1. Cost conscious project: Microcytic anemia
Internal medicine
Benjamin Yip
4/13/16

2. Background
Iron deficiency and iron deficiency anemia (IDA) are common medical problems.
Iron deficiency affects more than 2 billion people worldwide.
IDA is the most common cause of anemia.
Interpreting iron panels may be challenging.
1. Mclean E et al. Public Health Nutr 2009;12:

3. Definitions Anemia of chronic disorders or inflammation:
Multifactorial anemia associated with increased cytokine production, up-regulation of hepcidin
Iron deficiency:
Depressed levels of total body iron, especially iron stores, with preservation of levels of erythroid iron.
Iron-deficiency anemia:
Depressed levels of total body iron in the presence of anemia.

4. Laboratory tests - Diagnostics
2. Camaschella C. N Engl J Med 2015

5. Objective/Hypothesis
To determine if there is appropriate ordering of iron panels.
To determine if the internal medicine teams are appropriately treating microcytic anemia

6. Methods Screening Reference range
Retrospective analysis of all internal medicine patients hospitalized 4/13/16
81 patients screened for the presence of iron panel on labs
Identified 27 patients with recent iron panels.
Reference range
Fe: mcg/dl
TIBC: mcg/dl
TSAT: 20-55%
Ferritin: ng/ml

7. Total Patients Pt Fe TIBC TSAT Ferr Hgb MCV Tx Notes 1 41 342 12 79
10.8 80 N
n/a 2 35
232 15
376
7.0
91.2
Y, TID
Prior tx cont 3
105
218 48
146
97.4
ACD +/- GIB 4
129
144 90
4340
6.4
93.0 5
405 14
8.9
74.3
IDA 6 60
237 25
6.8
100.0
ACD, HIV from HAART 7
326 33
9.3
75.7
Y, IV 8 59
421 11
10.6
84.3 9
109
7.5
88.4
ACD vs. IDA 10 58
126 46
2950
7.3
98.5
Y, BID
Reported as ACD, cont tx since 2014
190
223 85
1196
101.4
MDS
174
215 81
2081
83.0
Atypical HUS? 13 36
127 28
751
7.2
85.4
Y IV 2 mos after
Chronic gib, chemo

8. Total Patients Pt Fe TIBC TSAT Ferr Hgb MCV Tx Notes 14 139 416 33 124
14.2
105.4
N, F/B12
Macrocytosis 15 79
373 21
123
13.3
91.4 N
n/a 16 44
236 19
145
9.1
96.6 17 26
128 20
430
9.6
88.4
MDS vs. ACD 18 97
148 66
360
9.5
94.0 13
197 7
361
10.5
81.1
ACD 2/2 HIV 37
256
309
7.6
94.6
ACD 22
311
298
8.0
78.1 71
150 47
5486
6.3
93.2
Chemo pancytopenia 23 35
279
297
11.1
Y, qd 24 31
235
754
10.8
79.7 25
243 99
70.1
Y, IV
Possible IDA from GIB 59
177
111
89.9 27
107
234 46
861
9.4
98.1

9. Oral Iron Pt Fe TIBC TSAT Ferr Hgb MCV Tx Notes 2 35 232 15 376 7.0
91.2
Y, TID
Prior tx cont 5
405 4 14
8.9
74.3
IDA 10 58
126 46
2950
7.3
98.5
Y, BID
Reported as ACD, cont tx since 2014 23
279 13
297
11.1
91.4
Y, qd
n/a
Received oral iron, but most likely ACD

10. Cost saving – Oral Iron
Only one patient without anemia – Appropriate ordering of iron panels.
12/21/15 – present TID dosing: 114 d x $0.06 = $6.84
8/30/11 – present BID dosing: 1688 d x $0.04 = $67.52
Unclear initiation – daily dosing: n/a

11. Intravenous iron Pt Fe TIBC TSAT Ferr Hgb MCV Tx Notes 7 14 326 4 33
9.3
75.7
Y, IV x 2
IDA 9 11
232 5
109
7.5
88.4
ACD vs. IDA 13 36
127 28
751
7.2
85.4
Y IV 2 mos before in ED
Chronic gib, chemo 25 16
243 99
7.6
70.1
Y, IV
Possible IDA from GIB

12. Indications for Parenteral Iron
2. Camaschella C. N Engl J Med 2015

13. Cost saving – IV Iron
Iron sucrose (200 mg - $120) compared to ferrous sulfate 325 mg x 1 - $0.02.
4 patients with IV iron treatment
2 doses sucrose – IDA. $240
2 doses sucrose – ACD vs. IDA. h/o CAD, HF. $240
4 doses (25 x 2, 1000 x 2) dextran – Severe anemia 2/2 GIB, panc CA. $606.27
1 dose sucrose – GI loss from rectal CA. AKI Cr 0.6  4.4. $120
2 x 200
2 x 25, 2 x 1000
1 x 200
= 2050 elemental iron received

14. Untreated Patients Pt Fe TIBC TSAT Ferr Hgb MCV Tx Notes 1 41 342 1279
10.8 80 N
n/a 3
105
218 48
146
97.4
ACD +/- GIB 4
129
144 90
4340
6.4
93.0 6 60
237 25
6.8
100.0
ACD, HIV from HAART 8 59
421 14 11
10.6
84.3
190
223 85
1196
7.0
101.4
MDS
174
215 81
2081
83.0
Atypical HUS?

15. Untreated Patients Pt Fe TIBC TSAT Ferr Hgb MCV Tx Notes 14 139 416 33
124
14.2
105.4
N, F/B12
Macrocytosis 15 79
373 21
123
13.3
91.4 N
n/a 16 44
236 19
145
9.1
96.6 17 26
128 20
430
9.6
88.4
MDS vs. ACD 18 97
148 66
360
9.5
94.0 13
197 7
361
10.5
81.1
ACD 2/2 HIV 37
256
309
7.6
94.6
ACD 22
311
298
8.0
78.1 71
150 47
5486
6.3
93.2
Chemo pancytopenia 24 31
235
754
10.8
79.7 59
177
111
89.9 27
107
234 46
861
9.4
98.1

16. Findings
Two patients on oral iron unnecessarily for several years end up spending $74.36 unnecessarily.
Four patients receiving IV iron cost $
Iron dextran: ½ the cost of iron sucrose (risk of hypersensitivity)
2050 mg elemental iron = 82 days of 325 mg TID (for 25 elemental iron). Compares at $4.92.
However this may be offset by a reduced number of hospital days/visits or clinic visits.
Iron deficiency anemia can be difficult to diagnose. Indications for prior iron should be reviewed on admission and discontinued if there is no indication.
Suggested elemental iron: mg (325 mg TID  65 mg elemental TID  195 mg total elemental iron, with 25 mg absorbed and utilized.

17. Conclusions 7.4% of patients with IDA were not treated
11.1% of patients with treated with PO ferrous sulfate unnecessarily.
While the cost is marginal, the patients were taking BID-TID dosing with a risk of constipation unnecessarily.
14.8% of patients were treated with IV iron without an established or even potential indication.
~$1200 increase in cost compared to PO comparison of elemental iron received.

18. Bibliography
Mclean E et al. Worldwide prevalence of anaemia, WHO vitamin and mineral nutrition information system, Public Health Nutr 2009;12:
Camaschella C. Iron-Deficiency Anemia. N Engl J Med 2015; 372: