1. IDA患者. 依照 ferritin 數值決定是否需補充鐵劑
2. IDA患者沒有貧血. 但ferritin 低於正常值, 建議補充鐵劑
剛剛看一個IDA患者. 病患詢問是否需補充鐵劑.
目前血色素還好 11.5 但元素鐵確實不足 24 且 TIBC 上升.
uptodate上面建議. 有缺鐵但沒有貧血. 還是建議補充鐵劑.
但IDA患者如果貧血及缺鐵狀況改善. 就不用補充鐵劑
臨床筆記有一篇IDA的文章 缺鐵性貧血. 裡面有一段
此外在口服鐵劑治療中的病人，血清Ferritin之追蹤可用來監測鐵儲存是否回升正常，可供決定何時停藥。
查詢uptodate上面的IDA治療篇. 缺鐵但是血色素正常個案. 仍可補充鐵劑
先將 uptodate上面的總結放上來.
(下面中文是用 google 翻譯)
總結和建議
●治療對象－無論是否有症狀，所有缺鐵性貧血患者和大多數缺鐵但無貧血的患者都應接受治療。也必須找出並解決缺鐵的原因，特別是對於新發缺鐵的成年人。健康的飲食可以提供足夠的鐵來滿足生理需要，但不能糾正鐵缺乏症。
●紅血球輸注的作用– 患有嚴重、嚴重症狀（例如，有心肌缺血症狀）或危及生命的貧血的患者應接受紅血球（RBC）輸注治療（流程圖 1）。
●口服鐵劑與靜脈注射鐵劑－某些情況可能會影響鐵劑的劑量和/或給藥途徑（口服與靜脈注射[IV]）（表 2）。由於給藥方便，我們通常口服鐵劑治療無併發症的缺鐵性貧血患者，如演算法（演算法 1）所示。然而，具有改善毒性特徵的靜脈鐵劑製劑的出現降低了許多患者選擇靜脈製劑的門檻。在治療孕婦以及患有發炎性腸道疾病、胃手術或慢性腎臟病的患者時，我們經常使用靜脈注射鐵劑。
•劑量和配方（口服鐵劑） ——在大多數情況下，所有口服鐵劑製劑都同樣有效（表 4）。接受口服鐵劑治療的個人可以選擇每隔一天（或週一、週三和週五）服用一顆藥片或每天服用一顆藥片。這兩個方案的功效看起來相似；每日給藥時胃腸道副作用較常見。上面列出了提高耐受性的策略。
•劑量和配方（靜脈鐵劑） ——在許多情況下，靜脈注射可能優於口服給藥，包括持續失血、幹擾口服吸收或鐵穩態的生理或解剖異常，以及口服鐵劑無法耐受的胃腸道副作用。有多種 IV 鐵製劑可供選擇（表 3）；它們的劑量和給藥方法如上所述。
●口服鐵劑的不良反應－口服鐵劑的胃腸道副作用極為常見。減少這些影響的策略包括將頻率減少到每隔一天一次（如果尚未這樣做）、調整飲食以及改用液體配方。
●靜脈鐵劑的副作用－由於擔心過敏反應，許多臨床醫生不願意使用靜脈鐵劑。我們認為，真正的過敏反應極為罕見，而且被嚴重高估，這主要是由於使用舊產品（例如已不再使用的高分子量右旋糖酐鐵(HMW ID)）的經驗，以及使用苯海拉明積極治療非過敏性輸注反應的做法以及其他將反應轉變為更嚴重事件的療法。我們在靜脈鐵劑治療前不使用常規術前用藥，並且避免使用苯海拉明。對於患有氣喘、發炎性風濕性疾病或多種藥物過敏的個體，我們通常將術前用藥限制為單獨使用糖皮質激素。
●預期反應– 缺鐵的有效治療可緩解症狀、出現適度的網狀紅血球增多（7 至 10 天內達到高峰），並在 6 至 8 週內使血紅素水平恢復正常。缺乏反應的原因包括不堅持口服鐵劑、持續失血、初步診斷不正確或有其他診斷（表 10）。其中一些額外的診斷，例如乳糜瀉，可能對評估特別重要。
●Whom to treat – Regardless of the presence of symptoms, all patients with iron deficiency anemia and most patients with iron deficiency without anemia should be treated. The cause of iron deficiency also must be identified and addressed, especially in adults with new onset iron deficiency. A healthy diet provides sufficient iron for physiologic needs but cannot correct iron deficiency. (See 'Initial considerations' above.)
●Role of RBC transfusion – Patients with severe, severely symptomatic (eg, with symptoms of myocardial ischemia), or life-threatening anemia should be treated with red blood cell (RBC) transfusion (algorithm 1). (See 'Severe/life-threatening anemia' above.)
●Oral versus IV iron – Some conditions may affect iron dosing and/or the route of administration (oral versus intravenous [IV]) (table 2). We generally treat patients who have uncomplicated iron deficiency anemia with oral iron due to the ease of administration, as illustrated in the algorithm (algorithm 1). However, the availability of IV iron formulations with improved toxicity profiles has lowered the threshold at which many patients would prefer an IV preparation. We often use IV iron when treating pregnant individuals and individuals with inflammatory bowel disease, gastric surgery, or chronic kidney disease. (See 'Oral versus IV iron' above and "Anemia in pregnancy" and 'Older adults' above and 'Inflammatory bowel disease and iron-restricted erythropoiesis' above and 'Following gastrointestinal/bariatric surgery' above and 'Perioperative' above and 'Chronic kidney disease' above and 'Heart failure' above and 'H. pylori, peptic ulcer disease, and gastritis' above.)
•Dose and formulation (oral iron) – For the most part, all oral iron preparations are equally effective (table 4). Individuals treated with oral iron can choose between taking one tablet every other day (or on Monday, Wednesday, and Friday) or one tablet per day. Efficacy between these two schedules appears similar; gastrointestinal side effects are more common with daily dosing. Strategies to improve tolerability are listed above. (See 'Oral iron' above.)
•Dose and formulation (IV iron) – There are a number of settings in which IV may be preferable to oral administration, including ongoing blood loss, physiologic or anatomic abnormality that interferes with oral absorption or iron homeostasis, and intolerable gastrointestinal side effects of oral iron. A number of IV iron formulations are available (table 3); their dosing and administration are described above. (See 'Choice of IV formulation' above and 'Dosing/administration of specific IV iron preparations' above.)
●Adverse effects of oral iron – Gastrointestinal side effects are extremely common with oral iron administration. Strategies to reduce these effects include reducing the frequency to every other day if not done already, dietary modifications, and switching to a liquid formulation. (See 'Side effects (oral iron)' above and 'Strategies to improve tolerability' above.)
●Adverse effects of IV iron – Many clinicians are reluctant to use IV iron due to concerns about anaphylaxis. We believe true allergic reactions are exceedingly rare and vastly overestimated, largely due to experience with older products such as high molecular weight iron dextran (HMW ID), which is no longer used, and the practice of aggressively treating non-allergic infusion reactions with diphenhydramine and other therapies that convert the reaction to a more serious event. We do not use routine premedication prior to IV iron and we avoid diphenhydramine. For individuals with asthma, inflammatory rheumatic conditions, or multiple drug allergies, we generally limit premedication to a glucocorticoid alone. (See 'Allergic and infusion reactions' above.)
●Expected response – Effective treatment of iron deficiency results in resolution of symptoms, a modest reticulocytosis (peaking in 7 to 10 days), and normalization of the hemoglobin level in six to eight weeks. Causes for a lack of response include nonadherence to oral iron, ongoing blood loss, and incorrect initial diagnosis or the presence of additional diagnoses (table 10). Some of these additional diagnoses, such as celiac disease, may be especially important to evaluate. (See 'Response to iron supplementation' above.)
幾項小型試驗和觀察性研究已經證明了補充鐵劑對治療缺鐵相關疲勞但不伴隨貧血的益處：
●一項試驗隨機分配90 名患有疲勞、血清鐵蛋白≤50 ng/mL、血紅素≥12.0 g/dL 的非貧血停經前女性，在兩週內接受累積劑量為800 mg 的靜脈注射(IV) 鐵劑或安慰劑 [ 2 ] 。治療開始六週後，靜脈鐵劑治療組的疲勞狀況得到改善（兩組的基線分別為 4.5 和 10 分制，分別為 1.1 和 0.7）。對於基線血清鐵蛋白≤15 ng/mL 的患者，效果更為明顯。補充鐵劑的益處持續到 12 週。 IV 鐵劑組的不良事件較多（21% 對 9%），但均不嚴重。如預期的那樣，靜脈鐵劑組鐵蛋白增加（平均增加 98 ng/mL），而安慰劑組則沒有。觀察性研究也報告，接受靜脈鐵劑治療的鐵蛋白水平較低的非貧血停經前女性的症狀有所改善 [ 3 ]。
●三項試驗將鐵蛋白水平較低的非貧血女性隨機分組，分別接受口服鐵補充劑（通常每天 80 毫克元素鐵）與安慰劑或高鐵飲食，所有試驗均報告口服鐵可改善疲勞情況 [ 4- 6 ]。使用膳食鐵作為比較的試驗也發現飲食鐵有改善，但補充劑組中鐵蛋白的平均增加幅度較大 [ 4 ]。
●對跑步者和捐血者的其他試驗表明，補充鐵可以改善運動表現、睡眠障礙和指甲斷裂 [ 7-9 ]。
這些數據支持了上述建議，即缺鐵但不貧血的人應該補充鐵。尋找失血或鐵流失來源的重要性也適用於這些人。 (參見下文『缺乏/失血的來源』 )
不建議對沒有缺鐵的個體進行常規補鐵。在極少數情況下，如果所有其他幹預措施都已用盡，一些專家會在沒有明顯實驗室證據表明鐵儲存減少的情況下，治療患有缺鐵症狀（嗜冰癖或不寧腿綜合症）的患者。The benefit of iron replacement for iron deficiency-associated fatigue without anemia has been demonstrated in several small trials and observational studies:
●A trial randomly assigned 90 non-anemic premenopausal females with fatigue, serum ferritin ≤50 ng/mL, and hemoglobin ≥12.0 g/dL to receive a cumulative dose of 800 mg of intravenous (IV) iron or placebo over two weeks [2]. Six weeks after treatment initiation, fatigue was improved in the IV iron arm (decrease of 1.1 versus 0.7 on a 10-point scale, from a baseline of 4.5 in both groups). The effect was more pronounced in those with a baseline serum ferritin ≤15 ng/mL. Benefits of iron supplementation persisted at 12 weeks. Adverse events were greater in the IV iron group (21 versus 9 percent), but none were considered serious. As expected, the IV iron group had increased ferritin (mean increase, 98 ng/mL) and the placebo group did not. Observational studies have also reported improvement in symptoms in non-anemic premenopausal females with low ferritin who were treated with IV iron [3].
●Three trials, which randomly assigned groups of nonanemic females with low ferritin to oral iron supplementation (typically 80 mg of elemental iron daily) versus placebo or a high-iron diet, all reported improvement in fatigue with oral iron [4-6]. The trial that used dietary iron as a comparator also found improvement with dietary iron, but mean increases in ferritin were greater in the supplement group [4].
●Additional trials in runners and blood donors have demonstrated that iron repletion can improve athletic performance, sleep disturbance, and fingernail breakage [7-9].
These data are supportive of the above recommendation that iron should be repleted in those with iron deficiency without anemia. The importance of finding the source of blood loss or iron loss also applies in these individuals.
(下面中文是用 google 翻譯)
此演算法適用於缺鐵的個體，無論是否患有貧血。我們治療所有缺鐵性貧血患者和大多數缺鐵但不貧血的患者。對於口服鐵劑，隔日給藥可促進吸收並減少不良反應；然而，如果願意，有些患者可以合理地每天服用劑量，而不是每隔一天服用一次。
This algorithm applies to individuals with iron deficiency, with or without anemia. We treat all individuals who have iron deficiency anemia and most who have iron deficiency without anemia. For oral iron, alternate-day dosing facilitates absorption and reduces adverse effects; however, some patients may reasonably take their dose daily rather than every other day if preferred. Refer to UpToDate for efficacy and adverse effects of different oral and intravenous iron formulations and supporting evidence. There is a separate algorithm in UpToDate for managing iron deficiency in pregnancy.
對於缺鐵但沒有貧血. 仍建議治療. 但治療一段時間之後可測量 ferritin 是否正常.
(下面中文是用 google 翻譯)
總結和建議
●治療對象－無論是否有症狀，所有缺鐵性貧血患者和大多數缺鐵但無貧血的患者都應接受治療。也必須找出並解決缺鐵的原因，特別是對於新發缺鐵的成年人。健康的飲食可以提供足夠的鐵來滿足生理需要，但不能糾正鐵缺乏症。
●紅血球輸注的作用– 患有嚴重、嚴重症狀（例如，有心肌缺血症狀）或危及生命的貧血的患者應接受紅血球（RBC）輸注治療（流程圖 1）。
●口服鐵劑與靜脈注射鐵劑－某些情況可能會影響鐵劑的劑量和/或給藥途徑（口服與靜脈注射[IV]）（表 2）。由於給藥方便，我們通常口服鐵劑治療無併發症的缺鐵性貧血患者，如演算法（演算法 1）所示。然而，具有改善毒性特徵的靜脈鐵劑製劑的出現降低了許多患者選擇靜脈製劑的門檻。在治療孕婦以及患有發炎性腸道疾病、胃手術或慢性腎臟病的患者時，我們經常使用靜脈注射鐵劑。
•劑量和配方（口服鐵劑） ——在大多數情況下，所有口服鐵劑製劑都同樣有效（表 4）。接受口服鐵劑治療的個人可以選擇每隔一天（或週一、週三和週五）服用一顆藥片或每天服用一顆藥片。這兩個方案的功效看起來相似；每日給藥時胃腸道副作用較常見。上面列出了提高耐受性的策略。
•劑量和配方（靜脈鐵劑） ——在許多情況下，靜脈注射可能優於口服給藥，包括持續失血、幹擾口服吸收或鐵穩態的生理或解剖異常，以及口服鐵劑無法耐受的胃腸道副作用。有多種 IV 鐵製劑可供選擇（表 3）；它們的劑量和給藥方法如上所述。
●口服鐵劑的不良反應－口服鐵劑的胃腸道副作用極為常見。減少這些影響的策略包括將頻率減少到每隔一天一次（如果尚未這樣做）、調整飲食以及改用液體配方。
●靜脈鐵劑的副作用－由於擔心過敏反應，許多臨床醫生不願意使用靜脈鐵劑。我們認為，真正的過敏反應極為罕見，而且被嚴重高估，這主要是由於使用舊產品（例如已不再使用的高分子量右旋糖酐鐵(HMW ID)）的經驗，以及使用苯海拉明積極治療非過敏性輸注反應的做法以及其他將反應轉變為更嚴重事件的療法。我們在靜脈鐵劑治療前不使用常規術前用藥，並且避免使用苯海拉明。對於患有氣喘、發炎性風濕性疾病或多種藥物過敏的個體，我們通常將術前用藥限制為單獨使用糖皮質激素。
●預期反應– 缺鐵的有效治療可緩解症狀、出現適度的網狀紅血球增多（7 至 10 天內達到高峰），並在 6 至 8 週內使血紅素水平恢復正常。缺乏反應的原因包括不堅持口服鐵劑、持續失血、初步診斷不正確或有其他診斷（表 10）。其中一些額外的診斷，例如乳糜瀉，可能對評估特別重要。
●Whom to treat – Regardless of the presence of symptoms, all patients with iron deficiency anemia and most patients with iron deficiency without anemia should be treated. The cause of iron deficiency also must be identified and addressed, especially in adults with new onset iron deficiency. A healthy diet provides sufficient iron for physiologic needs but cannot correct iron deficiency. (See 'Initial considerations' above.)
●Role of RBC transfusion – Patients with severe, severely symptomatic (eg, with symptoms of myocardial ischemia), or life-threatening anemia should be treated with red blood cell (RBC) transfusion (algorithm 1). (See 'Severe/life-threatening anemia' above.)
●Oral versus IV iron – Some conditions may affect iron dosing and/or the route of administration (oral versus intravenous [IV]) (table 2). We generally treat patients who have uncomplicated iron deficiency anemia with oral iron due to the ease of administration, as illustrated in the algorithm (algorithm 1). However, the availability of IV iron formulations with improved toxicity profiles has lowered the threshold at which many patients would prefer an IV preparation. We often use IV iron when treating pregnant individuals and individuals with inflammatory bowel disease, gastric surgery, or chronic kidney disease. (See 'Oral versus IV iron' above and "Anemia in pregnancy" and 'Older adults' above and 'Inflammatory bowel disease and iron-restricted erythropoiesis' above and 'Following gastrointestinal/bariatric surgery' above and 'Perioperative' above and 'Chronic kidney disease' above and 'Heart failure' above and 'H. pylori, peptic ulcer disease, and gastritis' above.)
•Dose and formulation (oral iron) – For the most part, all oral iron preparations are equally effective (table 4). Individuals treated with oral iron can choose between taking one tablet every other day (or on Monday, Wednesday, and Friday) or one tablet per day. Efficacy between these two schedules appears similar; gastrointestinal side effects are more common with daily dosing. Strategies to improve tolerability are listed above. (See 'Oral iron' above.)
•Dose and formulation (IV iron) – There are a number of settings in which IV may be preferable to oral administration, including ongoing blood loss, physiologic or anatomic abnormality that interferes with oral absorption or iron homeostasis, and intolerable gastrointestinal side effects of oral iron. A number of IV iron formulations are available (table 3); their dosing and administration are described above. (See 'Choice of IV formulation' above and 'Dosing/administration of specific IV iron preparations' above.)
●Adverse effects of oral iron – Gastrointestinal side effects are extremely common with oral iron administration. Strategies to reduce these effects include reducing the frequency to every other day if not done already, dietary modifications, and switching to a liquid formulation. (See 'Side effects (oral iron)' above and 'Strategies to improve tolerability' above.)
●Adverse effects of IV iron – Many clinicians are reluctant to use IV iron due to concerns about anaphylaxis. We believe true allergic reactions are exceedingly rare and vastly overestimated, largely due to experience with older products such as high molecular weight iron dextran (HMW ID), which is no longer used, and the practice of aggressively treating non-allergic infusion reactions with diphenhydramine and other therapies that convert the reaction to a more serious event. We do not use routine premedication prior to IV iron and we avoid diphenhydramine. For individuals with asthma, inflammatory rheumatic conditions, or multiple drug allergies, we generally limit premedication to a glucocorticoid alone. (See 'Allergic and infusion reactions' above.)
●Expected response – Effective treatment of iron deficiency results in resolution of symptoms, a modest reticulocytosis (peaking in 7 to 10 days), and normalization of the hemoglobin level in six to eight weeks. Causes for a lack of response include nonadherence to oral iron, ongoing blood loss, and incorrect initial diagnosis or the presence of additional diagnoses (table 10). Some of these additional diagnoses, such as celiac disease, may be especially important to evaluate. (See 'Response to iron supplementation' above.)
幾項小型試驗和觀察性研究已經證明了補充鐵劑對治療缺鐵相關疲勞但不伴隨貧血的益處：
●一項試驗隨機分配90 名患有疲勞、血清鐵蛋白≤50 ng/mL、血紅素≥12.0 g/dL 的非貧血停經前女性，在兩週內接受累積劑量為800 mg 的靜脈注射(IV) 鐵劑或安慰劑 [ 2 ] 。治療開始六週後，靜脈鐵劑治療組的疲勞狀況得到改善（兩組的基線分別為 4.5 和 10 分制，分別為 1.1 和 0.7）。對於基線血清鐵蛋白≤15 ng/mL 的患者，效果更為明顯。補充鐵劑的益處持續到 12 週。 IV 鐵劑組的不良事件較多（21% 對 9%），但均不嚴重。如預期的那樣，靜脈鐵劑組鐵蛋白增加（平均增加 98 ng/mL），而安慰劑組則沒有。觀察性研究也報告，接受靜脈鐵劑治療的鐵蛋白水平較低的非貧血停經前女性的症狀有所改善 [ 3 ]。
●三項試驗將鐵蛋白水平較低的非貧血女性隨機分組，分別接受口服鐵補充劑（通常每天 80 毫克元素鐵）與安慰劑或高鐵飲食，所有試驗均報告口服鐵可改善疲勞情況 [ 4- 6 ]。使用膳食鐵作為比較的試驗也發現飲食鐵有改善，但補充劑組中鐵蛋白的平均增加幅度較大 [ 4 ]。
●對跑步者和捐血者的其他試驗表明，補充鐵可以改善運動表現、睡眠障礙和指甲斷裂 [ 7-9 ]。
這些數據支持了上述建議，即缺鐵但不貧血的人應該補充鐵。尋找失血或鐵流失來源的重要性也適用於這些人。 (參見下文『缺乏/失血的來源』 )
不建議對沒有缺鐵的個體進行常規補鐵。在極少數情況下，如果所有其他幹預措施都已用盡，一些專家會在沒有明顯實驗室證據表明鐵儲存減少的情況下，治療患有缺鐵症狀（嗜冰癖或不寧腿綜合症）的患者。The benefit of iron replacement for iron deficiency-associated fatigue without anemia has been demonstrated in several small trials and observational studies:
●A trial randomly assigned 90 non-anemic premenopausal females with fatigue, serum ferritin ≤50 ng/mL, and hemoglobin ≥12.0 g/dL to receive a cumulative dose of 800 mg of intravenous (IV) iron or placebo over two weeks [2]. Six weeks after treatment initiation, fatigue was improved in the IV iron arm (decrease of 1.1 versus 0.7 on a 10-point scale, from a baseline of 4.5 in both groups). The effect was more pronounced in those with a baseline serum ferritin ≤15 ng/mL. Benefits of iron supplementation persisted at 12 weeks. Adverse events were greater in the IV iron group (21 versus 9 percent), but none were considered serious. As expected, the IV iron group had increased ferritin (mean increase, 98 ng/mL) and the placebo group did not. Observational studies have also reported improvement in symptoms in non-anemic premenopausal females with low ferritin who were treated with IV iron [3].
●Three trials, which randomly assigned groups of nonanemic females with low ferritin to oral iron supplementation (typically 80 mg of elemental iron daily) versus placebo or a high-iron diet, all reported improvement in fatigue with oral iron [4-6]. The trial that used dietary iron as a comparator also found improvement with dietary iron, but mean increases in ferritin were greater in the supplement group [4].
●Additional trials in runners and blood donors have demonstrated that iron repletion can improve athletic performance, sleep disturbance, and fingernail breakage [7-9].
These data are supportive of the above recommendation that iron should be repleted in those with iron deficiency without anemia. The importance of finding the source of blood loss or iron loss also applies in these individuals.
(下面中文是用 google 翻譯)
此演算法適用於缺鐵的個體，無論是否患有貧血。我們治療所有缺鐵性貧血患者和大多數缺鐵但不貧血的患者。對於口服鐵劑，隔日給藥可促進吸收並減少不良反應；然而，如果願意，有些患者可以合理地每天服用劑量，而不是每隔一天服用一次。
This algorithm applies to individuals with iron deficiency, with or without anemia. We treat all individuals who have iron deficiency anemia and most who have iron deficiency without anemia. For oral iron, alternate-day dosing facilitates absorption and reduces adverse effects; however, some patients may reasonably take their dose daily rather than every other day if preferred. Refer to UpToDate for efficacy and adverse effects of different oral and intravenous iron formulations and supporting evidence. There is a separate algorithm in UpToDate for managing iron deficiency in pregnancy.
對於缺鐵但沒有貧血. 仍建議治療. 但治療一段時間之後可測量 ferritin 是否正常.
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