It binds to ferroportin, the only iron exporter found on the membrane of mammalian cells and reduces iron export, lowering iron in circulation. and transmitted securely. With iron medication, these counts will improve. Wiesenthal M, Dignass A, Hartmann F, Stein J. She eventually completed her treatment with hemoglobin of 10.4 g/dL, ferritin of 359 g/L, and TSAT of 35%. In . 1-10%: hypophosphatemia, skin rash, nausea; Previously iron isomaltoside; verification of phosphate levels is recommended for repeated infusions. Searches were also performed using Essential Evidence Plus, the Cochrane database, the National Guideline Clearinghouse database, the Trip Database, DynaMed, and the Agency for Healthcare Research and Quality evidence reports. In line with these results, standardized AUC showed no statistically significant differences between high- and low-CRP groups in i.v. Diagnosis of iron deficiency anemia requires laboratory-confirmed evidence of anemia, as well as evidence of low iron stores.4 Anemia is defined as a hemoglobin level two standard deviations below normal for age and sex (Table 1).5, A complete blood count can be helpful to determine the mean corpuscular volume or red blood cell size. Baseline characteristic summary was described using counts for categorical variables and median and range for continuous variables. iron to improve their IDA and obtain a more rapid response. Not to be confused with high-molecular-weight dextran (discontinued); 4-wk interval recommended before MRI. The results of this study suggest that patients with IBD and IDA, who have elevated CRP at initiation of treatment, may benefit from first-line treatment with i.v. It affects 3% of adults and is slightly more common in women younger than 50 years. Results In total, 2141 participants were included in the analyses (mean age: 74.9 years, 61.5% of women, 26.8% with iron deficiency). In the inflammatory state, increased hepcidin levels block duodenal iron absorption [16]. A growing portfolio is currently available in the United States: low-molecular-weight iron dextran, iron sucrose, ferric gluconate, ferumoxytol, ferric carboxymaltose (FCM), and ferric derisomaltose (previously known as iron isomaltoside; Table 3). Most IBD patients become iron deficient at some stages of the disease [3, 4]. Low-grade inflammation in a CIC is enough to disrupt iron metabolism by increasing hepcidin, but does not necessarily correlate with inflammatory markers. doi: https://doi.org/10.1182/hematology.2020000132. In clinical practice, many patients receive initial treatment with iron tablets although intravenous (i.v.) The sensitivity of computed tomographic colonography for lesions larger than 1 cm is greater than 90 percent.7 The use of barium enema is less reliable, but may be of use if colonoscopy or computed tomographic colonography is not available. It is the most common nutritional disorder worldwide and accounts for approximately one-half of anemia cases.1,2 Iron deficiency anemia can result from inadequate iron intake, decreased iron absorption, increased iron demand, and increased iron loss.3 Identifying the underlying etiology and administering the appropriate therapy are keys to the evaluation and management of this condition. CICs caused by CKD, HF, and other disorders make the diagnosis of ID more difficult, but knowledge of how ferritin and TSAT measurements behave in concurrent CICs and ID helps identify patients who are more likely to benefit from iron supplementation. Macdougall IC, Malyszko J, Hider RC, Bansal SS. Conclusion: Thus, in SLE, anaemia is the most frequent hematological alteration; iron deficiencies supercede in contrast to ACD and further autoimmune haemolytic anaemia. Low transferrin saturation (TSAT), calculated by serum iron divided by total iron-binding capacity (TIBC), indicates iron deficiency. SKD received speaker honoraria from Vifor International. Current status of the measurement of blood hepcidin levels in chronic kidney disease. With progressive iron depletion, the intracellular store of ferritin (iron-rich) is depleted, and serum ferritin (iron-poor) release by macrophages decreases proportionately, along with a progressive decrease in circulating transferrin-bound iron. iron has been shown to be at least as effective as oral iron in randomized trials, delivering faster response rates and being better tolerated than oral iron [3, 9, 15, 2628]. Thomas C, Kobold U, Thomas L. Serum hepcidin-25 in comparison to biochemical markers and hematological indices for the differentiation of iron-restricted . Kulnigg S, Stoinov S, Simanenkov V, Dudar LV, et al. Ferritin is an acute-phase protein and its serum levels are elevated during inflammation, reflecting the inflammatory state rather than iron stores. 1000-mg single dose in 100-500 mL NS with a final concentration >1 mg iron/mL, infused over >20 min. Iron restriction eventually leads to the anemia of inflammation. The two most common causes of anemia in IBD patients are absolute iron deficiency and anemia of chronic disease (ACD; also referred to as anemia of chronic inflammation) [1, 3]. In patients with CD, the risk of folate deficiency is high, reaching up to 20-30% at CD diagnosis [13,18,19]. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity, Iron deficiency across chronic inflammatory conditions: International expert opinion on definition, diagnosis, and management, Plasma ferritin determination as a diagnostic tool, Ferritin is secreted via 2 distinct nonclassical vesicular pathways, Serum ferritin is derived primarily from macrophages through a nonclassical secretory pathway, Vitamin and Mineral Nutrition Information System (WHO/NMH/NHD/MNM/11.2). Iron deficiency anemia signs and symptoms may include: Extreme fatigue Weakness Pale skin Chest pain, fast heartbeat or shortness of breath Headache, dizziness or lightheadedness Cold hands and feet Inflammation or soreness of your tongue Brittle nails Unusual cravings for non-nutritive substances, such as ice, dirt or starch They found 1023 people with confirmed BMID with mean ferritin between 33.6 and 158.3 g/L, whereas individuals with detectable BM iron had a mean ferritin >171.6 g/dL. Iron saturation in ACD is typically >5% but <15%, and reduced TIBC is also suggestive of ACD. Responsiveness of IBD patients with high versus low baseline CRP. Ferrous fumarate (Ferretts, Ferrimin, Hemocyte), 1 tablet every other day (>100 mg Fe per dose). In addition, high hepcidin levels also block the release of ferritin-bound iron from cells of the reticuloendothelial system (e.g., macrophages) [6, 17]. Aapro M, Osterborg A, Gascon P, Ludwig H, Beguin Y. Correlation coefficient, linear regression and odds ratio (OR) were used to determine the relationship. Moreover, other mechanisms put patients with CICs at higher risk of ID and underscore the need to make a correct diagnosis despite interference in iron parameters (Table 1). Sharma N, Begum J, Eksteen B, Elagib A, et al. National Library of Medicine Lastly, a recently presented investigation from our group has shown that IBD patients with ACD respond differently to oral iron treatment compared to those with IDA [12]. fection, CRP >5.0 mg/L . Her rheumatologist was concerned that the patients anemia was too severe to be explained by her autoimmune disease, which was under control, or by her comorbidities and requested a hematologists opinion. Crohns disease, Ulcerative colitis, Inflammatory bowel disease, C-reactive protein, Iron deficiency, Iron therapy, Anemia. CRP is a readily available laboratory value that is usually included in the routine assessment of IBD patients. A significant difference was observed in the overall population at week 8 only (Fig. Kleber Yotsumoto Fertrin; Diagnosis and management of iron deficiency in chronic inflammatory conditions (CIC): is too little iron making your patient sick?. She had a medical history of rheumatoid arthritis treated with methotrexate, hypertension treated with lisinopril, type 2 diabetes mellitus treated with pioglitazone, nonalcoholic fatty liver disease, and stage 3 chronic kidney disease with an estimated creatinine clearance of 32 mL/min per 1.73 m2. Copyright 2023 American Academy of Family Physicians. Increased CRP and significantly elevated ESR support ACD. Elevated hepcidin in inflammation is . ID is defined as a health-related condition in which iron availability is insufficient to meet the bodys needs and which can be present with or without anemia,3(p1069) and it is fundamentally recognized that IDA is simply the most advanced stage of ID. 1b, p<0.05) and tended to be smaller until week 8 compared to the low-CRP group. Iron deficiency and iron deficiency anemia (IDA) are common complications in inflammatory bowel disease (IBD), IDA being a common cause of hospitalization and increased morbidity in this population [1, 2]. A newer formulation, ferumoxytol, can be given over five minutes and supplies 510 mg of elemental iron per infusion, allowing for greater amounts of iron in fewer infusions compared with iron sucrose.2, There are no standard recommendations for follow-up after initiating therapy for iron deficiency anemia; however, one suggested course is to recheck complete blood counts every three months for one year. In addition, gut luminal iron may induce oxidative stress [13] and increase local disease activity in IBD [3, 14]. ferric carboxymaltose (FCM) with oral ferrous sulfate (FS) in IBD patients, were retrospectively analyzed. Iron deficiency anemia is diminished red blood cell production due to low iron stores in the body. Schematic representation of the regulation of iron metabolism in absolute ID. Supplemental iron may be given initially, followed by further workup if the patient is not responsive to therapy. In ID, iron stores are progressively exhausted before red cell morphology of hemoglobin levels are affected, and patients may experience early symptoms such as fatigue, reduced cognitive performance, and exercise intolerance. Such symptoms include fatigue, loss of stamina, shortness of breath, weakness, dizziness, and pallor. The study population consisted of patients with Crohns disease or ulcerative colitis and IDA (Hb110g/L and TSAT<20% or serum ferritin<100ng/mL), randomized to either oral (ferrous sulfate) or i.v. In children and pregnant women, iron therapy should be tried initially. The guideline may not apply to all patients with chronic inflammatory conditions (CICs), such as obesity, chronic kidney disease (CKD), liver disease, and heart failure (HF), in whom an increase in CRP is frequently absent, or where AGP measurements are not routinely available. Prevalence and management of cancer-related anaemia, iron deficiency and the specific role of intravenous iron. Lack of iron available to the BM eventually manifests as hypochromic, microcytic anemia. Inflammation with increased cytokine production causes upregulation of liver hepcidin (H), which binds to ferroportin (F). Patients may be asymptomatic or present with nonspecific symptoms including fatigue, irritability, and dizziness. FCM and ferric derisomaltose have been associated with the development of hypophosphatemia in 27% to 90% and 4% of treatments, respectively, attributable to an increase in fibroblast growth factor 23 with renal phosphate wasting. A randomized, open-label, non-inferiority study of intravenous iron isomaltoside 1,000 (Monofer) compared with oral iron for treatment of anemia in IBD (PROCEED). 1c). To be absorbed, the folate must be deconjugated by a brush border peptidase of enterocytes; the intestinal mucosal . This hepcidin block during inflammation leads to diminished amounts of free iron available for erythropoiesis [5]. The https:// ensures that you are connecting to the The choice of route of administration of iron should take comorbidities and the patients preference into consideration. Iatrogenic iron overload is another concern in the absence of reliable ferritin levels. Weiss G, Goodnough LT. Its indication in clinical practice by itself has become rare with the ease of the use of ferritin, but it may occasionally prove useful in patients who undergo BM sampling for other reasons. Before starting parenteral iron, patients should be informed about potential adverse events. Further evaluation should be based on risk factors (Figure 2).10,15,1721, Excessive menstruation is a common cause of iron deficiency anemia in premenopausal women in developed countries; however, a GI source (particularly erosive lesions in the stomach or esophagus) is present in 6 to 30 percent of cases.20,22,23 If the gynecologic workup is negative and the patient does not respond to iron therapy, endoscopy should be performed to exclude an occult GI source.20,22,23, Excessive or irregular menstrual bleeding affects 9 to 14 percent of all women and can lead to varying degrees of iron deficiency anemia.24 Etiologies include thyroid disease, uncontrolled diabetes mellitus, polycystic ovary syndrome, coagulopathies, uterine fibroids, endometrial hyperplasia, hyperprolactinemia, and use of antipsychotics or antiepileptics. 8600 Rockville Pike iron therapy was retrospectively analyzed in an IBD patient population from a previously reported phase III clinical trial [15]. Schroder O, Mickisch O, Seidler U, de WA, et al. A week later, she called the office to report that she was still feeling weak and wondered whether her anemia was getting worse. If a ferritin test reveals that your blood ferritin level is lower than normal, it indicates your body's iron stores are low and you have iron deficiency. In particular, the small number of oral iron-treated CD patients did not allow for meaningful subanalyses, although differences are likely to be more pronounced in this subpopulation due to greater systemic inflammation compared to UC patients [7]. Despite their limitations, markers of inflammatory activity, such as erythrocyte sedimentation rate (ESR) and CRP levels have survived the test of time and are often used in clinical practice to help interpret ferritin levels, because ferritin is an acute-phase reactant. Liver iron overload has been diagnosed by MRI in up to 84% of patients with dialytic CKD and is associated with the infusion of more than 250 mg of iron per month.32 Kidney Disease Improving Global Outcomes 2012 guidelines33 warn against iron supplementation in patients with CKD with ferritin >500 g/L, but MRIs have shown that patients with ferritin in that range may have significant iron overload. Patients should always be investigated for blood loss, such as uterine and GI bleeding. 2020 by The American Society of Hematology. Anaemia is defined by the World Health Organization as a Hb level below 120 g/L in non-pregnant females and 130 g/L in males, which is consistent with the definition of anaemia in the National Blood Authority Patient Blood Management Guidelines. Burning pain in the hands or feet. Lindgren S, Wikman O, Befrits R, Blom H, et al. A ferritin test measures the amount of ferritin in your blood. the contents by NLM or the National Institutes of Health. Results: High serum hs-CRP (> 5 mg/l) was found in 42 (57.5 %) and anemia in 32 (43.8 %) patients. A recent study in patients with IBD has shown a close correlation between CRP and hepcidin serum levels [10]. Iron deficiency was defined by soluble transferrin receptor levels > 28.1 nmol/L and baseline anemia by hemoglobin levels < 130 g/L for men and < 120 g/L for women. Testing should be performed in patients with signs and symptoms of anemia, and a complete evaluation should be performed if iron deficiency is confirmed.13, The American Academy of Family Physicians, U.S. Preventive Services Task Force, and Centers for Disease Control and Prevention recommend routine screening of asymptomatic pregnant women for iron deficiency anemia.4,11,14 The American College of Obstetricians and Gynecologists recommends screening for anemia and implementing iron therapy if iron deficiency anemia is confirmed.15 The defined values consistent with anemia in pregnancy are hemoglobin levels less than 11 g per dL (110 g per L) in the first or third trimester, or less than 10.5 g per dL (105 g per L) in the second trimester.16 A maternal hemoglobin level of less than 6 g per dL (60 g per L) has been associated with poor fetal outcomes, including death.15. Weakness. Your feedback has been submitted successfully. Hepcidin binds to the iron exporter ferroportin located on the basolateral surface of gut enterocytes and causes its internalization and degradation. There are numerous causes of hemolytic anemia, including inherited and acquired conditions, acute and chronic processes, and mild to potentially life-threatening severity. Schematic representation of the regulation of iron metabolism in FID in CICs. Normal values for CRP range between 0.20 and 6.10 mg/L [8]. iron: n=136). Correspondence Kleber Yotsumoto Fertrin, University of Washington, 825 Eastlake Ave, E MS CE3-300, Seattle, WA 98109; e-mail: kleber@uw.edu. 2a), apart from early response in the CD subpopulation (p<0.05 at week 2; Fig. official website and that any information you provide is encrypted The site is secure. CRP is routinely measured in IBD patients and forms part of the recommended diagnostic workup in patients with anemia (hemoglobin [Hb]<12g/dL in non-pregnant women, <13g/dL in men) [3, 9]. Least-squares meansstandard errors, adjusted for gender and baseline Hb. Pathways for the regulation of hepcidin expression in anemia of chronic disease and iron deficiency anemia in vivo. Ferritin <30 g/L in the presence of TSAT <45% is indicative of absolute low iron stores (black). A small number of patients (n=11) only had categorized CRP measurements that are available (e.g., <5, <10mg/mL). Ferrous fumarate deteriorated plasma antioxidant status in patients with Crohn disease. She asked whether she could take iron tablets or should receive iron injections, which she had heard carry a risk for allergic reactions. In that condition, lymphocytes can be elevated. Of note, baseline levels of CRP and IL-6 strongly correlated with each other (R=0.2442; p=0.0007). SV is an employee of Vifor Pharma Ltd. CG has received grant and consultancy honoraria from Vifor Pharma Ltd, Pharmacosmos A/S, Fresenius Medical Care, and Renapharma Sweden. Following an inflammatory stimulus, causing, for example, IL6 expression which can directly induce CRP expression in the liver, CRP levels rise rapidly to peak levels of 350400mg/L. Please enter a valid username and password and try again. Studies that reported only ferritin levels are represented by red lines beneath the x-axis that encompass the range, and means are represented by diamonds situated on the lines. Federal government websites often end in .gov or .mil. Iron deficiency anemia (IDA) is the most common cause of anemia worldwide. Iron depletion occurs commonly and is related to associations among blood loss, low dietary iron intake, and malabsorption. Intravenous iron sucrose is superior to oral iron sulphate for correcting anaemia and restoring iron stores in IBD patients: a randomized, controlled, evaluator-blind, multicentre study. Recently, a large randomized clinical trial favored the use of a high-dose regimen of 400 mg/mo of iron to lower risk of death and nonfatal cardiovascular events in patients in hemodialysis within a 2-year time frame, but did not report incidence of liver iron overload, so concerns for late effects of excess iron remain.34 If iatrogenic iron overload is suspected, MRI can be used, but different intervals for each iron formulation are recommended before MRI scans, to prevent interference with imaging (Table 3).32 In patients on hemodialysis with confirmed iron overload, the discontinuation of iron infusions has been shown to correct it slowly over several months without the need for iron chelators. WHO guidelines recommend a ferritin level <15 g/L as a sign of absolute ID in adults,8 although a cutoff of 30 g/L is more often used because of its higher sensitivity (92%) and high specificity (98%).9 Unfortunately, its high accuracy is lost in the presence of inflammation. The World Health Organization (WHO) defines anemia as hemoglobin <13 g/dL and <12 g/dL in adult men and nonpregnant women, respectively,1 a well-known trigger for an investigation of ID. Patients were stratified by baseline CRP levels into a high-CRP (>4mg/L; n=96) and a low-CRP (4mg/L; n=100) group, and responsiveness to iron supplementation (Hb change from baseline) was compared. Shortness of breath and nausea. Screening serology for celiac disease should be considered for all adults with iron deficiency anemia. Laftah AH, Sharma N, Brookes MJ, McKie AT, et al. Yellow striped areas represent areas in which iron supplementation may be considered, depending on the CIC; only patients with CKD are likely to benefit from iron supplementation with ferritin <200 g/L and TSAT of 20% to 25%, whereas patients with HF or CKD treated with erythropoiesis-stimulating agents (ESAs) and/or hemodialysis may be considered for iron supplementation if TSAT is <20% and ferritin is up to 500 g/L. iron treatment appears to be independent of inflammatory status in IBD patients. MATTHEW W. SHORT, LTC, MC, USA, AND JASON E. DOMAGALSKI, MAJ, MC, USA. Consider dietitian referral. Infused iron is captured by Kupffer cells, which become overloaded and gradually shuttle the iron to hepatocytes. Iron deficiency (ID) is the most common nutritional deficiency affecting children undergoing intestinal rehabilitation (IR). You have had a history of viral flu. See permissionsforcopyrightquestions and/or permission requests. Background: C-reactive protein (CRP) is a widely used inflammatory marker. The history should focus on potential etiologies and may include questions about diet, gastrointestinal (GI) symptoms, history of pica or pagophagia (i.e., compulsive consumption of ice), signs of blood loss (e.g., epistaxis, menorrhagia, melena, hematuria, hematemesis), surgical history (e.g., gastric bypass), and family history of GI malignancy. Patients with several comorbidities may also prefer parenteral iron to avoid adding another pill to their routine. Absolute iron deficiency is defined by severely reduced or absent iron stores, while functional iron deficiency is defined by adequate iron stores but insufficient iron availability for incorporatio A 56-year-old woman was referred for evaluation of anemia. You may notice pale skin and cold hands and feet. Causes of iron deficiency in IBD patients include intestinal bleeding, poor absorption of iron by the diseased intestine, and/or self-imposed dietary restrictions relating to gastrointestinal symptoms. In oral iron-treated patients, a considerable trend toward lower Hb response was observed in the high- versus low-IL-6 groups, but differences did not quite reach the statistical significance (p<0.07 at weeks 2 and 8; Fig. Data Sources: A PubMed search was completed in Clinical Queries using the key terms iron deficiency and anemia. Conflict-of-interest disclosure: The author declares no competing financial interests. In clinical practice, CRP levels 5mg/L are usually considered elevated. A pragmatic way of understanding the implications of a certain ferritin threshold is to examine studies comparing ferritin levels with BM iron, the gold-standard test for determination of iron stores. Initial evaluation includes a history, physical examination, and pregnancy and thyroid-stimulating hormone tests. Iron deficiency anemia (IDA) is a common complication of inflammatory bowel disease (IBD). In patients with celiac disease, a correlation between iron deficiency and increased expression of ferritin in enterocytes of the duodenum was observed, indicating a link between iron absorption and local mucosal inflammation [20]. Serum iron levels inversely correlated with baseline CRP. Standardized AUC analysis confirmed a statistically significant difference between the CRP groups in oral iron-treated patients (high vs. low CRP, LS means: 21.3 vs. 29.3; p=0.012). Hb response to i.v. Here I present a pragmatic way of interpreting diagnostic lab tests to help clinicians recognize patients who are most likely to benefit from iron supplementation, choose between oral and parenteral administration, and make personalized decisions when patients do not fit usual guidelines. Correlations were estimated with Pearsons product-moment method. A total of 196 patients were evaluated (oral iron: n=60; i.v. The entered sign-in details are incorrect. This content is owned by the AAFP. Change in C-Reactive . Also at week 12, Hb increment tended to be smaller in the high- versus low-CRP group, but the difference did not reach statistical significance. By contrast, an iron saturation <5% and an elevated . Nevertheless, ESR varies with hematocrit and is driven mostly by the production of fibrinogen and immunoglobulins, which last for several days in the circulation, whereas CRP is mainly produced by the liver in response to cytokines, particularly IL-6, and has a much shorter half-life; discrepancies between ESR and CRP are unsurprisingly common.12 CRP >50 mg/L is frequent in bacterial infections, making it an excellent marker of acute inflammation, whereas the less-noted -1-acid glycoprotein (AGP) increases later in the inflammatory process and is more suitable for confirming chronic inflammation.13 Because ferritin increases >5 times in patients with CRP >80 mg/L than in those with CRP <10 mg/L,14 studies have examined the possibility of correcting ferritin for inflammatory activity. A percentage of hypochromic red cells >6% and a reticulocyte hemoglobin equivalent (CHr or Ret-He) <29 pg, as provided by some modern cell counters, also supports iron-restricted erythropoiesis. Ward DG, Roberts K, Stonelake P, Goon P, et al. Normal values for CRP range between 0.20 and 6.10mg/L [8]. The diagnosis of iron deficiency anemia is confirmed by the findings of low iron stores and a hemoglobin level two standard deviations below normal. . As a library, NLM provides access to scientific literature. Stein J, Hartmann F, Dignass AU. Of note, the efficacy data presented here are not confounded by compliance issues since adherence was monitored in the trial and was excellent (99.2%) [15]. When symptoms occur, they're often related to blood clots. Differences were less pronounced with stratification according to baseline IL-6. IV iron preparations: test dose, dosage, side effects, and average wholesale pricing. Although the observed differences to the i.v. 1d), and analysis of subpopulations showed that this difference was present in UC but not in CD patients (Fig. For both markers, there was no significant relationship with baseline Hb levels (CRP: R=0.0191, p=0.791; IL-6: R=0.0393, p=0.590). In absolute ID, mechanisms are activated to replenish iron: low hepcidin production keeps ferroportin on the membranes to facilitate iron absorption, and transferrin is upregulated to increase total iron binding capacity (TIBC) and transport of iron to the tissues. Contrary to IDA, AI is moderate anemia characterized by normochromic and normocytic erythrocytes [5,21,24]. Significantly impaired oral iron absorption was reported in pediatric patients (n=19) with active (defined by IL-6>5pg/mL) versus inactive CD [11]. Christoph Gasche, Email: ta.ca.neiwinudem@ehcsag.hpotsirhc. CKD patients suffer from both absolute and functional iron deficiency. Because of Ferritin is an acute phase reactant, It may increase disproportionately relative to iron stores.Accordingly in this case, serum . Haematologica 2011; 96:1761. A subscription is required to access all the content in Best Practice. Tariq Iqbal, Email: ku.ca.mahb@LABQI.H.T. Mean baseline Hb and laboratory measures of inflammatory markers were similar between treatment groups [15]. Overt inflammation with high ESR and CRP levels has usually been found in active autoimmune disorders (eg, Stills disease, rheumatoid arthritis, and inflammatory bowel disorders [IBDs]) and in chronic infections (eg, tuberculosis and chronic osteomyelitis). Among iron tablet-treated patients, Hb increase was significantly smaller in the high- versus low-CRP subgroup (1.1 vs. 2.0, 2.3 vs. 3.1, and 3.0 vs. 4.0g/dL at weeks 2, 4, and 8, respectively; all p<0.05). Copyright 2013 by the American Academy of Family Physicians. Low-molecular-weight iron deficiency, iron sucrose, and ferric gluconate may require several shorter infusions, whereas the remainder have become increasingly popular because of the lower number of visits required to administer high-dose infusions, despite the higher cost of the medication. The search included meta-analyses, randomized controlled trials, controlled trials, and reviews. Serum protein electrophoresis (SPEP) is a test that measures the antibodies in the blood and can find a monoclonal antibody.

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