and quality indicators of medical care for patients with iron deficiency anemia.

This standard is intended for use by medical organizations and institutions of federal, territorial and municipal health authorities, systems of compulsory and voluntary medical insurance, other medical organizations of various organizational and legal forms of activities aimed at providing medical care.

2 Normative references

This standard uses a normative reference to the following standard:

GOST R 52600.0-2006 Protocols for the management of patients. General Provisions

Note - When using this standard, it is advisable to check the validity of the reference standards in the public information system - on the official website of the Federal Agency for Technical Regulation and Metrology on the Internet or according to the annually published information index "National Standards", which was published as of January 1 of the current year , and according to the relevant monthly information signs published in the current year. If the reference standard is replaced (changed), then when using this standard, the replacing (modified) standard should be followed. If the reference standard is canceled without replacement, then the provision in which the reference to it is given applies to the extent that this reference is not affected.

3 General

The protocol for the management of patients "Iron deficiency anemia" was developed to solve the following problems:

Determination of the range of diagnostic and therapeutic procedures provided to patients with iron deficiency anemia;

Definition of algorithms for the diagnosis and treatment of iron deficiency anemia;

Establishment of uniform requirements for the procedure for prevention, diagnosis and treatment of patients with iron deficiency anemia;

Unification of calculations of the cost of medical care, development of basic programs of compulsory health insurance and tariffs for medical services and optimization of the system of mutual settlements between territories for medical care provided to patients with iron deficiency anemia;

Official edition

Formation of licensing requirements and conditions for the implementation of medical activities;

Definitions of formulary articles of drugs used to treat iron deficiency anemia;

Monitoring the volume, availability and quality of medical care provided to the patient in medical institution within the framework of state guarantees for the provision of citizens with free medical care.

This standard uses a unified scale for assessing the credibility of evidence of the use of medical technologies and data in accordance with GOST R 52600.0 (see Appendix A).

Anemia from a clinical point of view is a decrease in the concentration of hemoglobin in a unit of blood volume, often accompanied by a decrease in the number (concentration) of erythrocytes in a unit of blood volume. The syndrome of iron deficiency anemia is characterized by a weakening of erythropoiesis due to iron deficiency, due to a discrepancy between the intake and consumption (consumption, loss) of iron, a decrease in the filling of hemoglobin with iron, followed by a decrease in the hemoglobin content in the erythrocyte.

In accordance with the International Statistical Classification of Diseases, Injuries and Conditions Affecting Health, 10th revision, the following forms of anemia associated with iron deficiency are distinguished:

D50 Iron deficiency anemia (asiderotic, sideropenic, hypochromic);

D50.0 Iron deficiency anemia associated with chronic blood loss (chronic post-hemorrhagic anemia);

D50.1 Sideropenic dysphagia (Kelly-Patterson and Plummer-Vinson syndromes);

D50.8 Other iron deficiency anemias;

D50.9 Iron deficiency anemia, unspecified

According to statistics, iron deficiency anemia ranks first among the 38 most common human diseases. Of all forms of anemia, it is the most common: 70% - 80% of all diagnosed cases of anemia. In the world, iron deficiency anemia affects about 700 million people. In the Russian Federation, iron deficiency anemia is diagnosed in 6% - 30% of the population.

Risk groups for the development of iron deficiency anemia are:

Newborns;

Children of puberty;

Menstruating women;

Women during pregnancy and lactation;

Patients of older age groups.

A high risk of anemia occurs with a low socio-economic status of the family, donation, nutrition with limited intake of iron, in children - with a low birth weight (less than 2500 g), and feeding him only with cow's milk during the first year of life.

Iron deficiency anemia is caused by a discrepancy between the body's need for iron and its intake: in various diseases and conditions accompanied by minimal to significant blood loss, including frequent blood sampling, long-term donation. The causes of iron deficiency anemia are:

Increased need for iron (during the period of body growth, pregnancy, lactation);

Impaired iron absorption;

Insufficient intake of iron from food (vegetarianism, starvation).

A rare cause of iron deficiency anemia is congenital iron deficiency.

The main diseases and conditions that may be accompanied by iron deficiency anemia:

Pregnancy;

Crohn's disease;

Vegetarianism;

Helminthiasis;

Hemorrhoids;

Hemorrhagic esophagitis, gastritis;

Children who are bottle-fed with formulas with insufficient iron content;

Diverticulosis and diverticular bowel disease;

Dysfunctional uterine bleeding;

Menorrhagia;

GOST R 52600.4-2008

Myoma of the uterus;

Nonspecific ulcerative colitis;

Operations and trauma with large blood loss;

Tumors of the stomach and intestines;

Early umbilical cord ligation and impaired placental blood supply;

Endometriosis;

Enteritis;

A duodenal or stomach ulcer;

Iatrogenic causes (donation, hemodialysis, frequent blood sampling for research).

It should be borne in mind that in many cases, not one, but several diseases and / or conditions can

be the causes or risk factors for the development of iron deficiency anemia.

The pathogenesis of iron deficiency anemia is associated with the physiological role of iron in the body and its participation in the processes of tissue respiration. Iron is part of heme, a compound capable of reversibly binding oxygen. Heme is the non-protein part of the hemoglobin and myoglobin molecule. It binds oxygen, which, in particular, is necessary for the contractile processes in the muscles. In addition, heme is an integral part of tissue oxidative enzymes - cytochromes, catalase, and peroxidase. In the deposition of iron in the body, the proteins ferritin and hemosiderin are of primary importance. The transport of iron in the body is carried out by the protein transferrin. The body can only to a small extent regulate the intake of iron from food and does not control its consumption. With a negative balance of iron metabolism, iron is first consumed from the depot (latent iron deficiency), then tissue iron deficiency occurs, manifested by a violation of the enzymatic activity and respiratory function of tissues, and only later does iron deficiency anemia develop.

Clinical picture iron deficiency anemia is diverse and is caused by sideropenic (iron deficiency) and anemic syndromes.

Sideropenic syndrome (hyposiderosis) is associated with tissue iron deficiency, which is necessary for the functioning of cells. It is necessary to distinguish between hyposiderosis without anemia (subcompensated stage) and hyposiderosis accompanying anemia. There are 4 main groups of organs in which the manifestations of hyposiderosis are maximally expressed:

Skin, skin appendages and mucous membranes;

The gastrointestinal tract;

Nervous system (increased fatigue, tinnitus, dizziness, headaches, decreased intellectual capacity);

Cardiovascular system (tachycardia, diastolic dysfunction).

Symptoms of sideropenia in patients with iron deficiency anemia in decreasing order of frequency are as follows:

Dry skin, forcing women to constantly use creams;

Brittle and layered nails, there is no way to grow nails, they have to be cut very shortly;

Transverse striation of nails, nails become flat, sometimes take a concave "spoon-shaped" shape (koilonychia);

Exfoliation of hair ends, women are worried about the inability to grow hair;

Perversion of taste in the form of an irrepressible desire to eat chalk, toothpaste, ash, paint, earth, etc. (patophagy);

Unusual addiction to certain odors, more often acetone, gasoline (pathoosmia); streets of older age groups often do not have a perversion of appetite and smell;

Rarely, there is a violation of the integrity of the epidermis, in particular, in about 5% - 10% of patients, angular stomatitis (seizures) appears: ulceration, cracks with an inflammatory shaft in the corners of the mouth (it may also be a sign of vitamin B 2 hypovitaminosis);

Only some patients note a burning sensation of the tongue, signs of glossitis;

An extremely rare sign may be dysfunction of swallowing due to the formation of esophageal septa (sideropenic dysphagia - Plummer-Vinson syndrome);

The symptoms of gastritis (severity, pain) are not as pronounced as with gastritis of a different origin;

Dysuria and urinary incontinence when coughing, laughing, nocturnal enuresis is sometimes observed in girls, less often in adult women.

The presence of iron deficiency anemia causes neuropsychic functional disorders in children. According to special studies, with iron deficiency anemia in children of the first

year of life, the index of intellectual development is 96 (in control 102) by 12 months, and 89 (in control 100). There is an inverse correlation between physical and mental development, the severity and duration of anemia.

Anemic syndrome with iron deficiency is manifested by nonspecific symptoms: dizziness, headaches, tinnitus, flashing flies before the eyes, weakness, fatigue, decreased performance, chronic fatigue, pale skin and mucous membranes, palpitations, shortness of breath during exercise. Some of the symptoms may be due not so much to anemia as to sideropenia.

3.1 Classification of iron deficiency anemia

There is no generally accepted classification of iron deficiency anemia. According to the severity of clinical manifestations, the following stages of the development of an iron deficiency state are conditionally distinguished:

1st stage - iron loss exceeds its intake, gradual depletion of reserves, absorption in the intestine increases compensatory.

Stage 2 - depletion of iron stores (the level of serum iron is below 13 μmol / l in men and below 12 μmol / l in women, transferrin saturation is below 16%) prevents normal erythropoiesis, erythropoiesis begins to fall.

3rd stage - development of mild anemia (100 - 120 g / l of hemoglobin, compensated) with a slight decrease in the color index and other indices of saturation of erythrocytes with hemoglobin.

4th stage - severe (less than 100 g / l of hemoglobin, subcompensated) anemia with a clear decrease in the saturation of erythrocytes with hemoglobin.

5th stage - severe anemia (60 - 80 g / l of hemoglobin) with circulatory disorders and tissue hypoxia.

3.2 General approaches to the diagnosis of iron deficiency anemia

The diagnostic examination process can be conditionally represented in the form of the following sequential stages:

Identification of the actual anemic syndrome;

Determination (confirmation) of iron deficiency anemia;

Search for the cause of the disease underlying the iron deficiency in this patient.

Detection of anemic syndrome - determination of a decrease in serum hemoglobin levels

blood test - carried out in patients with clinical signs of the disease, and can also be accidental during a routine analysis of peripheral blood, carried out in connection with another disease, a screening study.

Normal blood hemoglobin indices: the lower threshold in an adult is 120 g / l (7.5 mmol / l) in women and 130 g / l (8.1 mmol / l) in men.

Establishing the iron deficiency nature of anemia is to determine the clinical manifestations of sideropenia, morphological signs of iron deficiency in erythrocytes, a decrease in the level of serum iron, and iron stores in the body.

At this stage of diagnosing iron deficiency anemia, a thorough laboratory study is carried out, which necessarily includes: determination of the level of hemoglobin, the number of erythrocytes, platelets, reticulocytes, leukocyte formula, calculation of the color index or the average hemoglobin content in the erythrocyte, viewing a blood smear to determine abnormal forms of erythrocytes and their saturation with hemoglobin, leukocytes and cell inclusions.

Determination of iron stores

The color index (CPU) is calculated by the formula

With iron deficiency, the color index usually falls below 0.85 (normal 1.0). Errors in calculating the color index are associated, first of all, with the incorrect determination of hemoglobin and the number of red blood cells. It is often necessary to observe in the results of a blood test that the color indicator is normal, and the red blood cells contain little hemoglobin - that is, there is an inadequate determination of this important indicator.

B - the number of erythrocytes in 1 liter of blood.

With an iron deficiency, the SIT is below 24 g.

The average concentration of hemoglobin in erythrocytes (MCHC) is calculated by the formula

ICSU \u003d -, (3)

Ht - hematocrit,%.

The normal MCSU value is 30 - 38 g / dl.

The most accurate method for assessing the hemoglobin content in erythrocytes is morphological examination of erythrocytes. With iron deficiency anemia, a distinct hypochromia is revealed, characterized by the presence of a wide enlightenment in the center of the erythrocyte, which resembles a ring (anulocyte). Normally, the ratio of the diameter of the central enlightenment and peripheral "darkening" in the erythrocyte is approximately 1: 1, with hypochromia - as 2-3: 1. In the blood smear of patients with iron deficiency anemia, microcytes predominate - erythrocytes of reduced size, anisocytosis (unequal sizes) and poikilocytosis ( various forms) erythrocytes. With iron deficiency anemia, target erythrocytes can also be detected, although their number is 0.1% - 1.0% of the total number of cells.

The number of siderocytes (erythrocytes with iron granules, detected with a special stain) is sharply reduced compared to the norm, up to their complete absence. The content of reticulocytes in the blood, as a rule, is within normal limits, with the exception of cases of severe blood loss in the corresponding pathologies (profuse nose and uterine bleeding) or during treatment with iron preparations (in these cases, it may increase). The number of leukocytes and platelets is usually not changed. Some patients may experience thrombocytosis, which disappears after correction of anemia.

Morphological examination of the bone marrow for the diagnosis of iron deficiency anemia can be important only with a special staining for iron for counting sideroblasts (erythroid bone marrow cells with iron granules), the number of which is significantly reduced in patients with this anemia.

To one degree or another, iron stores in the body can be determined by the following methods:

Serum iron testing;

Study of the total iron-binding capacity of serum with the calculation of the latent iron-binding capacity of serum;

A study of the level of ferritin in the blood;

Transferrin saturation study;

Desferal test.

Normal values \u200b\u200bof the serum iron index in men are 13 - 30 µmol / l, in women - 12 - 25 µmol / l; with iron deficiency, the value of this indicator is reduced, often significantly. When analyzing the results, one should take into account the susceptibility of the concentration of iron in the serum to daily fluctuations (in the morning, the level of iron is higher), as well as other influences (menstrual cycle, pregnancy, contraceptives, diet, blood transfusion, taking iron-containing drugs, etc.).

When carrying out these studies, strict adherence to the methodology is required. When preparing glass tubes for testing the level of serum iron, they must be treated with hydrochloric acid and washed with bidistilled water, since the use of ordinary distilled water containing a small amount of iron for washing affects the test results. Drying cabinets should not be used to dry test tubes: when heated, a small amount of iron gets into the dishes from their walls. Immediately after taking blood, the tube must be closed with a stopper or cap made of aluminum foil or a special waxed membrane, since fine metal dust gets into it during centrifugation. Plastic tubes can also be used, but the requirements for obtaining and processing blood remain valid in this case. The exception is vacutainers - disposable tubes specially adapted for taking such blood samples.

The total iron binding capacity of serum reflects the degree of serum starvation and iron saturation of transferrin. Normally, the total iron-binding capacity of serum is 30-85 μmol / l, with iron deficiency, the value of the indicator increases.

The difference between the indicators of total iron-binding capacity of serum and serum iron characterizes the latent iron-binding capacity of serum. The latter two tests are rarely used to diagnose iron deficiency anemia. The ratio of serum iron to total serum iron-binding capacity, expressed as a percentage, reflects the degree of saturation of transferrin with iron (normal - 16% - 50%). Iron deficiency anemia is characterized by an increase in the total iron-binding capacity of blood serum, a significant increase in the latent iron-binding capacity and a decrease in the percentage of transferrin saturation.

Decreased serum ferritin levels are the most sensitive and specific laboratory sign of iron deficiency; the normal ferritin content is 15 - 20 μg / l.

Desferal test - normally, after intravenous administration of 500 mg of desferal, from 0.8 to 1.2 mg of iron is excreted in the urine, while in patients with its deficiency, the amount of this microelement excreted in the urine is 0.2 mg or less. At the same time, with an excess of iron, its excretion in the urine after the administration of desferal exceeds the norm. This test is rarely used, more often for the diagnosis of hemosiderosis, and not sideropenia.

Determination of serum transferrin level allows to exclude anemia caused by impaired iron transport (atransferrinemia).

Glycoprotein transferrin is a protein involved in the transport of iron from the place of its absorption (small intestine) to the place of its use or storage (bone marrow, liver, spleen). One transferrin molecule is capable of binding up to two iron atoms. With a lack of absorption of iron, transferrin saturation becomes incomplete, i.e., the percentage of saturation decreases, which indicates anemia due to a lack of iron intake. However, such a model is only valid ideally. In reality, it should be borne in mind that transferrin is characterized by the qualities of a "negative" protein of the acute phase, ie, acute inflammation contributes to a decrease in the level of transferrin. In addition, the formation of transferrin is highly dependent on the state of the liver. On the other hand, iron deficiency affects transferrin levels by induction, i.e. ultimately causes an increase in its production. All of these factors can affect transferrin levels to such an extent that their initial diagnostic value may ultimately be ambiguous. Normal transferrin levels range from 2.0 to 3.8 g / L.

Iron transport into the cell occurs when the iron-transferrin complex interacts with the transferrin-specific plasma membrane receptor. The transferrin molecule, carrying up to two iron atoms, "moors" to the outer (extracellular) end of the receptor, after which it is absorbed by the cell by endocytosis. In the formed vesicle, the pH level changes, iron changes the oxidation state (from Fe +++ to Fe ++) and is subsequently used for the synthesis of hemoglobin or is stored in the form of deposited iron. The protein part of transferrin, freed from iron, together with the receptor goes to the cell surface, where apotransferrin is separated, and the whole cycle repeats. Normally, the level of transferrin receptors ranges from 8.8 to 28.1 nmol / L.

Schematically, the change in the indicators of iron metabolism, depending on the degree of its deficiency, is shown in Table B.1 (Appendix B).

To prevent errors, the doctor in determining the pathogenetic variant of anemia should be guided by the following: do not prescribe treatment with iron preparations until the level of serum iron and the number of reticulocytes is determined; if the patient receives iron supplements for a short time, they are canceled for 5 to 7 days, after which the iron content in the serum is determined.

To search for the disease underlying iron deficiency in this patient, additional methods of instrumental and laboratory examination are used (X-ray and endoscopic examination of the gastrointestinal tract; ultrasound examination of the abdominal cavity, small pelvis, kidney.). In the process of diagnosing the disease, blood loss from the gastrointestinal tract is assessed, most reliably using its own erythrocytes labeled with radioactive chromium. Finding the source of bleeding in small intestine may require a laparotomy; an alternative to it may be a special automated video camera in a video capsule swallowed by the patient.

Determination of the cause of iron deficiency is carried out according to the protocols for the management of patients with the corresponding diseases.

Features of diagnosis in patients with iron deficiency anemia in some age groups and in various conditions are characterized by the following. Patients with newly diagnosed signs

1. Definition

Iron deficiency anemia (IDA) is a pathological condition characterized by a decrease in the hemoglobin content due to a deficiency of iron in the body in violation of its intake, assimilation or pathological losses.

According to WHO (1973) - the lower limit of hemoglobin capillary blood in children under 6 years of age it is 110 g / l, and after 6 years - 120 g / l.

The causes of IDA in children:

Insufficient level of iron in the body (disorders of the uteroplacental circulation, fetomaterine and fetoplacental bleeding, fetal transfusion syndrome in multiple pregnancies, intrauterine melena, prematurity, multiple pregnancies, deep and long-term iron deficiency in the body of a pregnant woman, premature or late bleeding, intrauterine cord ligation; obstetric interventions or anomalies in the development of the placenta and umbilical cord vessels) Increased need for iron (premature babies, children with a large body weight at birth, with a lymphatic type of constitution, children in the second half of life). Insufficient amount of iron in food (early artificial feeding with cow or goat milk, flour, dairy or dairy-vegetarian food, unbalanced diet in which there is not enough dairy products) Increased iron losses due to bleeding of various etiologies, intestinal absorption disorders (chronic intestinal diseases, malabsorption syndrome), as well as significant and prolonged hemorrhagic uterine bleeding in girls. Disorders of iron metabolism in the body (pre and pubertal hormonal imbalance) Disorders of transport and utilization of iron (hypo and atransferinemia, enzymopathies, autoimmune processes) Insufficient resorption of iron in the digestive tract (post-resection and agastral states).

Stages of IDA development (WHO, 1977)

Prelate (depletion of tissue iron stores; blood counts are normal; no clinical manifestations). latent (iron deficiency in tissues and a decrease in its transport fund; blood counts are normal; the clinical picture is due to trophic disorders that develop as a result of a decrease in the activity of iron-containing enzymes and are manifested by sideropenic syndrome - epithelial changes in the skin, nails, hair, mucous membranes, distortion of taste, smell , disorders of intestinal absorption and asthenovegetative functions, decreased local immunity).

Iron deficiency anemia (more pronounced depletion of tissue reserves of iron and mechanisms to compensate for its deficiency; deviations from the norm of blood counts depending on the severity of the process; clinical manifestations in the form of siederopenic syndrome and general anemic symptoms, which are caused by anemic hypoxia - tachycardia, muffled heart sounds, systolic murmur , shortness of breath during physical exertion, pallor of the skin and mucous membranes, arterial hypotension, increased astheno-neurotic disorders).

The severity of anemic hypoxia depends not only on the level of hemoglobin, but also on the speed of development of anemia and on the compensatory capabilities of the body. In severe cases, metabolic intoxication syndrome develops in the form of memory loss, low-grade fever, headache, fatigue, hepatolienal syndrome, etc.
Iron deficiency contributes to a decrease in immunity, a delay in the psychomotor and physical development of children.

According to the level of hemoglobin IDA is divided into severity:

Light - Hb 110-91 g / L medium - Hb 90-71 g / L heavy - Hb 70-51 g / L super heavy - Hb 50 g / L or less

2. Laboratory criteria for the diagnosis of IDA

Blood test with determination of: hemoglobin level, erythrocytes morphological changes of erythrocytes color index of average diameter of erythrocytes average concentration of hemoglobin in erythrocyte (MHCS) average volume of erythrocytes (MS) level of reticulocytes blood serum analysis with determination of: concentration of iron and ferritin total iron-binding capacity of blood latent iron-binding capacity blood with the calculation of the coefficient of saturation of transferrin with iron

3. Basic principles of treatment

Elimination of etiological factors rational medical nutrition (for newborns - breastfeeding, and in the absence of milk from the mother - adapted milk formulas fortified with iron. Timely introduction of complementary foods, meat, especially veal, offal, buckwheat and oat groats, fruit and vegetable purees, solid varieties of cheese; a decrease in the intake of phytates, phosphates, tannin, calcium, which impair the absorption of iron.pathogenetic treatment with iron preparations mainly in the form of drops, syrups, tablets.

Parenteral administration of iron preparations is indicated only: with the syndrome of impaired intestinal absorption and conditions after extensive resection of the small intestine, nonspecific ulcerative colitis, severe chronic enterocolitis and dysbiosis, intolerance to oral preparations of jelly, severe anemia.

Preventive measures to prevent recurrence of anemia

Correction of iron deficiency in mild anemia is carried out mainly due to a balanced diet, sufficient stay of the child in the fresh air. The appointment of iron preparations at a hemoglobin level of 100 g / l and above is not indicated.

Daily therapeutic doses of oral iron preparations for moderate and severe IDA:
up to 3 years - 3-5 mg / kg / day of elemental iron
from 3 to 7 years - 50-70 mg / day of elemental iron
over 7 years old - up to 100 mg / day of elemental iron

Monitoring the effectiveness of the prescribed dose is carried out by determining the rise in the level of reticulocytes on days 10-14 of treatment. Iron therapy is carried out until the hemoglobin level is normalized with a further decrease in the dose by ½. The duration of treatment is 6 months, and for premature infants - within 2 years to replenish iron stores in the body.

In older children, the maintenance dose is 3 to 6 months, in adolescent girls - intermittently throughout the year - every week after menstruation.

It is advisable to prescribe ferric iron preparations due to their optimal absorption and the absence of side effects.

In young children, IDA is predominantly of alimentary genesis and is most often a combination of not only iron deficiency, but also protein and vitamins, which determines the appointment of vitamins C, B1, B6, folic acid, and correction of the protein content in the diet.

Since 50-100% of premature babies develop late anemia, from 20-25 days of life at a gestational age of 27-32 weeks, body weight 800-1600 g, (during a decrease in the hemoglobin concentration of blood below 110 g / l, the number of erythrocytes is lower 3.0 ґ 10 12 / l, reticulocytes less than 10%), except for iron preparations (3-5 mg / kg / day) and sufficient protein supply (3-3.5 g / kg / day), erythropoietin s / c is prescribed , 250 units / kg / day three times a day for 2-4 weeks, with vitamin E (10-20mg / kg / day) and folic acid (1mg / kg / day). Longer use of erythropoietin - 5 times a week, followed by its decrease up to 3 times, is prescribed to children with severe intrauterine or postnatal infection, as well as to children with a low reticulocytic response to therapy.

Parenteral iron supplements should be used strictly only for special indications, due to the high risk of developing local and systemic adverse reactions.

The daily dose of elemental iron for parenteral administration is:
for children 1-12 months - up to 25 mg / day
1-3 years - 25-40 mg / day
over 3 years old - 40-50 mg / day
The course dose of elemental iron is calculated by the formula:
МТґ (78-0.35ґ Hb), where
MT - body weight (kg)
Нb - child's hemoglobin (g / l)
Heading dose of an iron-containing preparation - KJ: SZhP, where
KJ - course dose of iron (mg);
SFP - iron content (mg) in 1 ml of the drug
Course number of injections - KDP: SDP, where
KDP - course dose of the drug (ml);
SDP - daily dose of the drug (ml)

Hemotransfusions are carried out only for health reasons, when there is acute massive blood loss. The preference is given to red blood cells or washed red blood cells.

Prototype indications of ferrotherapy:aplastic and hemolytic anemia hemochromatosis, hemosiderosis sideroachrestic anemia thalassemia other types of anemias not associated with iron deficiency in the body

4. Prevention
Antenatal: women from the second half of pregnancy are prescribed iron supplements or multivitamins fortified with iron.
With repeated or multiple pregnancies, it is mandatory to take iron supplements during the 2nd and 3rd trimester.
Postnatal prophylaxis for children from groups at high risk of developing IDA.

{!LANG-35feddd4f877a193a80f82d3f1c77a82!}

{!LANG-d21a5ae515a105caeccb9e7d3df3c4aa!}

{!LANG-13d3763b2e813f8ba30b1072581dd5d6!}

5. {!LANG-d049de2d26d45364bc339825716b1304!}
{!LANG-6712e691294203593c4ea68067b70e3d!}