IRON DEFICIENCY

ANEMIA

Presented by

Dr. Afeefa Kazmi

P.G scholar, Dept. of Moalajat
Govt. Tibbi college & Hospital, Patna.
 CONTENTS
• Anemia
• Unani concept of anemia
• Incidence
• Types of anemia
• Iron deficiency anemia (IDA)
• Prevalence of IDA
• Iron absorption
• Iron metabolism
• Causes of IDA
• Pathogenesis of IDA
• Clinical features
• Management of IDA
• Usool-e-Ilaj wo Ilaj
• Prevention of IDA
 ANEMI
A

What is Anemia?
WHO defines anemia as a condition in which the hemoglobin
content of blood is lower than normal as a result of deficiency of
one or more essential nutrients, regardless of the cause of such
deficiencies.
• It is a condition in which the oxygen carrying capacity of blood
is reduced.
• Various types of anemia are characterized by reduced numbers
of RBCs or a decrease d amount of hemoglobin in the blood.
 CONT...

According to WHO
Hb <11.0gm/dl in children of age group 6 to 59 months
Hb<11.5gm/dl in children of 5 to 11 years of age
Hb<12.0gm/dl in children of 12 to 14 years of age Hb <13.0 in adult male
Hb < 12.0 in non pregnant female
Hb<11.0 in pregnant female

Should be considered as evidence of anemia.

 UNANI CONCEPT OF ANEMIA

• In Unani literature anemia is described under the heading of

Soo-Ul-Qiniya. The term was firstly used by Ibne-Sina
(Avicenna) specifying it as the preceding condition of Istisqa-
e-aam (Anasarca). It develops due to altered temperament
and weakness of liver.

• Hakeem Kabiruddin described Soo-Ul-Qiniya with synonyms

of Faqr-ud-Dam, Fasad-ud-Dam and Qillat-ud-Dam.
 CONT...

• According to unani physician Ibne Sina, Ismail Jurjani and

Hakeem Azam Khan blood is considered to be the vital fluid of
Human body which is formed in the Liver/jigar/kabid.

• Due to altered temperament and weakness of liver or

sometimes due to associated diseases formation of blood is not
normal which leads to anemia.

• In this condition there is decreased amount of blood and

decreased number of Kuryat-e-Hamra (RBCs) in the body.
 INCIDENCE
Prevalence of anemia

 Globally
• In women of reproductive age (non pregnant) 29.9%
• In children 39.8%
• In pregnant women 36.5%
• 50% of anemia is due to iron deficiency and accounts for
approximately 8.41 lac deaths annually.
 CONT…
 India
• In Children aged 6-59 months 58%
• Adolescent girls 15-19 years 54%
• Adolescent boys 15-19 years 29%
• Women of reproductive age 53%
• Pregnant women 50%
• Lactating women 58%
 CONT…

 Bihar
• In children aged 6-59 months 69.4%
• All women aged 15-49 years 63.5%
• Pregnant women 63.1%
• Men aged 15-49 29.5%

 Patna
• Children aged 6-59 months 65.4%
• All women aged 15-49 years 67.1%
• Pregnant women 63.7%
 TYPES OF ANAEMIA
Acute

Impaired RBC Due to blood loss

production
Chronic
BASED
ON
ETIOLOGY
Intracorpuscular
Haemolytic defect
Ideopathic anemia

Extracorpuscular
defect
 Based on RBC
morphology
Normocytic Macrocytic Microcytic
anemia anemia anemia
MCV 76-96fL MCV >96fL MCV <76fL
Acute blood loss Megaloblastic (vit B9 & Iron deficiency anemia
Liver disease B12 def) Thalassaemia
Increased Non megaloblastic (liver Sidro blastic A
demand(pregnancy/ diease, drugs inhibiting
lactation) DNA synthesis)
 IRON DEFICIENCY
ANEMIA
Iron deficiency anemia (IDA) is a state in which reduction of iron stores
precedes development of overt iron deficiency anemia. It may percists
without progression.

• It is more severe condition in which low levels of iron are associated

with anemia and the presence of microcytic hypochromic red cells in
the circulation, the relative number of which reflects the severity of the
iron deficiency.

• It is one of the commonest nutritional disorders

 PREVALENCE OF IRON DEFICIENCY
ANEMIA

• Globally 50% of anemia is attributed iron deficiency & accounts for

approximately 8.41 lacs deaths annually.
• In India alone 80% of women are iron deficient.
• In developing countries iron deficiency & iron deficiency anemia typically
results from inadequate dietary intake/blood loss due to worm
manifestations or both.
• In developed countries certain eating habits/chronic blood
loss/malabsorption are the most common causes.
• Iron deficiency in developed countries is specially high in the elderly
people.
 ABSORPTION OF IRON

• Iron which we take in diet , are absorbed in all parts of

gastrointestinal tract. Specially in duodenal mucosa.
• Acid medium favours iron absorption.
• Acid medium also favours formation of macromolecular
complexes of iron with vitamin C, sugar, amino acid & bile in
duodenum.
• Only 10% of ingested iron is absorbed.
• Normal serum iron level is 50-150mg/dl.
• Frank iron deficiency increases absorption by 30-40% & in iron
overload, absorption decreases.
 CONT…
• Iron absorption increases in,
Ferrous state
Increased erythropoiesis
Iron deficiency
• Iron absorption decreases in,
Ferric state
In presence of phosphate
In presence of phytates
In bone marrow hypoplasia
• The absorbed iron is stored in the form of ferritin (water soluble) &
hemosiderin ( water insoluble)
• The storage organs are liver, spleen, lymph nodes & bone marrow.
 CONT…

• In males, storage compartment contains about 1000mg of iron while

in females, it contains 0-500 mg of iron.
• In 1/3rd of healthy females there is no significant iron in storage
compartment.
• Iron is transported after binding with transferrin (cytoplasmic
protein) transport iron compartment contains 3mg of iron.
• Transferrin concentration in plasma is measured by, estimating total
iron binding capacity(TIBC) or immunologically.
• Normally 1mg of elemental iron is lost from shedding of senescent
cells of Gastrointestinal tract, genitourinary tract & from
desquamation of skin.
 IRON METABOLISM
• Iron in the form of heme is vital to many metabolic functions
including oxygen transportation in hemoglobin, necessary for
energy generation & drug metabolism.
• Through the donation or acceptance of an electron, iron exists in
either a reduced ferrous(Fe2+) or an oxidative ferric (Fe3+) state.
• Majority of functional iron is contained in hemoglobin with smaller
quantity found in myoglobin & cytochromes.
• Liver, Which is the site of production of iron transport proteins,
contains the largest non-functional iron stores either as ferritin or
hemosiderin.
• Ferritin is both diffuse & soluble, & is the primary iron storage
protein.
 CONT…
• Hemosiderin is insoluble and is similar in structure as of ferritin, but
has more iron relative to ferritin.
• Iron is also stored in reticuloendothelial cells of bone marrow &
spleen
• The absorbed iron is transported across the epical membrane of
the enterocyte by divalent metal transporter1 & then transferred
across the enterocyte to the basolateral membrane by an unknown
mechanism.
• Iron is exported across the basolateral membrane of enterocytes
by ferroportin, then bound to transferrin in the plasma &
transported for use in target organs or storage.
• Body stores of iron are tightly regulated to provide adequate iron
for cellular needs without developing toxicity from excess.
 CONT…

• Because the body lacks a mechanism to excrete excessive iron,

homeostasis is strictly controlled by limiting enteric iron uptake
through impaired efflux from enterocytes.
• Iron efflux is controlled by hepcidin, a recently discovered
hormone produced by hepatocytes.
• When iron stores are high/adequate hepcidin is released & binds
to intestinal ferroportin.
• The reduction in ferroportin causes absorbed dietary iron to
remain in enterocyte shedding.
• Conversely, when iron stores are low, hepcidin production and
secretion are suppressed, increasing iron efflux from enterocytes
into the blood.
 CAUSES OF IRON DEFICIENCY
ANEMIA
 Excessive demand
• Growing children
• Pregnancy
• Lactation
 Defective intake
 Defective absorption
• Gastrectomy/Gastrojejunostomy
• Sprue disease
 Excessive loss
• Gastrointestinal bleeding
• Recurrent blood donation
• Menorrhagia
• Intrsvascular hemolysis
• Acute/chronic hemoglobinuria
• Pulmonary hemosiderosis
• Drugs like aspirin,non steroidal inflammatory drugs
• Long standing hemoptysis & hematuria
 PATHOGENESIS OF IDA
IDA may be classified into 3 stages
 Storage iron deficiency
 Iron deficient erythropoiesis
 Iron deficiency anemia
• Initially during blood loss, iron body stores are utilized for
accelerated erythropoiesis.
• After depletion of body iron stores, erythropoiesis and
production of other iron containing proteins ( such as
myoglobin) become limited, leading to an overt IDA.
• Anemia is worsen as iron deficient erythrocytes have a
shortened survival, due to their fragility which accelerates
destruction.
 CLINICAL FEATURES
Sign & symptoms of IDA depends on the severity.
Clinically anemia is categorized as
 Mild if Hb% ranges from 11-11.9g/dl
 Moderate if Hb% ranges from 8-10.9g/dl
 Severe if Hb% is less than 8g/dl
General
 Weakness
 Fatigue/tiredness
 Pallor
 Breathlessness
 Headache
 Irritability
 Oedema
 Cold extremities
 CONT…
Epithelial tissue
 Pale & Rough skin
 Thin & Lustreless hairs
 Nail
 Thin
 Brittle
 Flattened
 Koilonychia
 Atrophic glossitis resulting in bald tongue with soreness
 Leukoplakia
Gastrointestinal
 Anorexia
 Acidity
 Heartburn
 Pica
 CONT…
Neurological
 Dizziness
 Giddiness
 Tingling sensation
 Numbness
 Insomnia
 Diminished vision
 Forgetfulness/memory loss
 Lack of concentration
Reproductive system
 Amenorrhea
 Abortion
 Infertility
 CONT…
Cardiovascular
 Palpitation
 Anginal pain
 Sinus tachycardia (rarely bradycardia)
 Congestive cardiac failure
Others
Plummer-Vinson syndrome
 MANAGEMENT OF IRON DEFICIENCY
ANEMIA
Investigations

Blood examination
 Hb% low
 RBC count usually follows Hb%
 MCV low 50-80fL (N:-80-96 fL)
 MCHC low, 24-30g/dl (N:-30-35g/dl)
 MCH low, 15-26 Pg (N:-27-31 picogram/cell
 Peripheral blood film shows hypochromia, pencil shaped cells etc
 TLC& DLC normal
 Platelets normal
 CONT..
 Blood biochemistry
 Serum iron level < 60micro gram/dl (N:- 60-170mcg/dl
 Total iron binding capacity(TIBC) >400mcg/dl (N:- 240-
400mcg/dl)
 Transferrin saturation <15% (N:- 15% or more)
 Plasma ferritin level <10ng/ml (N:-12-300 ng/ml)

ferritin level <30mg/dl indicates loss of iron stores & a

very reliable indicator of iron deficiency.
 Bone marrow
• iron content of bone marrow is decreased or absent.
 TREATMENT
Treatment totally depends upon the severity.
when the Hb is below 40% Blood transfusion (packed cell)
should be given. Small amount of blood (100-150cc) to be
transfused in. slow rate at an interval of 24-36 hours.

When Hb level is between 40%-60%, iron should be given.

ORAL ROUTE
 Oral route is the best route.
 Best form of oral iron is ferrous salt.
 Common oral preparations are:-
• Ferrous sulphate: 325mg thrice daily
 CONT..
• Ferrous fumerate: 200mg thrice daily
• Ferrous gluconate: 300-600mg thrice daily
• Ferrous succinate: 150-300mg thrice daily
 Oral iron should be taken in full stomach to prevent gastric
irritation, but it can also be taken in empty stomach.
 Ferrous sulphate is usually given as it contains greater
amount of elemental iron & is better absorbed.
 Ferrous sulphate 325mgm TDS will provide about 180mgm
of iron daily, of which 10mgm is absorbed.
 Total duration of therapy should be very long e.g 3-6
months.
 Symptomatic improvement occurs within a few days but
haematological response begins in about 2 weeks.
 PARENTERAL IRON
Indication: when there is intolerance to oral iron, GI
disease(IBD), GI bleeding or adequate oral therapy has
failed.
Intramuscular iron(IM)
 There are 2 IM preparations available,
• Iron-dextran complex (Imferon)
• Iron sorbitol citric acid (Jectofer)
 These are given by deep IM injection in the gluteal region.
Dose
 Each of the above, preparations contains 50mg of iron per cc.
After a test dose of ½ cc if there is no reaction then 2cc to be
given & repeated daily or on alternate days.
 2cc of IM iron contains 100mg of elemental iron which raises
the Hb level by 0.5gm/dl.
 CONT…
 Dose of parenteral iron=(Normal Hb in gms-present Hb in
gms)x150mg)

 With it 500mg of iron should be added to replenish the loss of

iron from stores if there is no more blood loss. But the extra
amount is about 1000mg if there is continued loss of blood.

 Alternately the dose of iron can be calculated by the following

formula:-
• (15-Hb in gm/dl)x body wt. in kg x 3= mg of IM iron to be required.
 CONT…
Intravenous iron (IV)
 Preparations
a) Saccharated oxide of iron
b) Iron polymaltose
c) Iron-dextran complex
d) Sodium Ferric Gluconate

 All these IV preparations may produce anaphylactic reactions but

sodium ferric gluconate will have less severe anaphylactic
reaction.

 Of these iron-dextran complex is commonly used either by

intermittent intravenous method or by total dose infusion
method (TDI).
 CONT…
 3cc of iron-dextran complex contains 150mg of elemental iron which
raises the Hb level by 1mg/dl when given IV. Thus the total amount of
iron required can be calculated to restore the Hb level to normality.

 To replenish the loss from iron stores as before 500mg or 1000mg of

additional iron is to be given.

 Start with a small dose of 50mg on 1st day & if there is no reaction,
100mg on 2nd day,
 200mg on 3rd day & onwards till the total calculated dose is given.

 In total dose infusion (TDI) method the calculated dose of iron

dextran complex is diluted in a litre of 5% dextrose with normal
saline.
 The total dose can be given by IV injection by 4-6 hours. Patient
should be observed during the entire injection period.
 USOOL-E-ILAJ
 Remove the root cause.
 Avoid consumption of foods causing altered temperament of
jigar (liver) leads to baroodat (coldness) & taqleel e hararat
e ghareeziya (decreases innate heat) of the liver.
 Avoid ratab (moist), ghaleez & dushwar hazm ghiza (spicy &
hardly digestable food).
 Avoid use of freezing & cold water.
 Daily riyazat (exercise) in empty stomach.
 Dalak (massage) by rough cloth with roghan e haar (hot
oil).
 CONT…
 Remove fuzlat from the body.
 After removing fuzlat give mufattehat (deobstruent) wo
mudiraat (diuretic).
 If the cause of soo-ul-qiniya is ihtabas e haiz (amenorrhoea)
then try to treat amenorrhoea first.
 In the case of kami e dam give murakkabat e faulad
(compound drugs of iron)
 In the case of fasad-ud-dam give musaffi e dam advia(drugs)
 ILAJ
ILAJ BIL TADBEER
 Following tadabeer stimulates blood circulation & remove
toxic substances from the body thus helps in production of
khoon saleh (pure blood) which is essential for afa’al
haiwaniya (vital activity).
• Riyazat (exercise)
• Dalak (massage)
• Takmeed (fomentation)
• Hammam e yabis (dry bath)
• Hammam muarriq (steam bath)
 ILAJ BIL GHIZA
 Ghiza lateef (soft diet)
 Kaseerut-taghzia (high nutritious diet)
 Jaiyyad-ul-kaimus (easily absorbable)
 Zirbaj (a sour meat dish which dressed with vinegar & honey or with
raisins, few figs)
 Sikbaz ( similar to zirbaz)
 Zardah (rice dressed with zaafraan)
 Yakhni (prepared from meat & rice)
 Khajoor yabis wo ratab
 Shorba e teetar etc
 All the above diet are recommended by ancient physicians
corroborates with conventional diet as it is rich in iron, folic acid,
vitamin A, Vitamin B12, protein, minerals etc
 ILAJ BIL DAWA
There are many drugs which are used either in single form or
compound formulations.
Mufrad advia (single drugs)
 Zaafraan
 Maweez munaqqa
 Haleela
 Baleela
 Aamla
 Qaranfal
 Lahsun
 Rai etc
 CONT…
Murakkab advia
 Qurs e kushta faulad
 Kushta nuqrah
 Majoon e dabeedul ward
 Majoon e khabsul hadeed
 Jawarish aamla
 Sharbat e faulad
 Sharbat e maweez
 Sharbat e ananas
 Sharbat e afsanteen
 Sharbat e anarain etc
 PREVENTION OF IRON DEFICIENCY ANEMIA
Unani medicine recognizes the influence of environment &
surrounding on health.
It also prescribes Asbab e sitta zarooriya (six essentials) for
maintaining good health for example:-
 To live in those areas where hawa e muheet is present.
 To take makoolat wo mashroobat of matadil mizaj
 Avoid ratab(moist) ghaleez & dushwar e hazm ghiza(spicy &
hardly digestable food)
 Avoid use of freezing & cold water
 Avoid consumption of foods causinf altered temperament of jigar
which leads to baroodat.
 Avoid sedentary lifestyle which leads to baroodat.
 CONT…
 Daily iron intake age wise:-
 Infants :-0.27-11mg/day
 Children:-1-8 years:- 7-10mg/day
 Males
• 9-18 years:- 8-11mg/dl
• 9-70 years & >70 years:- 8-9 mg/day
 Females
• 9-18years:- 8-15mg/dl
• 19-50years:- 17-18mg/dl
• 51-70 years & >70 years:- 8-9mg/dl
 pregnant women:- 26-27mg/dl
 Lactating women:- 9-10mg/dl
Take iron rich foods like dates, pomegranate, jaggery
pineapple etc
 CONT…
Prophylactic iron supplementation irrespective of anemia,
under the Anemia mukt bharat,

 Children (6-59) months of age:- 1 ml iron syrup

biweekly (each ml contains 20mg elemental iron)

 Children (5-9)years of age:- 1 iron tab.

weekly (contains 45mg elemental iron)

 Adolescent girls & boys (10-19 years):- 1tab

weekly (containing 60mg elemental iron)

 Women of reproductive age (19-49) years:- 1tab

weekly (containing 60mg elemental iron)
 CONT…
 Pregnant women:- 1tab daily (starting from 4rth month of
pregnancy. Minimum 180days during pregnancy & to be
continued for 180 days post partum)

 lactating mothers of 0-6months old child:- 1tab. Daily

(containing 60mg elemental iron)
 take balanced diet.
IRON DEFICIENCY
ANEMIA

Thanks

Presented by

Dr. Afeefa Kazmi

P.G scholar, Dept. of Moalajat
Govt. Tibbi college & Hospital, Patna.