TREATMENT OF IRON DEFICIENCY ANAEMIA

A PROSPECTIVE, RANDOMIZED, OPEN-LABEL STUDY OF DAILY VERSUS ALTERNATE DAY DOSING OF ORAL IRON IN THE

TREATMENT OF IRON DEFICIENCY ANAEMIA

Dissertation submitted to THE TAMILNADU

DR. M.G.R. MEDICAL UNIVERSITY In partial fulfillment for the award of the degree of

DOCTOR OF MEDICINE IN

PHARMACOLOGY BRANCH VI

201716003

INSTITUTE OF PHARMACOLOGY Madras Medical College

Chennai - 600 003

MAY 2020

CERTIFICATE

This is to certify that the dissertation entitled “A prospective, randomized, open-label study of daily versus alternate day dosing of oral iron in the treatment of Iron Deficiency Anaemia” submitted by Dr. R.KAVITHA, in partial fulfillment for the award of the degree of Doctor of Medicine in Pharmacology by The Tamilnadu Dr.M.G.R.Medical University, Chennai is a Bonafide record of the work done by her in the Institute of Pharmacology, Madras Medical College during the academic year 2017-2020.

DEAN

Madras Medical College &

Rajiv Gandhi Govt. General Hospital Chennai – 600 003.

DIRECTOR AND PROFESSOR Institute of Pharmacology

Madras Medical College

Chennai – 600 003.

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This is to certify that the dissertation entitled, “A prospective, randomized, open-label study of daily versus alternate day dosing of oral iron in the treatment of Iron Deficiency Anaemia” submitted by Dr. R.KAVITHA, in partial fulfillment for the award of the degree of Doctor of Medicine in Pharmacology by The Tamilnadu Dr.M.G.R.Medical University, Chennai is a Bonafide record of the work done by her in the Institute of Pharmacology, Madras Medical College during the academic year 2017-2020.

Place : Date :

Prof Dr. K.M.SUDHA Director i/c & Professor

Institute of Pharmacology Madras Medical College

Chennai-3

DECLARATION

I, Dr.R.KAVITHA, solemnly declare that the dissertation titled “A prospective, randomized, open-label study of daily versus alternate day dosing of oral iron in the treatment of Iron Deficiency Anaemia” has been prepared by me and submitted to Tamil Nadu Dr. MGR Medical University, Chennai in partial fulfillment of the rules and regulations for the M.D degree examination in Pharmacology.

Place : Date :

Dr. R. KAVITHA

ACKNOWLEDGEMENT

I am grateful to our Dean, Dr. R. JAYANTHI, M.D., FRCP., Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai who initiated this work with permission.

I am very thankful to Dr. K.BASKARAN., M.D., Vice Principal, Madras Medical College for her encouragement that helped me to accomplish my goal.

I would like to express my gratitude to Dr. K.M.SUDHA, M.D.DCH,

Director i/c and professor, Institute of Pharmacology, Madras Medical College for her valuable guidance, untiring support and continuous encouragement throughout the dissertation work

I wish to express my sincere thanks to our Associate Professors Dr. R. JAYALALITHA, M.D., and Dr. S. JAYA PONMARI, M.D., Institute of Pharmacology, Madras Medical College for their valuable support.

I am grateful to Assistant Professors of the Department, Dr. S. Deepa,M.D., Dr. A. Meera Devi, M.D., Dr. T. Meenakshi, M.D., Dr. R.Vishnu Priya, M.D., Dr.

S. Ramesh Kannan, M.D., and Dr. S. Suganeshwari, M.D., for their constant support during the study.

I also extend my sincere thanks to all other staff members and colleagues of this Institute of Pharmacology for their wholehearted support and valuable suggestions throughout the study.

Last but not least, I am always grateful to My Husband, Parents and My Inlaws and the almighty for supporting me throughout my life since my birth.

I also wish to thank the patients who voluntarily participated in the study.

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A prospective, randomized, open-label study of daily versus alternate day dosing of oral iron in the treatment of Iron Deficiency Anaemia

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INDEX

S.No Contents Page no.

1. Introduction 1

2. Review of literature Epidemiology

Classification of anemia Iron deficiency anemia History

Clinical features Causes of IDA Complication

Physiology of iron metabolism Diagnosis of IDA

Principles of therapy

History of iron pharmacotherapy National health programs

Pharmacotherapy of IDA Parenteral iron therapy

Role of Hepcidin in oral iron therapy

6

3. Aims and Objectives 46

4. Methodology 47

5. Statistical analysis 53

6. Results

Demographic profile Lost to follow up Adverse effect profile Compliance

Analysis of efficacy

54

S.No Contents Page no.

7. Discussion

Background Study discussion

Strength and limitations

69

8. Conclusion 79

9. Bibliography 10. Appendices

Introduction

1

INTRODUCTION

Iron is the third most abundant element in earth but paradoxically Iron deficiency anemia is the most prevalent micronutrient deficient condition globally. The World Health Organisation (W.H.O.) has identified iron deficiency anemia as one of the top ten risk factors contributing to global disease burden. Iron deficiency anemia can have serious consequences for national development. It has been shown to reduce the IQ of children by half a standard deviation. It also leads to decreased productivity of the workforce due to easy fatiguability.

Worldwide $50 billion is lost annually due to the cognitive and productive deficiency caused by iron deficiency anemia.

While it doesn‟t discriminate between developed and developing countries, the burden of disease is higher in countries like India. It has been estimated that iron deficiency anemia contributes to a million deaths every year. Three quarters of these deaths occur in Africa and south Asian countries. Thus, iron deficiency anemia has been identified as a major public health problem in India by World Health Organisation.

Iron deficiency anemia is not a disease entity in itself but is the end

result of various causes of imbalance between iron demand and supply. In

the pediatric population, iron deficiency is commonly due to insufficient

2

dietary iron. In young women, iron deficiency most often results from excessive blood loss during menstruation or due to blood loss at the time of pregnancy or childbirth. In older adults, gastrointestinal bleed is often the cause of iron deficiency, originating from hemorrhoids, peptic ulcer, angiodysplasia or cancer of the gastro intestinal tract. Similarly, while the diagnosis of iron deficiency anemia is straightforward, it should include workup for the cause of iron deficiency anemia.

Once the diagnosis of iron deficiency anemia is established, replacement therapy should be instituted.

This anemia can be treated with supplementation using oral or parenteral iron formulations. Generally oral iron supplementation is preferred. While there are numerous oral iron preparations available, ferrous sulphate (FS) is the oral formulation preferred for use in government health institutions. The most popular prescription is 2–3 tablets of FS per day for 3-6 months [Traditional treatment].

Oral iron therapy is inexpensive and has no major or life

threatening adverse effects. But it has several disadvantages including

high incidence of predominantly gastro-intestinal adverse effects and as a

result, a very low compliance rate.

3

Recent studies have shown that only a small fraction (about 10–

20%) of this high dose of oral iron is effectively absorbed. The remaining unabsorbed iron causes direct toxicity to the intestinal mucosa. Thus, the unabsorbed iron is the main cause for the gastrointestinal side effects which have been reported in as high as 70% in some studies. The ensuing reduction of adherence along with the need of prolonged treatment results in inadequate therapy of a significant proportion of anaemic patients.

To address this concern multiple new formulations of iron have been developed which have a better tolerability profile. Despite their better acceptability, there are 2 major drawbacks for most newer iron formulations - (i)Lower elemental iron content and (ii)higher cost of therapy. This is why ferrous sulphate continues to be the preferred formuation of iron in government health institutions, for the treatment of iron deficiency anemia.

There are multiple factors which interfere with the absorption of

dietary iron. The dietary presence of phytates or vitamin C, respectively

decrease or increase the absorption of iron. Oral FS tablets are usually

taken on an empty stomach and hence they are not affected by the dietary

inhibitors of iron absorption. The main factors which modulate the

4

absorption of oral iron tablets are at the bowel mucosa level. The factors responsible for optimal absorption of oral iron are

(i) the integrity of the gastrointestinal mucosa

(ii) suppression of hepcidin to allow for the absorption of the ingested iron

Hepcidin is a peptide hormone produced by the liver. It‟s main role is to prevent a state of iron overload in the body. Hepcidin is not a static parameter and studies have shown that hepcidin levels rise sharply with iron absorption. The resultant elevation of hepcidin leads to internalisation of the ferroportin receptor expressed on the basolateral surface of the enterocyte. This leads to limitation of further absorption of iron from the gut.

The traditional daily iron tablet regimen induces a sharp rise in

hepcidin production. When the second dose of iron is given twelve hours

later, the hepcidin levels are yet to normalise, hence there is limitation of

the absorption of iron. An alternate day regimen will allow enough time

for hepcidin to return to baseline, hence maximizing the fraction of iron

absorbed while minimising the gastrointestinal (GI) adverse effects. This

is the hypothesis which we would like to prove through this study.

5

Iron deficiency is the most prevalent micronutrient deficiency in India. Through this study we hope to contribute to a better understanding of its therapy. By using ferrous sulphate instead of the newer preparation of iron, we hope to ensure that any benefit shown in this study will be applicable in the population that is at the highest risk of iron deficiency – the economically backward people who visit the government hospital as they can‟t afford private medical care. With these ideals in mind, we performed this study comparing daily versus alternate day regimen of ferrous sulphate in the treatment of iron deficiency anemia.

Review of

Literature

6

REVIEW OF LITERATURE

According to World Health Organisation (WHO) “anemia or iron deficiency should be considered to exist” when haemoglobin is below the following levels as shown in Table 1⁽¹⁾.

Anemia is functionally defined as an insufficient Red Blood Cells (RBC) mass to adequately deliver oxygen to peripheral tissues. Haemoglobin (Hb) concentration of 14g/dl and 12g/dl were considered as the lower limits of normal, in adult men and women, respectively.⁽²⁾

TABLE - 1 : CUT – OFF POINTS FOR THE DIAGNOSIS OF ANEMIA⁽¹⁾

CATEGORY g/dl PCV

Adult Male 13 39

Adult Female – Non Pregnant 12 36

Adult Female – Pregnant 11 33

Children, 6 months to 6 years 11 34

Children 6 to 14 years 12 36

7

Anemia in non-pregnant women is defined as haemoglobin concentration less than 12 g/dl and less than 10 g/dl during pregnancy or puerperium. Haemoglobin concentration will be lower in mid pregnancy. Early in pregnancy and again near term the haemoglobin of most women with adequate iron stores is 11g/dl or higher. Hence the Centre for Disease Control (1990) modified the WHO definition anemia as less than 11g/dl in the first and third trimester and less than 10.5 g/dl in the second trimester.⁽³⁾

EPIDEMIOLOGY

Globally 30% of the total world population is anaemic.⁽⁴⁾ The WHO report gives an anemia prevalence at the global level as 55.9% among the expectant mothers.⁽⁵⁾

India has probably the highest prevalence of nutritional anemia in women and children. Indian Council of Medical Research (ICMR) in 1989 carried out a countrywide evaluation of the anemia in pregnant women at or beyond 20 weeks of gestational age. The prevalence of anemia was found to be 87%, with 32 % of women having Hb less than 8g/dl.⁽⁶⁾ Another study by ICMR in 1992 among pregnant women in second trimester reported a prevalence rate of 62 %. ⁽⁷⁾ The ICMR Multicentric Study under District Nutrition Project 2001, showed over all prevalence of anemia among pregnant women as about 85%.⁽⁸⁾

8

According to the National Family Health Survey 2015-16 (NFHS-4), 53.4% non-pregnant women and 50.4% pregnant woman are anemic. The prevalence of anemia is much higher in children, with 56% incidence of anemia in the urban population, while it is 60% in the rural population. The male gender has a relatively lower incidence, according to NFHS-4 the incidence of anemia is 23% in men.⁽⁹⁾ The risk factors for iron deficiency anemia in women include low socioeconomic status, multiparity, teenage pregnancy, menorrhagia and presence of other comorbid illnesses. The most frequent cause of anemia is iron deficiency and less frequently folate and Vit B₁₂ deficiency.⁽¹⁾

9

CLASSIFICATION OF ANEMIA

Kinetic Classification of anemia: ⁽¹⁰⁾

In this the anemia is classified based on the reticulocyte count.

1. Marrow production defect (hypo-proliferative)

2. Red cell maturation defect (ineffective erythropoiesis) 3. Decreased red cell survival (Blood loss / Haemolysis)

1. Hypoproliferative

· Anemia of renal disease

· Anemia of chronic disorders

· Aplastic Anemia

· Pure Red Cell Aplasia

· Endocrine anemia 2. Maturation abnormalities

· Iron Deficiency anemia

· Megaloblastic anemia

· Sideroblastic anemia

· Thallasemia 3. Hemolytic anemia

· Hemoglobinopathies

· Immune mediated hemolysis

· Infection related hemolysis

· RBC membrane abnormalities

10

· Mechanical hemolysis

Classification based on Red Cell morphology

⁽¹⁰⁾

With the wide availability of automated cell analysers, anemia can be classified based on readily available RBC indices. Anemia classified on the basis of Mean Corpuscular Volume (MCV) and RBC Distribution Width (RDW) as shown in the tabular column below.

Normal RDW High RDW

Microcytic anemia (Low MCV)

Thalassemia Iron deficiency anemia

Normocytic anemia (Normal MCV)

Anemia of chronic disease

Macrocytic anemia (Increased MCV)

Chronic liver disease, chemotherapy, alcohol,

aplastic anemia, Hypothyroidism

Megaloblastic anemia, Myelodysplasia,

Autoimmune hemolytic anemia

11

IRON DEFICIENCY ANEMIA

It is the most common cause of anemia. It develops when there is iron available for haemoglobin production is not adequate. The a body tries to maintain a normal haemoglobin production for as long as possible after the iron levels are depleted. This stage of iron deficiency is called as latent iron deficiency.

Iron deficiency anemia is not a disease but a manifestation of underlying pathology. Although it is a very common finding, its never normal to be anemic. The clinical presentation of iron deficiency depends upon the underlying etiology of anemia and the rapidity of onset of

anemia. It can vary from severe but asymptomatic anemia in patients with chronic minor blood loss (eg. Menstruating women). Or it can be an acute onset symptomatic anemia, as seen after massive gastrointestinal

bleeding.

The clinical features of anemia represent decreased supply of

oxygen to the tissues. Hence asymptomatic patients are usually diagnosed

on routine blood counts or with complaints of decreased work capacity or

exercise tolerance.

⁽¹¹⁾

12

HISTORY Ancient History

The empirical use of iron in the treatment of anemia dates from ancient times. The calcined iron preparation of ancient Hindu medicine, known as Lawha Bhasma was prepared by casting sheets of iron and then macerating them to a fine white powder in oil, whey, vinegar, cow‟s milk. The Greek physicians employed iron for the cure of weakness, a prominent symptom of anemia, in the attempt to impart to the patient, the strength of the iron. Indeed, it was believed that Mars, the god of war, had imbued the metal with strength and alchemists designated iron as Mars. Patients with marked pallor were given drinking water in which old swords, had been allowed to rust, and Celsius advised that enlarged spleens be treated by using water in blacksmith shops and in which white hot iron had been drenched. He claimed that animals drinking such water had abnormally small spleens.⁽¹²⁾

13

Modern History

Chlorosis

Chlorosis (also known as the „green sickness‟, morbus virgineus, mal d‟amour and other names) was described in relatively modern times as „a hypochromic anemia in adolescent girls usually associated with gastrointestinal and menstrual disorder.⁽¹³⁾

Hirsch quotes Sennart stating that „pallor or yellow tinge to the skin‟

was a sign of chlorosis.⁽¹⁴⁾ Hart cites the eminent US physician W.Crosby‟s 1955 case of anemia with green discoloration, which he explained as combined protein and iron deficiency.⁽¹⁵⁾

Most features of chlorosis fit well with severe IDA in adolescent girls and young women. Long before the microscopy of stained blood was commonplace, Gabriel Andril had commented on the very small red cells in chlorosis.⁽¹⁶⁾ John Coakley Lettsom in 1795, a successful physician who founded the London Society of Medicine and the Royal Seabathing Hospital at Margate among other institutions, wrote reassuring tracts on a number of common medical problem, including one on chlorosis in girl‟s boarding schools.

He described the features of chlorosis as paleness and sallowness of complexion, palpitations of the heart, difficulty breathing on exertion, bloated

14

appearance, loss of appetite, reluctance to exercise and amenorrhoea.

Amenorrhoea is difficult to explain except that delayed puberty can be a feature of severe anemia, and amenorrhoea features in severe malnutrition.⁽¹⁷⁾

One hundred years later, Stockman concluded that excessive menstrual loss together with habitually low intake of iron from the diet have the direct causes of chlorosis. Treatment was iron.⁽¹⁸⁾

15

CLINICAL FEATURES Symptoms

Mild anemia is usually diagnosed by performing haemoglobin estimation. Moderate anemia may present with fatigue, dizziness.

Breathlessness and palpitation are features of severe anemia. The other symptoms include headache, light-headedness, difficulty concentrating and insomnia. ⁽¹⁹⁾

Signs

Pallor of the tongue and conjunctiva are important signs of anemia;

Bilateral pedal edema is common feature of severe anemia. Person with long standing anemia will develop a constellation of features due to defect in structure of the epithelium. The signs include brittle nails, koilonychia, soreness of the tongue, angular stomatitis. Some patients may present with dysphagia secondary to a post cricoid web. Cardiovascular manifestations of anemia include a haemic murmur and tachycardia.⁽¹⁹⁾

16

CAUSES OF IDA

Dietary habits

In comparison to non-vegetarians, vegetarians are at an additional disadvantage because certain food stuff that include phytates and phosphates reduce iron absorption by about 50%. Iron in vegetable is only about one – twentieth as available, egg iron one-eight, liver iron one half and haem iron one half to two third. Hence liver and haem iron are absorbed well as iron salt added to food, while the iron in vegetables and eggs is much less available.⁽²⁰⁾

Worm Infestation

Iron deficiency anemia may also arise from certain associated illness such as ankylostomiasis.⁽²¹⁾ This remains a common etiology of IDA in India

Increased iron requirements

The causes for the same include menorrhagia, pregnancy and lactation.

Other causes

include

massive hemmorhhage, hemoglobinurea and alveolar haemorrhage. A major sub category under increased iron requirements is the gastrointestinal bleeding – which is the most common cause of iron deficiency anemia in adult male population.

17 Gastrointestinal bleeding

The causes include haemorrhoids, peptic ulcer disease, NSAID abuse, inflammatory bowel disease, diverticulosis, varices and malignancy.

Malabsorption

The causes of decreased absorption of iron include gastric bypass surgery, achlorhydria, celiac disease, duodenal bypass surgery and drugs which increase the gastric pH.

Genetic causes

These are uncommon causes of iron deficiency anemia. They include iron refractory iron deficiency anemia, atransferrinemia, and

aceruloplasminemia.

Regular blood donation has also been identified to cause iron

deficiency anemia. Hence iron supplementation is advised for frequent blood donors.⁽¹⁰⁾

18

COMPLICATIONS OF ANEMIA General complications

1. High output heart failure

2. Infections are more common in iron deficiency anemia (IDA) especially those of respiratory, gastro intestinal and urinary tract.

Tuberculosis is common in them. Cell mediated immunity is reduced in these subjects.

3. Chronic anemia reduces the efficiency in work.

4. Decreased oxygen consumption.

5. Decreased oxygen affinity due to increased amount of 2,3- bisphosphoglycerate and this phosphate compound has the capacity to combine with deoxygenated haemoglobin and decrease its affinity for oxygen.

6. Increased cardiac output 7. Uncorrected tissue hypoxia.

During pregnancy

1. Pre-eclampsia.

2. Intercurrent infection- not only does anemia diminish resistance to infection but also pre – existing lesion, if present will flare-up.

It should be noted that infection itself impairs erythropoiesis by bone marrow depression.

19

3. Heart failure at 30- 32weeks of pregnancy.

4. Pre-term labour⁽²²⁾

PHYSIOLOGY OF IRON METABOLISM

Iron is quantitatively the most important biocatalytic element in human enzymology, with important roles in oxygen transport and storage, oxidative metabolism in cellular growth and proliferation. This is because of its ability to reversibly and readily cycle between the ferrous(Fe²⁺) and ferric iron(Fe³⁺) oxidation state.

Iron is present in the body in three compartments

1. Functional iron 2. Transport iron 3. Storage iron.⁽²³⁾

Functional iron proteins

Haem contains a porphyrin molecule namely protoporphyrin IX, with iron at its centre. Haemoglobin is a conjugated protein, containing globin – the apoprotein part and heme – the non-protein part.⁽²⁴⁾ Four of them in turn bind loosely to form the whole haemoglobin molecule.⁽²⁵⁾

The functional iron compartment includes iron 30mg/kg as haemoglobin iron contained within the circulating red cells and an additional 6-7mg/kg that

20

is present in tissues throughout the body in myoglobin and in a variety of haem enzymes and non-haem enzymes.⁽²⁶⁾

Transport iron and storage iron

Apotransferrin is a single chain glycoprotein composed of two lobes.

Each lobe binds a single ferric ion so that the molecule exists as transferrin.

The total amount of apotransferrin in human is about 240mg/kg, equally divided between the plasma and extravascular fluids. Apotransferrin is produced by hepatocytes.It is a spherical protein having two subunits; provide route for movement of iron in and out of the interior of sphere. ⁽²³⁾

Transferrin receptor

Transferrin receptor is transmembrane glycoprotein. The transferrin receptor can bind two molecules of transferrin. They are expressed virtually on all nucleated cells. They are expressed virtually on large numbers in erythroid precursors, placenta and liver. The number of transferrin receptor on the cell surface is a prime determinant of cellular iron supply. The half-life for disappearance of transferrin receptors from the cell has been reported to range from < 24 hours to 2 – 3days. ⁽²³⁾

Storage iron

Ferritin is a major storage protein composed of 24 subunits. Each ferritin molecule can reversibly store as many 4500 iron atoms within the cell.

Catabolism of cellular ferritin may result in digestion of protein shell with

21

reutilization of the iron core. Normally, the amount of plasma ferritin synthesized and secreted seems to be proportional to the amount of cellular ferritin produced in the internal iron storage pathway so that the plasma ferritin concentration is related to the magnitude of body iron stores.⁽²³⁾

Intestinal iron absorption

Iron is absorbed in the upper part of the gut, specifically the brush border of epithelial cells of the intestinal villi in the duodenum and upper jejunum. The absorption of heme iron (derived from animal products) and non- heme iron differs from each other.

22 Intestinal absorption of non-heme iron

Gastric juice stabilizes dietary ferric iron; preventing its precipitation as insoluble ferric hydroxide. Several complexes can capture iron and prevent its absorption, mainly phytates and tannins. On the contrary ascorbic acid and other acidic compounds derived from the diet will enhance iron absorption.

DMT1 is the transporter of ferrous iron in the brush border epithelium.

Ferric reductase activity by duodenal cytochrome B and STEAP (six

transmembrane epithelial antigen of prostate protein) which are present on the brush border of duodenum reduces ferric iron to ferrous form, facilitating its absorption by DMT1.

Intestinal absorption of heme iron

Heme iron is present in hemoproteins such as myoglobin and

hemoglobin (Hb). In the acidic pH of the stomach, heme is dissociated from the hemoprotein. The absorption of heme iron is more efficiently done when

compared to non-heme iron derived from vegetables and grains. It is

predominantly absorbed in the proximal intestine. The absorption decreasing distally. Hephaestin (HCP1), which has homology to bacterial metal-

tetracycline transporter, mediates the uptake. HCP1 mRNA is highly expressed

23

in the duodenum and is regulated by hypoxia and by Iron Regulatory Proteins (IRPs).⁽²⁷⁾

Mucosal Regulation of Iron Absorption

It is regulated by

1. Mucosal uptake of iron across the brush border membrane.

2. Retention of iron in storage form within the mucosal cell.

3. Export of iron from the mucosal cell to the plasma.

24 Iron exportation from the intestine

The fate of iron present inside the enterocyte is decided by the iron pool within the cell. Ferroportin (FPN1) is responsible for export of iron from the enterocyte into circulation. FPN1 is a multi-pass protein in the basolateral membrane of the enterocytes. It is also present in large quantities in macrophages. The fate of iron present inside the enterocyte is regulated through FPN1.

Hepcidin suppresses FPN1. Hepcidin binds to FPN1 and induces its internalization, followed by lysosomal degradation. Thus, the iron efflux from enterocytes is suppressed. This leads to reduced iron absorption by duodenal enterocytes.⁽²⁷⁾

Iron transportation

It is taken up by apotransferrin in the interstitium. It circulates in the plasma as transferrin bound iron. Two molecules of transferrin bind to the transferrin receptor. This complex is internalized to form a clathrin coated pit.

In acidic environment iron is released from transferrin and is made available for cellular use or storage. When the iron is incorporated into protoporphyrin in the mitochondria, haem is synthesized. Any excess iron is stored in the cytoplasm as ferritin. Each transferrin molecule undergoes 100–200 cycles of iron binding and release during its life time in the circulation.⁽²³⁾

25

Role of Iron Regulatory Proteins

Iron regulatory proteins IRP-I and IRP-2 function as both sensors and controller of intracellular iron supply.⁽²³⁾

A decrease in intracellular available iron results in an increase in the proportion of high affinity IRPs. Increased IRP binding to IRE increases transferin receptor protein production but decrease ferritin protein production.

An increase in intracellular iron results in fewer IRP binding with IREs, decreasing transferin receptor protein production while increasing ferritin protein production.⁽²³⁾

In the red cells, most iron is utilized for haemoglobin synthesis.

Synthesis of haem is linked to iron availability by regulation of amino levulinic acid synthetase, which is the first enzyme in the biosynthesis of protoporphyrin. The final step in haem synthesis is the formation of heme from protoporphyrin IX and ferrous iron catalysed by the mitochondrial enzyme ferrochelatase.⁽²³⁾

26

Transport of Iron between compartments

The catabolism of senescent erythrocyte release iron, which requires return to plasma transferrin, for delivery to the erythroid marrow. The outpouring of iron to plasma apotransferrin from macrophages in the bone marrow, liver and spleen constitute the largest single flux of iron from cells in the body. With iron deficiency, all the iron derived from the hemoglobin catabolism is promptly returned to the plasma and none is diverted to macrophage store. Maximal rate of release from this source in the adult is limited to 40 – 60 mg of iron per day. All the haemoglobin is catabolised, with the globin proteolytically processed to aminoacids, releasing heme. The heme is transported to the endoplasmic reticulum of the macrophage to be degraded by heme oxgenase. Heme oxygenase is a microsomal enzyme that catalyse oxidative catabolism of haem to yield biliverdin and iron.⁽²³⁾

Iron Excretion

Physiologically, iron is excreted by the following mechanism.

1. Exfoliated epithelial cells of Gastro-intestinal tract 2. Exfoliated cells of skin

3. Bile 4. Urine 5. Sweat

6. Menstrual blood loss.⁽²⁶⁾

27 Iron distribution in normal adults ⁽²⁸⁾

Men Women

Hemoglobin 3050 1700

Myoglobin 430 300

Enzymes 10 8

Transport protein 8 6

Storage 750 300

Total 4248 2314

28

DIAGNOSIS

There are two components in the diagnosis of anemia.

1. To establish that the anemia is due to iron deficiency 2. To determine the cause of the iron deficiency.

The diagnosis of iron deficiency anemia is often recognised by the clinical features, and history. It can be established with certainty only by blood examination. Satisfactory response to iron therapy can also be used as a confirmation of the diagnosis.⁽²⁹⁾

Initial Investigation of Anemia

The initial investigations required for diagnosis of anemia are

· Full blood count – Hemoglobin, packed cell volume, total count, differential count, platelets and ESR

· RBC indices – Mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration and RBC distribution width.

· Examination of blood film: Anisocytosis, hypochromic, microcytic

· Serum Ferritin

29

Additional investigations as clinically indicated include

· Serum B₁₂

· Red cell folate

· Haemolysis screening (if indicated) - Reticulocyte count, Bilirubin, Lactate dehydrogenase, Haptoglobin⁽³⁰⁾

Laboratory findings

Iron deficiency develops in stages. The first stage is depletion of iron stores. At this point there is anemia but no change in red blood cell size. A ferritin value less than 30 micro grams/dl is an indicator of iron deficiency. The serum total iron binding capacity rises.

After iron stores have been depleted red blood cell formation will continue with deficient supplies of iron. Serum iron values decline to less than 30 mcg/dl and transferrin saturation to less than 15%.

In the early stages, mean corpuscular volume remains normal;

subsequently mean corpuscular volume falls and the blood smear shows hypochromic microcytic cells. With further progression anisocytosis and poikilocytosis develop. Severe iron deficiency will produce a bizarre peripheral smear, with severely hypochromic cells, and occasionally small number of nucleated red blood cells.⁽³¹⁾

30

PRINCIPLES OF TREATMENT OF IRON DEFICIENCY ANEMIA

1. Determine the cause of iron deficiency anemia

While excess menstural loss is the most common cause in woman, GI blood loss is the most common etiology of IDA in men. If the etiology is not evident on history taking and basic laboratory tests, further evaluation including an endoscopy may be required to identify the source of GI bleed.

2. Aim of therapy

a.To normalise the haemoglobin level b.To replenish the body‟s iron stores 3. Lifestyle management: dietary advice 4. Non pharmacological measures:

a.Tea and coffee inhibit iron absorption

b.Vitamin C will increase the absorption of iron

c. Fermentation of cereals and legumes increase the absorption of iron. ⁽³²⁾

31 Sources of Iron

Diet

On average, 1000 calories worth of food provides about 6 mg of iron.⁽³³⁾ Meat is an important source of haem iron, which is the most bioavailable form of iron in the diet. The content of iron in food has been significantly reduced since the stone age, when the diet contained about 28.5 mg of iron per 1000 K.

calories, compared to presently 4.5 to 5.0 mg per 1000 kilo calories.⁽³⁴⁾ Haem iron is highly available for absorption, about 20 – 30% is absorbable. Non- haem iron is absorbed less than 5%. Availability is determined by the balance between inhibitors – phytates, tannates, phosphates and enhancers – amino acids and ascorbic acid.⁽²³⁾ The bioavailability of iron in vegetarian diet is of special concern because vegetarians do not consume meat and their diet commonly contain more inhibitors of iron absorption such as phytic acid. The absorption of non-haem iron from a vegetarian diet is up to 70% lower than from non-vegetarian diet, which explains why vegetarians often have small iron stores.⁽³⁴⁾ Tea is a stronger inhibitor than coffee, while orange juice and

other Vitamin C containing food stimulate the uptake of iron.⁽³⁵⁾

Vegetable Foods Rich in Iron:

Green vegetables, peas, beans, bananas, spinach are rich in iron.

Animal Foods Rich in Iron:

Meat, liver, heart, crab muscle, fish. Food cooked in iron and stainless steel pans can be significant source of iron.⁽³⁶⁾

32

HISTORY OF PHARMACOTHERAPY OF IRON DEFICIENCY ANEMIA

Sydenham was probably the first physician to employ iron in a manner that would be approved today; in 1681, Sydenham prescribed, “steel in substance or iron or steel filings steeped in cold rhenish wine”, the dose amounting to 0.5 to 1.0g of iron daily.⁽¹²⁾

In 1832, Blaud introduced pills containing 1.39g of Ferrous sulphate and 0.1g of potassium carbonate, and these became widely recommended for chlorosis and other conditions.⁽³⁷⁾ The original pills contained 64mg of iron.

Many physicians, even into the 1930s, Thomson, Findlay and Osler, thought iron was more effective.⁽³⁸⁾

Understanding of IDA by the early 1930s can be summarised by the Americans, Wintrobe and Beebe. They stated that „there is only presumptive evidence that idiopatic hypochromic anemia develops because an individual is unable to meet the demands for haemoglobin or replace the normal loss of blood on account of defective utilization of blood building materials in the diet.

This was the era, when micronutrient deficiencies had been recognized.

Further, haemorrhagic conditions were known to lead to hypochromic microcytic anemia, so the relevance of balancing iron intakes with needs might have been made.⁽³⁹⁾

33

Defining the Role of Iron in Iron Deficiency Anemia

Helen Mackay and the Children Of East London

After working in Vienna post-World War 1, Helen Mackay, the first woman to receive the fellowship of the Royal College of Physicians of London, studied young children in East London in the 1920s to determine „normal‟

haemoglobin values for different stages of infancy.⁽⁴⁰⁾

In earlier studies, Mackay had found that infants attending her clinics gained weight when treated for infection and given supplementary milk. These interventions had not prevented the decline in haemoglobin levels.

Supplementation with iron salts, however, produced dramatic changes.

The late anemia of infancy (that is after the physiological post-natal fall) was either prevented or, when iron was started after 6 months, diminished in iron- supplemented infants compared with those not receiving supplementary iron Mackay also remarked that iron-treated infants looked much healthier. Iron supplemented infants had only around 50% of the episodes of respiratory tract infection, diarrhoea and specific fevers experienced by the un-supplemented infants.⁽⁴⁰⁾

34

Mackay showed high haemoglobin levels at birth, a gradual fall from birth to around 2 months and then (in Mackay‟s infants), a steady level until further fall from 6 months into the second year. Although the low haemoglobin of late infancy seemed more common and more severe in non-breast-fed than in breast-fed infants, both methods of feeding led to falling haemoglobin levels, hypochromia and microcytosis from 6 months onwards with the most marked falls in low-birthweight infants. As it was not known whether these findings reflected normal physiology or not, trials of likely therapeutic interventions seemed the logical way to resolve the question.⁽⁴¹⁾

Mackay‟s studies established the pattern of haemoglobin change in early infancy and demonstrated the nutritional vulnerability of premature infants. She drew very definite conclusions that the anemia of late infancy resulted from insufficient iron in the diet and could be eliminated by iron therapy. Her recommendation, that iron should be given to non-breast-fed infants from the first months of life because this can support higher levels of haemoglobin later in infancy, stands good today.^(40,41)

35

NATIONAL HEALTH PROGRAMS FOR IRON DEFICIENCY ANEMIA IN INDIA

Nutritional anemia is a widespread multifactorial problem, which is relatively easy to correct by means of supplementation therapy and improving the nutritional status. Keeping in view the widespread prevalence of anemia, the government of India in the fourth 5 year plan – 1970 planned the National Nutritional anemia prophylaxis programme. This consists of supplementing iron and folic acid to the high risk population. 60mg of ferrous sulphate and 500mcg of folic acid for adults and 20mg of ferrous sulphate and 100mcg of folic acid for children. After 20 years of implementation, not much improvement was seen. Hence the programme has been merged with RMNCH +A intervention under the national health mission.

In 2011 national Iron plus initiative was started. The programme has 2

components – preventive and therapeutic. The preventive component consists of

biweekly iron+ folic acid supplementation for pre-school children i.e. 6 months

to 5 years of age. Weekly supplementation of ferrous sulphate was done for

adolescents and reproductive age women.

⁽⁴²⁾

36

PHARMACOTHERAPY OF IRON DEFICIENCY ANEMIA

There are two objectives of the treatment

1. Correction of the deficit in haemoglobin mass and 2. Restoration of iron stores.

Both these objectives can be accomplished with orally administrated simple iron compounds- ferrous sulphate, fumarate or gluconate – that provide a daily dose of about 200mg of elemental iron. If the person cannot or will not take oral iron preparations, then parenteral iron is given. To replenish iron stores oral therapy should be continued for three months or so after the anemia has been corrected.⁽³⁾

Iron therapy is indicted only for the prevention or cure of iron deficiency. When oral therapy is used there is an enormous variety of official and proprietary iron preparations.⁽⁴³⁾

Considerable increase in haemoglobin by an oral agent will obviate the need for blood transfusion and will lead to avoidance of the risks associated with blood transfusion.

Iron is absorbed in the ferrous form. Ferrous salts are absorbed about three times as well as ferric salts. Various iron preparations are available.

37

Ferrous sulphate, Ferrous fumarate, ferrous gluconate, polysaccharide iron complex are some of the iron preparations.

Other iron compounds have utility in fortification of food. Reduced iron (metallic iron, elemental iron) is as effective as ferrous fumarate, provided that the material employed has a small particle size.⁽¹²⁾

When IDA is diagnosed, the usual treatment is an oral iron preparation;

Several iron preparations are available for oral administration.⁽⁴⁵⁾

Oral iron Preparations Ferrous Sulphate

Ferrous sulphate is the hydratred salt FeSO₄.7H₂O, contains 20% of iron; it consists of pale bluish green crystal or granules, soluble in ratio of 1:1.5 in water. It effervesces in dry air; in moist air, crystals of ferrous sulphate readily oxidized and become coated with a brownish yellow, basic ferric sulphate and must then not be used for medicinal purposes. The drug is odourless and has a saline, astringent taste. It is usually dispensed as pills or tablets coated to protect them from moisture. The salt is mixed with glucose or lactose to protect it against oxidation. Official ferrous sulphate tablet usually contains 300 mg of the salt.⁽¹²⁾

38

Ferrous Fumarate

This salt occurs as an anhydrous, reddish brown granular powder. It contains 33% of iron and is moderately soluble in water, stable and almost tasteless. Unlike ferrous sulphate it does not require mixing or coating with glucose to protect it against oxidation. Official ferrous fumarate tablets usually contain 200 mg of the salt. The average adult dose is 3 – 4 tablets daily. ⁽¹²⁾

Ferrous gluconate

Gluconate contains 12% of metallic iron. ⁽¹²⁾

Ferrous lactate

Ferrous lactate contains 9% of metallic iron.⁽¹²⁾

The average dose for the treatment of iron deficiency anemia is about 200 mg of iron per day (2–3 mg/kg), given in three equal dose of 65 mg. When the object is the prevention of iron deficiency in pregnant women a dose of 15–

30 mg of iron per day is adequate to meet the 3– 6 mg daily requirement of the last two trimesters. When the purpose is to treat iron deficiency anemia, a total dose of about 100 mg may be used⁽¹²⁾.

39

THERAPEUTIC PRINCIPLES OF ORAL IRON THERAPY

In iron deficiency anemia patients, the response to oral iron therapy is determined by several factors including

(i) Severity of anemia

(ii) Ability of patient to tolerate oral iron (iii) Other comorbid illness

The best marker to assess the response to therapy is red blood cell production by the bone marrow. The marrow‟s response to therapy is in turn determined by the severity of anemia and the amount of iron

administered.

The ability of the patient to tolerate oral iron is the key factor in deciding the success of oral iron therapy. The small intestine decides the amount of iron that can be absorbed. The small intestine provides a natural ceiling on how much iron can be absorbed – thus determining the

maximum dose of oral iron that can be administered.

The response to oral iron therapy is monitored clinically using the

following markers

40

1.Reticulocyte response : Expected to be seen in 7 – 10 days after start of therapy

2.Hemoglobin response: Hb is expected to rise by 2gm/dL in 3-4 weeks of oral iron therapy for it to be considered to be effective.

If the Hb rise is less than 1gm/dL – there is a need to evaluate for compliance to therapy and also to look for any ongoing blood loss. In case there is no compliance issue or blood loss which can explain the suboptimal rise in haemoglobin then oral iron therapy is considered a failure and it should not be continued further.

⁽⁹⁾

Side Effect of Oral Iron preparations of Iron

Conventional doses of iron salts used in anemia may cause gastrointestinal reactions such as heart burn, nausea, upper gastric discomfort, constipation and diarrhoea. Intolerance to oral iron preparations of iron is primarily a function of the amount of soluble iron in the upper gastrointestinal tract. Nausea and upper abdominal pain are common. If liquid is given, transient staining of teeth also occurs.⁽⁴⁶⁾

Toxicity of Oral Preparation of Iron

Long continued administration of iron results in haemochromatosis. ⁽⁴⁶⁾

41

THERAPY WITH PARENTERAL IRON

When oral therapy fails, parenteral iron administration may be an effective alternative. Indications are severe oral iron intolerance and in patients, with renal disease who are receiving erythopoietin. The concern regarding the use of parenteral iron therapy is regarding hypersensitivity reactions. Acute hypersensitivity, including anaphylactic and anaphylactoid reactions can occur in from 0.2% to 3% of patients.

Iron dextran injection is the older parenteral preparation. It contains 50mg/ml of elemental iron. It can be administered Intramuscularly or Intravenously. It is not commonly used nowadays due to higher incidence of anaphylaxis

Sodium ferric gluconate complex in sucrose: Another parenteral iron preparation used in patients undergoing chronic haemodialysis who are receiving supplemental erythropoietin therapy. Maximum dose of 200mg can be administered in a single sitting.

Newer preparations of iron include ferric carboxymaltose and isomaltose are currently available. They have a slow release and hence are associated with a very low incidence of anaphylactic reaction. They also have an added advantage of administration of 1000mg in a single setting.

42

The established indications for use of parenteral iron include

gastrointestinal malabsorption, systemic inflammatory processes, intolerance to oral iron, iron need in excess of the absorptive capacity of the intestine, and noncompliance. In addition, parenteral iron is preferred in chronic kidney

disease patients on long-term hemodialysis. Due to systemic inflammation, these patients do not respond adequately to therapy with oral iron. ⁽⁹⁾

The dose of parenteral iron required is calculated using the Ganzoni equation⁽⁴⁰⁾

Iron requirement (mg) = 4.4 x body weight(k.g.) x (target hb – current hb)

Reactions to parenteral therapy include arthralgia, fever and rare anaphylactic reaction, which may be fatal in-spite of treatment. Thus, there must be specific indications for the parenteral administrations of iron⁽⁴⁷⁾.

Adjuvant therapy

The benefit of supplementation with other nutritional agents like copper

and pyridoxine is not clear

43

THE ROLE OF HEPCIDIN IN REGULATING ORAL IRON THERAPY

Hepcidin is a 25 amino acid peptide hormone, produced by hepatocytes.

The role of hepcidin in iron regulation was elucidated by the pioneering works of Tomas Ganz and Elisabeta Nemeth at the university of California.⁽⁴⁶⁾

Hepcidin is encoded by the HAMP gene, which codes for the precursor protein pro-hepcidin which then is cleaved into the active hepcidin. Many mechanisms involved in the regulation of hepcidin synthesis in relation to iron have been elucidated. ⁽⁴⁹⁾

Physiological and pathological conditions such as release of bone morphogenetic protein (BMP), hypoxia as well as endocrine, metabolic, and inflammatory processes modulate hepcidin biosynthesis and may therefore regulate availability of iron to erythropoiesis by adaptation of iron absorption and recirculation. A JAK-STAT3 pathway, triggered by IL-6 receptor

dimerization with gp130 upon binding of the cognate ligand IL-6 is the primary pathway for hepcidin regulation in inflammation.

Iron sensing is dependent on an external pathway, involving the

interactions of transferrin (Tf) with the transferrin receptors - Tfr1 and Tfr2. If iron-Tf is high, the Tfr2-mediated signaling by the BMP6 receptor complex is

44

increased. After activation of the BMP receptor, the SMAD pathway is

activated leading to over-expression of hepcidin. In contrast, hepcidin mRNA is suppressed in anemia⁽⁵⁰⁾

Oral Iron therapy acutely increases circulating plasma hepcidin levels.

This was tested in a short-term clinical study by Moretti et al. In this study women with low iron stores (ferritin ≤ 20 ng/mL) received oral iron administered for three days in varying frequency and doses. It was found that higher or more frequent doses of iron raised circulating hepcidin levels and reduced subsequent fractional iron absorption. ⁽⁵¹⁾

45

Stoffel et al conducted an open-label randomized trials assessing iron absorption in iron-deficient women. The primary outcome was iron

bioavailability (fractional iron absorption, measured by radio-labelled iron bound to RBCs) and serum hepcidin level.

In the first study, forty women were randomly assigned to either daily oral iron for 14 days, or on alternate days for 28 days. It was found that the cumulative fractional iron absorptions were 16.3 percent in the consecutive-day group versus 21.8 percent in the alternate-day group (p=0.0013). The serum hepcidin level was higher in the consecutive-day group than the alternate-day group (p=0.0031). Additionally, there was a trend toward decreased nausea in the alternate-day group. ⁽⁵²⁾

This study suggests that alternate-day dosing of oral iron, can overcome the hepcidin-mediated block of absorption of iron that is seen with daily dosing of oral iron. This study also suggests that tolerability and compliance to oral iron might improve.

Aim &

Objectives

46

AIMS AND OBJECTIVES

AIM OF THE STUDY

To evaluate the efficacy and tolerability of daily versus alternate day oral iron supplementation in the treatment of iron deficiency anaemia in adults.

OBJECTIVES

PRIMARY OBJECTIVE

To compare the rise in Haemoglobin & serum ferritin after completion of therapy, between Ferrous Sulphate daily and alternate day regimens.

SECONDARY OBJECTIVE

1.To compare the incidence of GI adverse effects (epigastric pain, gastritis, and constipation) between Ferrous Sulphate daily and alternate day regimens.

2.To compare the patient's drug compliance between Ferrous Sulphate

daily and alternate day regimens

Methodology

47

METHODOLOGY STUDY TYPE: Interventional

STUDY DESIGN: Randomised, open-label prospective study

STUDY CENTRE: Department of General Medicine, Rajiv Gandhi Government General Hospital

STUDY PERIOD: 20 weeks per patient (Drug therapy – 16 weeks & Follow up – 4 weeks)

STUDY POPULATION: Consecutive cases of iron deficiency anemia presenting to the general medicine OPD.

STUDY SIZE: 70 patients [35 – group 1(daily iron therapy) & 35 – group 2(alternate day iron therapy)]

STUDY DURATION: June 2018 to January 2019.

48

STUDY CRITERIA INCLUSION CRITERIA 1. Both genders

2. Age 18 – 60 years

3. Haemoglobin 7-12gm/dL

4. Diagnosed as Iron deficiency anemia by the physician (Hb < 12gm/dL, MCV <80fL and ferritin <12ng/ml)

5. Willing to give consent for the study

EXCLUSION CRITERIA

1. Severe anemia presenting with cardiac failure 2. Prior history of iron intolerance

3. Patient is already taking iron supplements

4. Patient enrolled in another study

49

STUDY PROCEDURE

The study will be performed in accordance with the Declaration of Helsinki & Good Clinical Practice (GCP) guidelines. The study shall be initiated after obtaining approval from the Institutional Ethics Committee, Madras Medical College.

Patients will be explained about the purpose of the study and that the study does not require any expenditure by the patient. They will be explained about the need for aspirating a blood sample to check haemoglobin and answering few questions asked by the investigator at follow up.

Informed consent will be obtained from the patients who are willing to participate in the trial in the prescribed format in the regional language.

The demographic details of the patients will be obtained. Patients will be screened by History, physical examination, and appropriate laboratory investigations. The patient who fulfils the inclusion and exclusion criteria will be enrolled and randomized to either test group or control group.

(Group 1) Control group: Tab. Ferrous sulphate containing 100mg elemental

iron & 0.5mg folic acid twice daily for 16 weeks

50

(Group 2) Test group: Tab. Ferrous sulphate containing 100mg elemental iron

& 0.5mg folic acid once every alternate day for 16 weeks

The study medication will be issued for 4 weeks. After assessing the compliance, study medication will be issued for the subsequent 4 weeks at each visit.

Institute ethics committee approval obtained

70 patients were enrolled Consent taken

Simple randomisation

Group 1 - Daily iron 35 patients 2 tablets /day

16 weeks therapy

follow up till 4 weeks after therapy

completion

Monitor Hb rise and side effects

Group 2 - Alternate day iron 35 patients 1 tablet /every 2^nd day

16 weeks therapy

follow up till 4 weeks after therapy

completion

1⁰ outcome: Hb improvement 2⁰ outcome: GI adverse effects

& drug compliance

51

INVESTIGATIONS:

Baseline investigations:



Complete blood count- Hb, RBC, TC, DC, platelets and ESR



Red blood cell indices: MCV, MCH, MCHC and RDW



Peripheral smear



Serum ferritin

Diagnosis of Iron Deficiency Anemia

The diagnosis will be made if (i) Haemoglobin <12gm/dL (ii) MCV less than 80fl (iii)RDW more than 14.5% (iv) peripheral smear examination favours a diagnosis of IDA.

Mentzer index will be used to rule out thalassemia and only those patients with a Mentzer index more than 13 will be included in this study.

⁽⁵³⁾

Mentzer index = MCV in fl / RBC in millions/µL

RANDOMIZATION

Subjects who were enrolled will be randomized by simple randomization into

test and control group.

52

FOLLOW UP:

The patient will be asked to come for follow up 4 weeks after treatment completion.

At follow up, adverse effects related to therapy will be recorded. The patients will be asked about the following symptoms: heartburn, epigastric pain, nausea, vomiting, abdominal cramps, and constipation.

The onset of the adverse event, causal relationship to the study drug and action taken will be recorded. Appropriate medical care will be provided.

The compliance to therapy shall be calculated by pill count using the following formula.

⁽⁵⁴⁾

(Number of tablets issued − number of tablets remained) Pill Count = ______________________________________________

(prescribed no. of tablets/ day × 28 (no. of days between visits)

WITHDRAWAL:

During the study period, the subject can withdraw his/her voluntary

consent and opt out of the study. Similarly, the subjects can be withdrawn from

the study if any adverse event is reported by the patient or observed by the

physician.

53

STATISTICAL ANALYSIS

Demographic profiles were given in frequencies with their percentages for each group.

Age, Height, Weight difference between groups were analysed by using the student t-test.

Blood chemistry and haemogram between groups were analysed by using student t-test.

Results

54

RESULTS

The study was conducted at the General Medicine out patient

department at Madras Medical College between June 2018 and January 2019.

A total of 98 patients were recruited in the study. Only patients who completed at-least 1 follow up were included for the purpose of study analysis.

Seventy patients were included in study. They were randomised to the two groups by simple randomisation. Thirty five patients were included in each treatment group. Group 1 patient received ferrous sulphate twice daily while group 2 patients received ferrous sulphate once in 2 days.

55

DEMOGRAPHIC PROFILE OF THE STUDY POPULATION

The demographic profile of the patients is presented below. The study included 55 women and 15 men. The gender distribution was similar in both groups.

All patients aged more than 18 years were included in the study. The age of the study population ranged from 24 years to 66 years. The study population was arbitrarily divided into 5 age groups. The distribution among the five age groups between the two study population was not statistically significant. (p=0.569)

0 5 10 15 20 25 30 35 40

Group 1 Group 2

Gender distribution

Men Women

Gender Group 1 Group 2

Number Percentage Number Percentage

Men 8 53.3 7 46.6 Paired t

test p=0.77

Women 27 49.1 28 50.9

Total 35 100 35 100

56 AGE DISTRIBUTION

Age group Group 1 Group 2

No Percentage No Percentage

18 – 30 years 3 8.57 3 8.57

Paired t test p=0.569

31 – 40 years 7 20.0 11 31.4

41 – 50 years 12 34.2 6 17.1

51 – 60 years 11 31.4 11 31.4

> 60 years 2 57.1 4 11.4

Total 35 100 35 100

The body mass index of the patient was also calculated at baseline. While three patients were under-weight in the study population (BMI <18.5), fifteen patients were overweight (BMI 25-30) and none of the patients were obese (BMI >30).

0 2 4 6 8 10 12 14

18 -30yr 31 - 40yr 41 - 50yr 51 - 60yr >60yr

Age distribution

Group 1 Group 2

57

BMI Group 1 Group 2

Mean 22.8 23.5

Range 18.1 – 28.4 19.1 – 28.3

All patients with haemoglobin less than 12gm who fulfilled the criteria for iron deficiency anemia were included in the study. For the sake of analysing the hemoglobin difference between the 2 groups, the patients were divided into 5 groups based on the level of haemoglobin. The difference between the 2 groups was not statistically significant.

Hemoglobin Group 1 Group 2

No Percentage No Percentage

< 8gm 4 11.4 7 20.0

Paired t test p=0.328

8.1 – 9.0gm 15 42.8 9 25.7

9.1 – 10.0gm 7 20.0 11 44.0

10.1 – 11.0gm 9 25.7 7 20.0

11.1 – 11.9gm 0 0 1 2.8

Total 35 100 35 100

0 5 10 15 20

Less than 8gm 8.0 - 8.9gm 9.0 - 9.9gm 10.0 - 10.9gm 11.0 - 11.9gm

Hemoglobin values at baseline

Group 1 Group 2