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Iron deficiency anaemia: overlooked and under-treated?

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An online survey of nurses was carried out to find out more about awareness and knowledge of iron deficiency anaemia

This online-only article presents the results of a survey carried out by Nursing Times in April and May 2015 to explore nurses’ awareness and knowledge of iron deficiency anaemia (IDA).

Vifor Pharma UK has provided funding to Nursing Times to conduct this survey. VPUK has provided some IDA information and has reviewed this article to ensure factual accuracy and compliance with industry guidelines. The views expressed in this article are not necessarily the views of the sponsoring company.


Guidelines developed by the British Society of Gastroenterology state that iron deficiency anaemia (IDA) is often missed or not fully investigated in clinical practice and that management of the condition is often suboptimal (Goddard et al, 2011). This was reflected in the results of a Nursing Times survey with nearly nine out of 10 nurses surveyed feeling they have not had sufficient training on IDA. The survey was carried out in April and May of this year, with 855 respondents answering the majority of the 15 questions.

In answer to the question “Would you like more information on how to monitor for patients at risk of IDA in hospitals?”, 69% answered yes (Fig 1). The majority of nurses who took part in the survey were experienced nurses with 61% working as a nurse for more than 15 years and with 83% having more than five years’ experience. The most common groups were that of staff nurses and clinical nurse specialists.

Anaemia survey fig 1

Asked about their knowledge levels, only 1 in 100 felt able to say it is a subject they are expert in and another eight in 100 saying that IDA is a subject they know well. Others who took part in the survey were much less confident about their knowledge with 49% of those saying they did not feel expert having “only basic knowledge” of this topic with 14% confirming that they know “very little about this topic” (Fig 2).

The Royal College of Nursing is currently developing guidelines on how to identify and treat IDA across a number of therapy areas. Their aim is to fill any knowledge gaps for nurses on the identification and management of this common condition and they will be available from June.

anaemia survey fig 2

Incidence and definitions

IDA occurs in 2-5% of adult men and post-menopausal women in the developed world (Goddard et al, 2011). See Table 1 for common signs and symptoms. Specifically in the UK, the prevalence of IDA is more than 5% in the following groups (Scientific Advisory Committee on Nutrition, 2011):

  • Females aged 15-18 and 35-49 years;
  • Adults aged over 85 years;
  • Men aged 65 years or over living in an institution.

IDA is identified by the World Health Organization at a haemoglobin level of <12g/dL in adult women (excluding pregnancy) and <13g/dL in adult men where there is evidence of iron deficiency (Goddard et al, 2011).

Anaemia survey table 1

At-risk groups

The three main clinical reasons for occurrence of IDA are blood loss, systemic inflammation and malabsorption (Goddard et al, 2011; Huang and Means, 2011). As such, it is frequently associated with a large variety of conditions. The survey tested the nurses’ knowledge of which groups of patients should be actively monitored for IDA. The majority of those surveyed correctly identified that patients with inflammatory bowel disease and gastrointestinal bleeds should be actively monitored.

Many of the nurses identified pregnant women (92%), patients with chronic kidney disease (57%) and older people (77%) as being groups that should be actively monitored. Furthermore, the natural reduction in red blood cell production with age and lower tolerability to low haemoglobin levels exacerbate the effect IDA has on older patients. (Price, 2008; Bross et al, 2010). Age-related inflammation and higher stomach pH, which can be caused by concomitant proton pump inhibitor use (Ajmera et al, 2010), worsen the absorption of iron and can prevent correction of iron deficiencies (Baylis et al, 2013).

However, other groups that should be actively monitored for the condition were not correctly identified by survey participants; for example, patients with congestive heart failure were only identified by 34% of the nurses who answered this question.


Two of the most reliable tests for confirming iron deficiency are taking a full blood count and testing the level of serum ferritin. Three-quarters of the nurses who answered this question correctly identified serum ferritin and an even higher number (83%) correctly identified full blood count. However, knowledge of the transferrin saturation (TSat) test for aiding interpretation of ferritin in patients with active inflammation (Gasche, 2008) was not so strong, with only 28% identifying this diagnostic test.


The survey also investigated nurses’ knowledge of treatment for IDA. When the nurses were asked whether treatment of the patient’s underlying condition would be sufficient to normalise the haemoglobin levels, four out of five nurses incorrectly answered that it would depend on the treatment of the underlying condition. Although treatment of the underlying condition should be sufficient to prevent further iron loss, iron supplementation is recommended in all patients to restore Hb levels and replenish iron stores (Goddard et al, 2011).

The most common treatment for IDA remains oral iron. Guidelines recommend that treatment with oral iron be maintained for three months following Hb correction in order for iron stores to be fully replenished (Goddard et al, 2011). Over three quarters of the nurses surveyed correctly answered that patients should be followed up at three-month intervals following treatment for anaemia.

Iron supplementation

In some patients oral iron is not an appropriate treatment. Nearly half of the participants correctly identified that oral iron may be ineffective in patients with active inflammatory conditions. Two thirds correctly answered that oral iron might not represent an appropriate treatment for patients with gastrointestinal bleeding, consistent with the fact that ongoing blood loss may exceed the capacity of the body to absorb oral iron and that unabsorbed oral iron mimics the tarring of the stool consistent with gastrointestinal bleeds (Bayraktar, 2010).

In addition, as over 90% of ingested iron remains unabsorbed, oral iron is frequently associated with gastrointestinal adverse effects including nausea, diarrhoea and constipation (Stein and Dignass, 2012; Van Assche, 2012).

Some patients with IDA may need treatment with intravenous iron because of intolerance to oral iron or an inadequate response to the treatment (Goddard et al, 2011).

Increased morbidity

Inadequate treatment and management of IDA leads to increased morbidity, impacts on quality of life and daily functioning (Stein and Dignass, 2012; Gasche, 2008). Prompt diagnosis and treatment of this condition will benefit patients and the healthcare system. Reducing unplanned hospital admissions for patients with IDA is a priority for the NHS and could provide significant cost savings for the health service (Department of Health, 2013;  Goddard and Phillips, 2014).

Of the survey participants who answered the question on the consequences of poor management of anaemia, 99% correctly identified fatigue and two-thirds correctly nominated syncope as another consequence.

Key role for nurses

Nurses have a significant role to play in the identification and management of IDA. The survey shows that nurses were responsible for ordering blood tests in just under half (46%) of the areas where the respondents worked and that many nurses come across patients with IDA in their daily work. Of the survey respondents 44% identified that they saw these patients at least once a month. Some saw them at an even higher frequency with 16% seeing these patients once a week and 11% seeing them daily.

This survey highlights some gaps in the knowledge among nurses of IDA that should be clarified through the development of guidelines for nurses on how to identify and treat IDA.

It is hoped that the RCN guidance will allow nurses to improve their assessment of at-risk patients, check patient diagnostic values and treat more proactively to better patient outcomes. As the survey participants have shown, this guidance will be welcomed by nurses who have clearly stated that this is a therapy area that they need more information on.

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