Treating a Common Extraintestinal Manifestation of Inflammatory Bowel Disease

Expert Opinion

Dr Tauseef Ali is a Clinical Assistant Professor of Medicine at the University of Oklahoma in the section of Digestive Disease and Nutrition. He is the chief of Gastroenterology Section at Saint Anthony Hospital and the director of the Inflammatory Bowel Disease Program and Research Center.

If the patient has active disease that requires iron supplementation due to iron deficiency anemia (IDA), we generally do not prescribe oral iron supplements because, in many cases, they can cause stomach upset such as abdominal pain and constipation. Moreover, iron absorption is often impaired with inflammatory bowel disease (IBD) and the patient may not benefit from an oral agent, as is the case with Mr. C. So we prefer to go straight to IV iron infusion.

We do prescribe oral supplementation (usually 100mg/d) if a patient’s hemoglobin is >10 g/dL (mild-to moderate-IDA) and the CRP is normal. However, if the patient shows signs of intolerance or shows no response (hemoglobin <2g/dL increase in 4 weeks) we then go to IV iron therapy. In patients who have either mild-to-moderate IDA with elevated CRP or clinically active IBD, as is the case with Mr. C, or who have hemoglobin <10 g/dL (severe IDA), we immediately initiate IV iron therapy.

Iron sucrose is an older agent indicated for IDA in CKD. It is efficacious, safe, and has good tolerability. But its use is limited due to its increased number of infusions and the length of time—up to 3.5 or 4 hours—of each infusion.

Iron dextran, another older agent, takes even longer—up to 6 hours—for infusion and may cause dextran-induced IgE-mediated anaphylaxis, hypotension, and anemia. It also requires test dosing, which is very cumbersome.

In most cases, we generally prefer ferric carboxymaltose, which has been studied in patients with iron deficiency of various etiologies, such as chronic kidney disease (CKD), IBD, heavy menstrual bleeding, post-partum IDA, or patients with chronic heart failure and IDA. Importantly, it is specifically indicated for IBD. And it has been shown to be both efficacious and well-tolerated. Additional advantages are that it is extremely convenient, since it is administered in two infusions, administered 1 week apart. Moreover, it can be infused in 15 minutes, which increases the adherence rate. It has also been shown to be more cost-effective and convenient than iron sucrose.