COMMENTARY

Refractory Iron Deficiency Anemia -- Is Helicobacter pylori the Culprit?

Keechilat Pavithran, DM, Rajalakshmi Arjun, MBBS, Raman Aruna, MD, Mathew Thomas, MD

Disclosures

April 28, 2003

Introduction

Iron deficiency anemia (IDA) is the most common type of anemia worldwide, with a higher prevalence in India compared with developed countries. Refractory IDA accounts for about 15% of all IDAs. Prevalence of Helicobacter pylori infection is also higher in India (49.4%),[1] when compared with developed countries, and the evidence for causal association between H pylori and IDA is emerging.

We report 5 cases of patients with refractory IDA (resistant to optimal oral iron therapy for more than 3 months)/recurrent IDA who had H pylori infection and improved after treatment for H pylori. All patients were from the high-income group and had a suboptimal response to oral iron therapy or needed continuous or intermittent oral/parenteral iron treatment.

These 5 patients (3 females, 2 males) were specially screened, as nutritional deficiency was unlikely in this group. All had detailed evaluation to exclude any blood loss. Their median age was 36 years (range, 16-42 years) ( Table 1 ). These patients were tested for serum immunoglobulin G antibody against H pylori by ELISA method and were found to be positive. 14C breath test was not available. All patients received triple drug therapy for H pylori with clarithromycin, tinidazole, and lanzoprazole for 1 week along with supplemental oral iron for a period of 6 months. By 10 weeks, symptoms of anemia, hemoglobin percentage, and ferritin improved and were maintained on further follow up (median follow-up period, 14 months; range, 8-20 months). None of them relapsed during this period. This probably reflects a causal association between the two, though randomized controlled trials with larger numbers of patients are necessary to substantiate the same.

The postulated mechanisms[2] by which H pylori causes IDA are multiple -- (1) increased iron loss due to active bleeding secondary to gastritis; (2) achlorhydria resulting in reduced iron absorption; and (3) iron utilization by the bacterium. Choe and colleagues,[3] investigating an association between H pylori and IDA, randomized young female athletes with IDA into 2 groups and found that the group who received treatment for H pylori improved faster while the control group who were treated with oral iron alone showed no significant changes. Annibale and colleagues[4] and Ashorn and colleagues[5] also found a similar association between the two.

We strongly feel that H pylori infection might have a role in causing refractory iron deficiency anemia. Hence, H pylori infection has to be looked for, in all cases of refractory or recurrent iron deficiency anemia, as both the conditions are very common and coexistent in this part of the world. Proper eradication therapy for H pylori will help in reducing the morbidity associated with recurrent or refractory IDA.

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