Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Original article

Vol. 149 No. 3738 (2019)

Indications and associated factors for prescribing intravenous iron supplementation in Swiss general practice: a retrospective observational study

  • Rahel Meier
  • Ellen Keizer
  • Thomas Rosemann
  • Stefan Markun
DOI
https://doi.org/10.4414/smw.2019.20127
Cite this as:
Swiss Med Wkly. 2019;149:w20127
Published
12.09.2019

Summary

BACKGROUND

Intravenous iron supplementation (IVIS) is increasing in Swiss general practice. This is controversial because of higher costs and risks compared with oral iron supplementation (OIS). In this study, we aimed to investigate indications for OIS and IVIS in Swiss general practice and test which factors are associated with prescribing IVIS instead of OIS.

METHODS

This was a retrospective observational study using data from electronic medical records of 279 Swiss general practitioners (GPs), including all their patients at their first OIS and IVIS administration who were at least 14 years old and with available pretreatment serum ferritin and haemoglobin measurements. We also collected data about the following comorbidities: chronic kidney disease (CKD) stage 3b or higher, inflammatory bowel disease (IBD), chronic heart failure and restless legs syndrome. Outcomes were proportions of cases treated with IVIS or OIS by assumed indication (anaemic or non-anaemic iron deficiency [NAID]) or the abovementioned comorbidities. We evaluated associations with IVIS prescription using regression models adjusting for patient and GP variables.

RESULTS

We assessed 1282 IVIS and 3003 OIS cases (median age 44 and 40 years, female in 86.7 and 88.6%, respectively). The most important indication for both IVIS and OIS was NAID (59.4 and 74.7%, respectively). Significant associations with prescribing IVIS instead of OIS were the severity of iron deficiency (reflected by serum ferritin levels and the presence of anaemia), the presence of advanced CKD, IBD and male sex of the GP. There was a time trend towards increasing serum ferritin levels associated with initiation of IVIS in NAID.

CONCLUSION

When preferring IVIS to OIS, Swiss GPs seem to consider severity of iron deficiency and comorbid conditions. However, pretreatment serum ferritin levels in IVIS for NAID are increasing, suggesting an ongoing indication extension and potential overuse.

References

  1. Kassebaum NJ, Jasrasaria R, Naghavi M, Wulf SK, Johns N, Lozano R, et al. A systematic analysis of global anemia burden from 1990 to 2010. Blood. 2014;123(5):615–24. doi:.https://doi.org/10.1182/blood-2013-06-508325
  2. Mast AE, Blinder MA, Gronowski AM, Chumley C, Scott MG. Clinical utility of the soluble transferrin receptor and comparison with serum ferritin in several populations. Clin Chem. 1998;44(1):45–51.
  3. Camaschella C. Iron-deficiency anemia. N Engl J Med. 2015;372(19):1832–43. doi:.https://doi.org/10.1056/NEJMra1401038
  4. Kwack C, Balakrishnan VS. Managing erythropoietin hyporesponsiveness. Semin Dial. 2006;19(2):146–51. doi:.https://doi.org/10.1111/j.1525-139X.2006.00141.x
  5. Qian C, Wei B, Ding J, Wu H, Wang Y. The Efficacy and Safety of Iron Supplementation in Patients With Heart Failure and Iron Deficiency: A Systematic Review and Meta-analysis. Can J Cardiol. 2016;32(2):151–9. doi:.https://doi.org/10.1016/j.cjca.2015.06.009
  6. Allen RP, Picchietti DL, Auerbach M, Cho YW, Connor JR, Earley CJ, et al.; International Restless Legs Syndrome Study Group (IRLSSG). Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease in adults and children: an IRLSSG task force report. Sleep Med. 2018;41:27–44. doi:.https://doi.org/10.1016/j.sleep.2017.11.1126
  7. Yokoi K, Konomi A. Iron deficiency without anaemia is a potential cause of fatigue: meta-analyses of randomised controlled trials and cross-sectional studies. Br J Nutr. 2017;117(10):1422–31. doi:.https://doi.org/10.1017/S0007114517001349
  8. Clénin GE. The treatment of iron deficiency without anaemia (in otherwise healthy persons). Swiss Med Wkly. 2017;147:w14434. doi:.https://doi.org/10.4414/smw.2017.14434
  9. Pratt JJ, Khan KS. Non-anaemic iron deficiency - a disease looking for recognition of diagnosis: a systematic review. Eur J Haematol. 2016;96(6):618–28. doi:.https://doi.org/10.1111/ejh.12645
  10. Muñoz M, Gómez-Ramírez S, Bhandari S. The safety of available treatment options for iron-deficiency anemia. Expert Opin Drug Saf. 2018;17(2):149–59. doi:.https://doi.org/10.1080/14740338.2018.1400009
  11. Goddard AF, James MW, McIntyre AS, Scott BB ; British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut. 2011;60(10):1309–16. doi:.https://doi.org/10.1136/gut.2010.228874
  12. 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 (Baltimore). 2016;95(2):e2308. doi:.https://doi.org/10.1097/MD.0000000000002308
  13. 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. Am J Kidney Dis. 2016;68(5):677–90. doi:.https://doi.org/10.1053/j.ajkd.2016.04.018
  14. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al.; ESC Scientific Document Group. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–200. doi:.https://doi.org/10.1093/eurheartj/ehw128
  15. Giger M, Achermann R. Ambulante Eisensubstitution in der Schweiz – Kostensteigerung infolge venöser Applikation [Iron substitution in outpatients in Switzerland: Increase of costs associated with intravenous administration]. Z Evid Fortbild Qual Gesundhwes. 2013;107(4-5):320–6. doi:.https://doi.org/10.1016/j.zefq.2012.12.023
  16. Biétry FA, Hug B, Reich O, Susan JS, Meier CR. Iron supplementation in Switzerland - A bi-national, descriptive and observational study. Swiss Med Wkly. 2017;147:w14444. doi:.https://doi.org/10.4414/smw.2017.14444
  17. World Health Organization, Centers for Disease Control and Prevention. Assessing the iron status of populations; Second edition, including Literature Reviews. 2007. Geneva: World Health Organization: 2007. Available from: https://www.who.int/nutrition/publications/micronutrients/anaemia_iron_deficiency/9789241596107/en/
  18. Seiler C. Healthy persons at risk for iron substitution. Swiss Med Wkly. 2017;147:w14452. doi:.https://doi.org/10.4414/smw.2017.14452
  19. Chmiel C, Bhend H, Senn O, Zoller M, Rosemann T ; FIRE study-group. The FIRE project: a milestone for research in primary care in Switzerland. Swiss Med Wkly. 2011;140:w13142. doi:.https://doi.org/10.4414/smw.2011.13142
  20. Swiss Medical Association (FMH). Aerztestatistik 2017. Updated 27 Mar. 2018 14 Dec. 2018. Available from: http://aerztestatistik.myfmh2.fmh.ch/.
  21. WHO Collaborating Centre for Drug Statistics Methodology. ATC-Structure and principles. Oslo, Norway: World Health Organization; 2018 Accessed 09 July 2019. Available from: https://www.whocc.no/atc/structure_and_principles/.
  22. World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System (WHO/NMH/NHD/MNM/111). Geneva: World Health Organization; 2011. Available from: http://www.who.int/vmnis/indicators/haemoglobin.pdf.
  23. R Core Team. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2018. Available from: https://www.R-project.org/.
  24. Lopez A, Cacoub P, Macdougall IC, Peyrin-Biroulet L. Iron deficiency anaemia. Lancet. 2016;387(10021):907–16. doi:.https://doi.org/10.1016/S0140-6736(15)60865-0
  25. Houston BL, Hurrie D, Graham J, Perija B, Rimmer E, Rabbani R, et al. Efficacy of iron supplementation on fatigue and physical capacity in non-anaemic iron-deficient adults: a systematic review of randomised controlled trials. BMJ Open. 2018;8(4):e019240. doi:.https://doi.org/10.1136/bmjopen-2017-019240
  26. Favrat B, Balck K, Breymann C, Hedenus M, Keller T, Mezzacasa A, et al. Evaluation of a single dose of ferric carboxymaltose in fatigued, iron-deficient women--PREFER a randomized, placebo-controlled study. PLoS One. 2014;9(4):e94217. Published online April 23, 2014. doi:.https://doi.org/10.1371/journal.pone.0094217
  27. Krayenbuehl PA, Battegay E, Breymann C, Furrer J, Schulthess G. Intravenous iron for the treatment of fatigue in nonanemic, premenopausal women with low serum ferritin concentration. Blood. 2011;118(12):3222–7. doi:.https://doi.org/10.1182/blood-2011-04-346304
  28. Vaucher P, Druais PL, Waldvogel S, Favrat B. Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial. CMAJ. 2012;184(11):1247–54. Published online July 11, 2012. doi:.https://doi.org/10.1503/cmaj.110950
  29. Verdon F, Burnand B, Stubi CL, Bonard C, Graff M, Michaud A, et al. Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomised placebo controlled trial. BMJ. 2003;326(7399):1124. doi:.https://doi.org/10.1136/bmj.326.7399.1124
  30. Albaramki J, Hodson EM, Craig JC, Webster AC. Parenteral versus oral iron therapy for adults and children with chronic kidney disease. Cochrane Database Syst Rev. 2012;1:CD007857. doi:.https://doi.org/10.1002/14651858.CD007857.pub2
  31. Fachgremium Swiss Medical Board. Orale oder parenterale Behandlung des Eisenmangels. Bern: Swiss Medical Board; 2014. Available from: https://www.swissmedicalboard.ch/fileadmin/public/news/2014/bericht_smb_eisenmangel_lang_2014.pdf.
  32. Cancelo-Hidalgo MJ, Castelo-Branco C, Palacios S, Haya-Palazuelos J, Ciria-Recasens M, Manasanch J, et al. Tolerability of different oral iron supplements: a systematic review. Curr Med Res Opin. 2013;29(4):291–303. doi:.https://doi.org/10.1185/03007995.2012.761599
  33. Schuepbach RA, Bestmann L, Béchir M, Fehr J, Bachli EB. High Prevalence of Iron Deficiency among Educated Hospital Employees in Switzerland. Int J Biomed Sci. 2011;7(2):150–7.
  34. Schleiffenbaum BE, Schaer DJ, Burki D, Viollier AF, Viollier E, Stettler ER, et al. Unexpected high prevalence of metabolic disorders and chronic disease among young male draftees--the Swiss Army XXI experience. Swiss Med Wkly. 2006;136(11-12):175–84.
  35. Djalali S. Wer eHealth sucht, findet einen Haufen Papier. Schweiz Arzteztg. 2015;96(43):1575–8. doi: https://doi.org/10.4414/saez.2015.03985
  36. Morgan DJ, Brownlee S, Leppin AL, Kressin N, Dhruva SS, Levin L, et al. Setting a research agenda for medical overuse. BMJ. 2015;351:h4534. doi:.https://doi.org/10.1136/bmj.h4534
  37. Kale MS, Korenstein D. Overdiagnosis in primary care: framing the problem and finding solutions. BMJ. 2018;362:k2820. doi:.https://doi.org/10.1136/bmj.k2820
  38. Keyhani S, Siu AL. The underuse of overuse research. Health Serv Res. 2008;43(6):1923–30. doi:.https://doi.org/10.1111/j.1475-6773.2008.00920.x

Most read articles by the same author(s)

<< < 1 2 3 > >>