P435. Management of iron deficiency in inflammatory bowel disease: results from a RAND/UCLA appropriateness study
W. Reinisch1, Y. Chowers2, S. Danese3, A. Dignass4, F. Gomollón5, O. Haagen Nielsen6, P. Lakatos7, C. Lees8, S. Lindgren9, M. Lukas10, G. Mantzaris11, P. Michetti12, B. Moum13, L. Peyrin Biroulet14, M. Toruner15, C.J. van der Woude16, G. Weiss17, H. Stoevelaar18, 1Medical University of Vienna, Department Internal Medicine III, Vienna, Austria, 2Rambam Medical Center, Department of Gastroenterology, Haifa, Israel, 3Humanitas Clinical and Research Center, Department of Gastroenterology, Milan, Italy, 4Agaplesion Markus Hospital, Department of Gastroenterology, Oncology, Infectious Diseases and Metabolism, Frankfurt, Germany, 5Hospital Clínico Universitario, CIBEREHD, Zaragoza, Spain, 6Herlev Hospital, University of Copenhagen, Department of Gastroenterology, Copenhagen, Denmark, 7Semmelweis University, 1st Department of Medicine, Budapest, Hungary, 8Western General Hospital, Department of Gastroenterology, Edinburgh, United Kingdom, 9University of Lund, University Hospital Skane, Department of Gastroenterology, Malmö, Sweden, 10Charles University, IBD Clinical and Reasearch Centre, ISCARE Lighthouse and 1st Medical Faculty, Prague, Czech Republic, 11Evangelismos Hospital, Department of Gastroenterology, Athens, Greece, 12Lausanne University Medical Center, Department of Gastroenterology, Lausanne, Switzerland, 13Oslo University Hospital, Department of Gastroenterology, Oslo, Norway, 14University Hospital of Nancy, Université Henri Poincaré 1, Inserm, U954 and Department of Hepato-Gastroenterology, Vandoeuvre-lès-Nancy, France, 15Ankara University School of Medicine, Department of Gastroenterology, Ankara, Turkey, 16Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, Netherlands, 17Medical University of Innsbruck, Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Innsbruck, Austria, 18Ismar Healthcare, Center for Decision Analysis and Support, Lier, Belgium
Iron deficiency, with or without anaemia, is a common and undertreated problem in patients with inflammatory bowel disease (IBD). Iron supplementation has been proven to be beneficial in many situations, and can be administered in various ways. This study aimed at formulating recommendations on treatment choice in relation to relevant clinical conditions.
Using the RAND/UCLA Appropriateness Method (RUAM), a European panel of 17 experts in IBD and iron deficiency assessed the appropriateness of different treatment regimens for a variety of clinical scenarios in patients with non-anaemic iron deficiency (NAID) and iron deficiency anaemia (IDA). Scenarios were permutations of variables considered relevant to treatment choice, including previous ID treatment, conditions associated with increased iron need, and IBD activity status. For IDA, also the haemoglobin level and physical symptoms of iron depletion were taken into consideration. Treatment options included no active treatment, adjustment of IBD medication only, oral iron supplementation (IS), intravenous (IV) regimens in low-dose (LD-IV) and high-dose (HD-IV), IV+ESA (erythropoietin stimulating agent), and blood transfusion. The panel process consisted of two individual rating rounds (9-point scale) and two plenary discussion meetings. Based on the median panel score and extent of agreement, appropriateness statements (appropriate, inappropriate, uncertain) were calculated for all clinical scenarios.
In the second round, the panel reached agreement on 71% of the 1148 treatment indications. ‘No treatment’ was never considered an appropriate option, and repeat treatment after previous failure was generally discouraged. For 98% of scenarios at least one treatment was appropriate. Adjustment of IBD medication was deemed appropriate in all NAID patients with active disease. Use of oral IS was mainly considered an option in NAID patients after previous successful treatment. IV regimens were often judged appropriate, with HD-IV being the preferred option in 77% of IDA scenarios. Blood transfusion and IV+ESA may be indicated in exceptional cases.
The RUAM was useful in establishing recommendations on the management of iron deficiency in patients with IBD. High-dose intravenous supplementation was more often considered appropriate than other options. An electronic tool is being developed to facilitate dissemination of the panel results.