REMEDY : BNSSG referral pathways

Anaemia

Checked: 20-12-2017 by Rob.Adams Next Review: 20-12-2018

Introduction

The management of anaemia can become quite complicated, so the Bristol Referral Service (BRS) has developed some guidelines with the support of local gastroenterologists and haematologists to help guide further investigation.

The Haematology section of Remedy also has a link to  Haematology Guidelines for Primary Care which includes advice on assessment and management of anaemia.

Vitamin B12 and Folate Deficiency Anaemia

Please refer to the NICE Clinical Knowledge Summaries for the management of B12 and folate deficiency anaemia.

Please note that secondary care referral is not routinely required for pernicious anaemia which can usually be managed with hydroxocobalamin injections within the primary care setting.

Consider further investigation or referral in the following circumstances:

Suspected Coeliac disease

Gastrointestinal malabsorption - consider referral to gastroenterology or the Gastroenterology Advice and Guidance service.

Neurological symptoms - refer to haematology or the Haematology Advice and Guidance service.

Pregnancy - get advice from Haematology Advice and Guidance service or refer to antenatal clinic.

Haematological abnormalities or suspected malignancy - See 2WW guidelines

Management of Anaemic of Chronic Disease

Where haematinics are normal, an anaemia of chronic disease should also be considered - see the  Anaemia guidance on Patient.co.uk for further information - chronic infection, inflammation (eg rheumatoid arthritis), neoplasia and chronic kidney disease are the main culprit causes. Mild anaemia of chronic disease may not require any treatment.

Ferritin Normal with Suspected Iron Deficiency Anaemia

The important thing not to miss is an underlying iron deficiency as iron deficiency anaemia may be normocytic in some elderly patients and sometimes the ferritin is spuriously raised and so appears to be “normal”. Any inflammatory condition (such as rheumatoid disease) can falsely raise the ferritin even in the presence of iron deficiency anaemia, as can chronic kidney disease, liver disease, malignancy, hyperthyroidism and heavy alcohol intake. To help clarify the situation, it may be worth also checking the patient’s iron status (for NBT, available on ICE as iron status under haematology panel, for UHB can request zinc protoporphyrin - ZZP). The finding of a low serum iron and/or low transferrin saturation (or raised ZPP) would point towards an iron deficiency. Dr Charlotte Bradbury (Consultant Haematologist at BRI) has previously advised us on this and recommends the following:

If microcytic anaemia/possible iron deficiency, it may be worth checking another marker of iron status – if transferrin saturation <20% or ZZP raised, and ferritin <200, a trial of iron is reasonable.

Iron Deficiency Anaemia

Please refer to the NICE clinical knowledge summary guidance for the management of iron deficiency anaemia.

Lower GI Endoscopy

2016 NICE guidelines on suspected cancer now suggest 2WW lower gastrointestinal (GI) referral for all patients aged 60 and over who are found to have any degree of iron-deficiency anaemia (however mild – there is no longer a Hb cut off).

Please also see guidelines on when to do a FIT test in patients with iron deficiency anaemia or non-iron deficiency anaemia.

Upper GI Endoscopy

A non-urgent upper GI endoscopy is recommended in people over 55 with upper abdominal pain and low haemoglobin levels (see NICE) The quickest way to organise this would be to request a direct access community endoscopy available from Prime Endoscopy, Care UK or Nuffield (patients should be seen within 6 weeks).

Our recommendation is that all endoscopy referrals (other than 2WW referrals) be submitted on one of the generic forms. (see Upper GI Proforma (word doc) & Lower GI Proforma (word doc))

However, patients with medical contraindications such as BMI over 40 would need to be seen in secondary care. If criteria are fulfilled, 2WW anaemia pathways are also available via ICE for NBT practices only.

Iron deficiency without anaemia

The British Society of Gastroenterology Guidelines on Management of IDA (2011) has advice on how to manage patients with low iron and normal Hb as well as iron deficiency anaemia - summary as below:

'Iron deficiency without anaemia  is three times as common as IDA, but there is no consensus on whether these patients should be investigated, and further research is needed. The largest study shows very low prevalence of GI malignancy in patients with iron deficiency alone (0.9% of postmenopausal women and men, and 0% of premenopausal women)(1). Higher rates have been reported only in more selected groups. In the absence of firm evidence, we tentatively recommend coeliac serology in all these patients but that other investigation be reserved for those with higher-risk profiles (eg, age >50 years) after discussion of the risks and potential benefits of upper and lower GI investigation. All others should be treated empirically with oral iron replacement for 3 months and investigated if iron deficiency recurs within the next 12 months.

(1) Ioannou GN, Rockey DC, Bryson CL, et al. Iron deficiency and gastrointestinal malignancy: a population-based cohort study. Am J Med 2002;113:276e80.'

Normal Colonoscopy and Gastroscopy in Iron Deficiency Anaemia

If a GI cause for iron deficiency anaemia is not apparent, culprit drugs (e.g. NSAIDs, aspirin, anticoagulants, bisphosphonates) should be reviewed and Dr Tom Creed (Consultant gastroenterologist, BRI) recommends to check the following:

  1. Ensure the picture is true iron deficiency (you would be surprised how often patients are investigated in whom it isn’t true iron deficiency….)

  2. Check they have had upper and lower GI endoscopy within the recent past (certainly within 12 months) and ensure that the quality of the endoscopic investigations are good (e.g. sometimes there is very poor bowel prep, incomplete colonoscopy etc) and consider repeating if concerned.

  3. Dip the urine for blood.

  4. Check coeliac serology – may be worth checking IgA levels to exclude false negative anti-TTG in IgA deficiency (if no biopsy available) - NBT labs do this routinely, UHB only if requested.

  5. Refer to gastroenterology for capsule endoscopy study of the small bowel unless contraindicated (eg possible stricture/ lots of previous surgery – in these cases, it may still be possible to do a patency capsule, but referrers must make this clear). In frail patients in whom you would not wish to intervene (ie would they tolerate double balloon enteroscopy – much more difficult/ invasive than a colonoscopy), I will often just watch their Hb/ ferritin and give iron infusion as required and not proceed to capsule endoscopy. Often the capsule endoscopy is normal, but we do pick up occasional small bowel tumours/ carcinoid/ occult crohns.

Referrals should be made via e-referral to gastroenterology at NBT as this is where capsule endoscopies are currently done – the service is led by Dr Ana Terlevich, so referrals to her would be best.

Iron Infusions

In patients who do not tolerate or do not respond to oral iron supplements then an iron infusion should be considered.

 UHB - Referrals for an iron infusion at UHB should be made directly to the Ambulatory Care Unit via email: ubh-tr.PathClinic@nhs.net (Fax referrals are no longer accepted). If advice is required then please call the ACU on 0117 3424363.

NBT - Referrals for a blood transfusion or iron infusion at NBT should be made via fax to the Medical Day Unit on 0117 414 9484 or email : MedicalDayCare@nbt.nhs.uk with [ENCRYPT] as the first word on the “subject” line of the email. If advice is required then please call the Day Unit on 0117 4143205 or 0117 414 3206. Please use their proforma and pathway when referring.

 Referrals should include:

  • Patient contact details.
  • The diagnosis/ cause of anaemia.
  • Recent FBC and ferritin (within last month).
  • List of symptoms and examination findings.

All referrals are triaged and then the patient contacted by the hospital to arrange the infusion.