Priority 17 from the Blood Transfusion and Blood Donation PSP

UNCERTAINTY: Does the use of oral or intravenous iron for patients with iron deficiency anaemia reduce the need for some transfusions? (JLA PSP Priority 17)
Overall ranking 17
JLA question ID 0063/17
Explanatory note Not available for this PSP


Nice Guideline Recommendations:
Alternatives to blood transfusion for patients having surgery: Oral iron, IV iron and erythropoietin
2. Offer oral iron before and after surgery to patients with iron-deficiency anaemia.
3. Consider intravenous iron before or after surgery for patients who:
• have iron-deficiency anaemia and cannot tolerate or absorb oral iron, or are unable to adhere to oral iron treatment (see the NICE guideline on medicines adherence)
• are diagnosed with functional iron deficiency
• are diagnosed with iron-deficiency anaemia, and the interval between the diagnosis of anaemia and surgery is predicted to be too short for oral iron to be effective.
4. For guidance on managing anaemia in patients with chronic kidney disease, see the NICE guideline on anaemia management in chronic kidney disease.
5. For guidance on managing blood transfusions for people with acute upper gastrointestinal bleeding, see section 1.2 in the NICE guideline on acute upper gastrointestinal bleeding.

1. Aksan A, Isik H, Radeke HH, Dignass A, Stein J. Systematic review with network meta-analysis: comparative efficacy and tolerability of different intravenous iron formulations for the treatment of iron deficiency anaemia in patients with inflammatory bowel disease. Alimentary Pharmacology & Therapeutics. 2017.
2. Shepshelovich D, Rozen-Zvi B, Avni T, Gafter U, Gafter-Gvili A. Intravenous versus oral iron supplementation for the treatment of anemia in CKD: an updated systematic review and meta-analysis. American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation. 2016.
3. Shah A, Roy NB, McKechnie S, Doree C, Fisher SA, Stanworth SJ. Iron supplementation to treat anaemia in adult critical care patients: a systematic review and meta-analysis. Critical Care (London, England). 2016. Sep 29;20(1):306..
4. Rognoni C, Venturini S, Meregaglia M, Marmifero M, Tarricone R. Efficacy and safety of ferric carboxymaltose and other formulations in iron-deficient patients: a systematic review and network meta-analysis of randomised controlled trials. Clinical Drug Investigation. 2016;36(-3):177-94.
5. Roger SD, Tio M, Park HC, Choong HL, Goh B, Cushway TR, et al. Intravenous iron and erythropoiesis-stimulating agents in haemodialysis: a systematic review and meta-analysis. Nephrology (Carlton, Vic). 2016.
6. Qian C, Wei B, Ding J, Wu H, WangY. The efficacy and safety of iron supplementation in patients with heart failure and iron deficiency: a systematic review and meta-analysis. The Canadian Journal of Cardiology. 2016;32(-2):151-9.
7. Mhaskar R, Wao H, Miladinovic B, Kumar A, Djulbegovic B. The role of iron in the management of chemotherapy-induced anemia in cancer patients receiving erythropoiesis-stimulating agents. The Cochrane Database of Systematic Reviews. 2016(-2):CD009624-CD.
8. Jankowska EA, Tkaczyszyn M, Suchocki T, Drozd M, von Haehling S, Doehner W, et al. Effects of intravenous iron therapy in iron-deficient patients with systolic heart failure: a meta-analysis of randomized controlled trials. European Journal of Heart Failure. 2016.
9. Clevenger B, Gurusamy K, Klein AA, Murphy GJ, Anker SD, Richards T. Systematic review and meta-analysis of iron therapy in anaemic adults without chronic kidney disease: updated and abridged Cochrane review. European Journal of Heart Failure. 2016.
10. Bonovas S, Fiorino G, Allocca M, Lytras T, Tsantes A, Peyrin-Biroulet L, et al. Intravenous versus oral iron for the treatment of anemia in inflammatory bowel disease: a systematic review and meta-analysis of randomized controlled trials. Medicine. 2016;95(-2):e2308-e.
11. Tay HS, Soiza RL. Systematic review and meta-analysis: what is the evidence for oral iron supplementation in treating anaemia in elderly people? Drugs & Aging. 2015;32(2):149-58.
12. Shi Q, Leng W, Wazir R, Li J, Yao Q, Mi C, et al. Intravenous iron sucrose versus oral iron in the treatment of pregnancy with iron deficiency anaemia: a systematic review. Gynecologic & Obstetric Investigation. 2015;80(-3):170-8.
13. Peyrin-Biroulet L, Williet N, Cacoub P. Guidelines on the diagnosis and treatment of iron deficiency across indications: a systematic review. American Journal of Clinical Nutrition. 2015;102(-6):1585-94.
14. Pasricha S, Speedy J, Low M. What do systematic reviews of iron supplementation in women tell us about the functional consequences of donor iron deficiency? Vox Sanguinis. 2015;109((Suppl. 1)):58-.
15. Nielsen OH, Ainsworth M, Coskun M, Weiss G. Management of iron-deficiency anemia in inflammatory bowel disease: a systematic review. Medicine. 2015;94(-23):e963-e.
16. Ng O, Keeler BD, Mishra A, Simpson A, Neal K, Brookes MJ, et al. Iron therapy for pre-operative anaemia. Cochrane Database of Systematic Reviews. 2015(-12):CD011588-CD.
17. Markova V, Norgaard A, Jorgensen KJ, Langhoff-Roos J. Treatment for women with postpartum iron deficiency anaemia. Cochrane Database of Systematic Reviews. 2015(-8):CD010861-CD.
18. Jin HX, Wang RS, Chen SJ, Wang AP, Liu XY. Early and late iron supplementation for low birth weight infants: a meta-analysis. Italian Journal of Pediatrics. 2015;41(1):16-.
19. Hogan M, Klein AA, Richards T. The impact of anaemia and intravenous iron replacement therapy on outcomes in cardiac surgery. European Journal of Cardio-Thoracic Surgery. 2015;47(2):218-26.
20. Borstlap WA, Stellingwerf ME, Moolla Z, Musters GD, Buskens CJ, Tanis PJ, et al. Iron therapy for the treatment of preoperative anaemia in patients with colorectal carcinoma: a systematic review. Colorectal Disease. 2015;17(-12):1044-54.
21. Bauer M, Ressl S, Walter E. Iron deficiency in patients with chronic heart failure: a systematic literature review. Value in Health. 2015;18(-7):A405-A.
22. Avni T, Amir B, Alon G, Hefziba G, Leonard L, Anat GG. The safety of intravenous iron preparations: systematic review and meta-analysis. Mayo Clinic Proceedings. 2015;90(1):12-23.
Health Research Classification System category Generic Health Relevance
Extra information provided by this PSP
Original uncertainty examples The role of iron in the management of chemotherapy-induced anaemia in cancer patients receiving erythropoiesis-stimulating agents. Implications for research: Since the included RCTs had shorter follow-up duration (up to 20 weeks), the long-term effects of iron supplementation are unknown. Nonetheless, further studies are required to define the optimal dosage of iron. Future trials with a longer follow-up and various re-dosing regimens are also required to determine the risk of adverse events and the impact of iron supplementation on mortality as well as the optimal re-dosing schedule after the patients received the initial cumulative iron supplementation. ~ Does use of pre-op/pre-procedure iv iron in iron deficient patients improve clinic outcomes and reduce peri-operative blood product use? 
Submitted by 3 blood donors ~ 8 health professionals ~ 5 Other (questions not from survey)
PSP information
PSP unique ID 0063
PSP name Blood Transfusion and Blood Donation
Total number of uncertainties identified by this PSP 51  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 28 February 2018