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Ferritin Cutoff Values Affect Diagnosis of Iron Deficiency
Ferritin is the parameter most often used in primary care to diagnose iron deficiency. The cutoff value of ferritin can affect the number of cases diagnosed, however. A study published in JAMA Network Open investigated how different cutoff values affect the diagnosis of iron deficiency.
The study, which included 255,351 adult primary care patients in Switzerland, showed that ferritin cutoff values of 15, 30, and 45 ng/mL were associated with incidences of iron deficiency diagnoses of 10.9, 29.9, and 48.3 cases per 1000 patient-years, respectively. In other words, as the cutoff value increases, the frequency of diagnosis also increases.
“It is a study to take into account, especially because of the number of patients it includes, and it can guide primary care clinical practice. As expected, as the cutoff point increases with respect to ferritin values, the incidence percentages of both iron deficiency and iron-deficiency anemia also increase,” Miguel Turégano-Yedro, MD, a family physician at the Casar de Cáceres Health Center in Spain, and coordinator of the Hematology Working Group of the Spanish Society of Primary Care Physicians, told this news organization. Ferritin is the most sensitive parameter for diagnosing iron deficiency and iron-deficiency anemia, he added. “When it is necessary to supplement a patient with iron, other parameters are taken into account, such as hemoglobin, to see if there is anemia.”
Ferritin Level
The ferritin level associated with iron deficiency in primary care is usually 15 ng/mL, said Dr. Turégano-Yedro. “If we assess patients with a ferritin level of 15 or less than 15, then we know that many cases will be symptomatic (with fatigue, tiredness, or lack of appetite) and, therefore, will need iron treatment. But if the ferritin cutoff value is increased to 30 ng/mL or 45 ng/mL, the incidence will be higher, although in many cases they will be asymptomatic and iron supplementation will not be necessary.”
He also pointed out that he does not consider it necessary to raise the cutoff to 45 ng/mL; however, “establishing the cutoff at 30 ng/mL, in a certain population at risk of iron deficiency or iron-deficiency anemia, may be interesting, for example in women of childbearing age, women with very heavy menstruation, children, frail elderly, people with gastrointestinal bleeding, or those who engage in physical exercise.”
Iron deficiency must be distinguished from anemia. “If the ferritin is below 15 ng/mL, there is iron deficiency, which may or may not be accompanied by symptoms, although usually most patients will have symptoms. Normally, to diagnose a patient with iron-deficiency anemia, on the one hand, they must have low hemoglobin, which indicates anemia, and on the other hand, low ferritin, which indicates iron deficiency.” Taking these parameters into account, the study does have a weakness. “It is striking that a percentage of patients in the study requested ferritin analysis without including hemoglobin, when hemoglobin is part of the basic analysis performed in Spain,” said Dr. Turégano-Yedro.
When to Supplement
The study highlights the incidence of nonanemic iron deficiency diagnoses associated with the choice of ferritin cutoff value. However, as Dr. Turégano-Yedro explained, the percentage of patients who have iron deficiency but do not have anemia is not very relevant. “In the case of family physicians in Spain, it is not usually taken into account, because if a patient has iron deficiency with or without anemia and is symptomatic, they should be given iron supplements.”
What if they do not have a deficiency but do have anemia? “In principle, iron supplementation is not necessary, because that anemia may be due to chronic disorders or it may be hemolytic anemia, so the case should be studied,” Dr. Turégano-Yedro concluded.
This story was translated from Univadis Spain, which is part of the Medscape Professional Network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Ferritin is the parameter most often used in primary care to diagnose iron deficiency. The cutoff value of ferritin can affect the number of cases diagnosed, however. A study published in JAMA Network Open investigated how different cutoff values affect the diagnosis of iron deficiency.
The study, which included 255,351 adult primary care patients in Switzerland, showed that ferritin cutoff values of 15, 30, and 45 ng/mL were associated with incidences of iron deficiency diagnoses of 10.9, 29.9, and 48.3 cases per 1000 patient-years, respectively. In other words, as the cutoff value increases, the frequency of diagnosis also increases.
“It is a study to take into account, especially because of the number of patients it includes, and it can guide primary care clinical practice. As expected, as the cutoff point increases with respect to ferritin values, the incidence percentages of both iron deficiency and iron-deficiency anemia also increase,” Miguel Turégano-Yedro, MD, a family physician at the Casar de Cáceres Health Center in Spain, and coordinator of the Hematology Working Group of the Spanish Society of Primary Care Physicians, told this news organization. Ferritin is the most sensitive parameter for diagnosing iron deficiency and iron-deficiency anemia, he added. “When it is necessary to supplement a patient with iron, other parameters are taken into account, such as hemoglobin, to see if there is anemia.”
Ferritin Level
The ferritin level associated with iron deficiency in primary care is usually 15 ng/mL, said Dr. Turégano-Yedro. “If we assess patients with a ferritin level of 15 or less than 15, then we know that many cases will be symptomatic (with fatigue, tiredness, or lack of appetite) and, therefore, will need iron treatment. But if the ferritin cutoff value is increased to 30 ng/mL or 45 ng/mL, the incidence will be higher, although in many cases they will be asymptomatic and iron supplementation will not be necessary.”
He also pointed out that he does not consider it necessary to raise the cutoff to 45 ng/mL; however, “establishing the cutoff at 30 ng/mL, in a certain population at risk of iron deficiency or iron-deficiency anemia, may be interesting, for example in women of childbearing age, women with very heavy menstruation, children, frail elderly, people with gastrointestinal bleeding, or those who engage in physical exercise.”
Iron deficiency must be distinguished from anemia. “If the ferritin is below 15 ng/mL, there is iron deficiency, which may or may not be accompanied by symptoms, although usually most patients will have symptoms. Normally, to diagnose a patient with iron-deficiency anemia, on the one hand, they must have low hemoglobin, which indicates anemia, and on the other hand, low ferritin, which indicates iron deficiency.” Taking these parameters into account, the study does have a weakness. “It is striking that a percentage of patients in the study requested ferritin analysis without including hemoglobin, when hemoglobin is part of the basic analysis performed in Spain,” said Dr. Turégano-Yedro.
When to Supplement
The study highlights the incidence of nonanemic iron deficiency diagnoses associated with the choice of ferritin cutoff value. However, as Dr. Turégano-Yedro explained, the percentage of patients who have iron deficiency but do not have anemia is not very relevant. “In the case of family physicians in Spain, it is not usually taken into account, because if a patient has iron deficiency with or without anemia and is symptomatic, they should be given iron supplements.”
What if they do not have a deficiency but do have anemia? “In principle, iron supplementation is not necessary, because that anemia may be due to chronic disorders or it may be hemolytic anemia, so the case should be studied,” Dr. Turégano-Yedro concluded.
This story was translated from Univadis Spain, which is part of the Medscape Professional Network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Ferritin is the parameter most often used in primary care to diagnose iron deficiency. The cutoff value of ferritin can affect the number of cases diagnosed, however. A study published in JAMA Network Open investigated how different cutoff values affect the diagnosis of iron deficiency.
The study, which included 255,351 adult primary care patients in Switzerland, showed that ferritin cutoff values of 15, 30, and 45 ng/mL were associated with incidences of iron deficiency diagnoses of 10.9, 29.9, and 48.3 cases per 1000 patient-years, respectively. In other words, as the cutoff value increases, the frequency of diagnosis also increases.
“It is a study to take into account, especially because of the number of patients it includes, and it can guide primary care clinical practice. As expected, as the cutoff point increases with respect to ferritin values, the incidence percentages of both iron deficiency and iron-deficiency anemia also increase,” Miguel Turégano-Yedro, MD, a family physician at the Casar de Cáceres Health Center in Spain, and coordinator of the Hematology Working Group of the Spanish Society of Primary Care Physicians, told this news organization. Ferritin is the most sensitive parameter for diagnosing iron deficiency and iron-deficiency anemia, he added. “When it is necessary to supplement a patient with iron, other parameters are taken into account, such as hemoglobin, to see if there is anemia.”
Ferritin Level
The ferritin level associated with iron deficiency in primary care is usually 15 ng/mL, said Dr. Turégano-Yedro. “If we assess patients with a ferritin level of 15 or less than 15, then we know that many cases will be symptomatic (with fatigue, tiredness, or lack of appetite) and, therefore, will need iron treatment. But if the ferritin cutoff value is increased to 30 ng/mL or 45 ng/mL, the incidence will be higher, although in many cases they will be asymptomatic and iron supplementation will not be necessary.”
He also pointed out that he does not consider it necessary to raise the cutoff to 45 ng/mL; however, “establishing the cutoff at 30 ng/mL, in a certain population at risk of iron deficiency or iron-deficiency anemia, may be interesting, for example in women of childbearing age, women with very heavy menstruation, children, frail elderly, people with gastrointestinal bleeding, or those who engage in physical exercise.”
Iron deficiency must be distinguished from anemia. “If the ferritin is below 15 ng/mL, there is iron deficiency, which may or may not be accompanied by symptoms, although usually most patients will have symptoms. Normally, to diagnose a patient with iron-deficiency anemia, on the one hand, they must have low hemoglobin, which indicates anemia, and on the other hand, low ferritin, which indicates iron deficiency.” Taking these parameters into account, the study does have a weakness. “It is striking that a percentage of patients in the study requested ferritin analysis without including hemoglobin, when hemoglobin is part of the basic analysis performed in Spain,” said Dr. Turégano-Yedro.
When to Supplement
The study highlights the incidence of nonanemic iron deficiency diagnoses associated with the choice of ferritin cutoff value. However, as Dr. Turégano-Yedro explained, the percentage of patients who have iron deficiency but do not have anemia is not very relevant. “In the case of family physicians in Spain, it is not usually taken into account, because if a patient has iron deficiency with or without anemia and is symptomatic, they should be given iron supplements.”
What if they do not have a deficiency but do have anemia? “In principle, iron supplementation is not necessary, because that anemia may be due to chronic disorders or it may be hemolytic anemia, so the case should be studied,” Dr. Turégano-Yedro concluded.
This story was translated from Univadis Spain, which is part of the Medscape Professional Network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
FROM JAMA NETWORK OPEN
New international consensus document on treating OSA
The Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) has issued a new international consensus document (ICD) on obstructive sleep apnea (OSA). The objective is to improve the diagnosis and treatment of one of the most prevalent sleep disorders.
It provides a series of clinical guidelines to help health care professionals make the best decisions for adult patients with OSA. Notably, the authors propose changing the name from sleep apnea syndrome. In recommending the term OSA, they reintroduce the term “obstructive” – to differentiate the disorder from central sleep apnea – and remove the outdated word “syndrome.”
“The definition has also been changed, as it was a bit vague and difficult to understand. And there are significant changes to the treatment and to the diagnostic algorithms – one for primary care and another for sleep units,” Olga Mediano, MD, said in an interview. She is a SEPAR pulmonologist, first author of the ICD, and the coordinator of SEPAR 2022 Year of Intermediate Respiratory Care Units.
Diagnosis in primary care
The ICD indicates that all levels of care must be involved in the management of OSA, a condition in which complete or partial upper airway blockage occurs during sleep, causing the individual to stop breathing for a few seconds. These pauses, which produce hypoxia and sleep fragmentation, increase the risk of workplace and traffic accidents, affect cardiovascular health, and contribute to uncontrolled or resistant hypertension.
The recommendations in the ICD aim at increasing the role of primary care physicians so as to reduce underdiagnosis of OSA in primary care. “The vast majority of patients with OSA haven’t been diagnosed. In fact, those whom we have diagnosed are the patients with the most severe cases – in other words, patients who present with the most symptoms,” said Dr. Mediano. She explained that many patients with OSA don’t consider it a medical condition, so they do not go to the doctor.
“The other big problem is that, before, there was a preconceived notion of the typical OSA patient: A middle-aged obese man who’s fallen asleep in the waiting room. However, there are many other profiles: thin build, women. ... Sleep has a heterogeneous profile, and all profiles need to be known,” said Dr. Mediano. The difficulties in carrying out a sleep study with the various patients are an added problem that the new consensus document also seeks to resolve. “The step we’ve taken is to involve the primary care physician in super-simplified studies to reach more people,” she said. For this, the primary care site must work in coordination with a sleep unit.
“In the super-simplified study, the patient is given a machine to use at home; they hook themselves up to it when they go to sleep. This machine records the number of apnea episodes the patient experiences during the night, as well as the oxygen level. The next day, the patient returns the machine. The data are downloaded to a computer. The software analyzes the breathing pauses that the patient had during the night and automatically gives a series of values that, if very pronounced, as the document indicates, would lead to a diagnosis of OSA. Once diagnosed by a primary care physician, the patient is referred to a sleep unit where treatment can then be assessed,” explained Dr. Mediano.
Different treatments
The new ICD’s approach incorporates therapeutic alternatives as well. Until now, many consensus documents and clinical guidelines have focused on continuous positive airway pressure therapy, in which a machine delivers continuous airflow to help keep the patient’s airway open and unobstructed during sleep. Some guidelines recommend its use, and others do not. “However, in this new document, management of the patient is much more multidisciplinary. What changes, with respect to the treatment, is the philosophy. It’s not one single type of treatment; rather, other therapeutic options are kept in mind,” said Dr. Mediano.
First, treatment of reversible causes of OSA must be offered. The conditions that lead to OSA and that can be reversed are addressed. These include overweight and obesity; heavy drinking; tonsillar hypertrophy, or severe dental or facial alterations, for which surgery can be considered; and gastroesophageal reflux or hypothyroidism, both of which can be treated. “For example, the leading cause of sleep apnea is obesity. If we can get the patient to lose weight, that can end up making the OSA go away. What does the document say? Well, you have to try to implement intensive strategies regarding diet, exercise, etc. And if that’s not enough, you need to consider using drugs or even bariatric surgery,” said Dr. Mediano.
“If there’s no one definitive treatment, we highly recommend that all patients implement hygienic-dietary measures and then assess all the therapeutic options. In some cases, several can be in place at the same time,” she said. Various medical specialists can play a role in the treatment of OSA, said Dr. Mediano. They include otolaryngologists, maxillofacial surgeons, dentists, cardiologists, and neurophysiologists, to mention a few.
A website has been created to explain the ICD. There, visitors will be able to find the most up-to-date version of the ICD as well as related information, news, and materials.
A version of this article appeared on Medscape.com. This article was translated from Univadis Spain.
The Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) has issued a new international consensus document (ICD) on obstructive sleep apnea (OSA). The objective is to improve the diagnosis and treatment of one of the most prevalent sleep disorders.
It provides a series of clinical guidelines to help health care professionals make the best decisions for adult patients with OSA. Notably, the authors propose changing the name from sleep apnea syndrome. In recommending the term OSA, they reintroduce the term “obstructive” – to differentiate the disorder from central sleep apnea – and remove the outdated word “syndrome.”
“The definition has also been changed, as it was a bit vague and difficult to understand. And there are significant changes to the treatment and to the diagnostic algorithms – one for primary care and another for sleep units,” Olga Mediano, MD, said in an interview. She is a SEPAR pulmonologist, first author of the ICD, and the coordinator of SEPAR 2022 Year of Intermediate Respiratory Care Units.
Diagnosis in primary care
The ICD indicates that all levels of care must be involved in the management of OSA, a condition in which complete or partial upper airway blockage occurs during sleep, causing the individual to stop breathing for a few seconds. These pauses, which produce hypoxia and sleep fragmentation, increase the risk of workplace and traffic accidents, affect cardiovascular health, and contribute to uncontrolled or resistant hypertension.
The recommendations in the ICD aim at increasing the role of primary care physicians so as to reduce underdiagnosis of OSA in primary care. “The vast majority of patients with OSA haven’t been diagnosed. In fact, those whom we have diagnosed are the patients with the most severe cases – in other words, patients who present with the most symptoms,” said Dr. Mediano. She explained that many patients with OSA don’t consider it a medical condition, so they do not go to the doctor.
“The other big problem is that, before, there was a preconceived notion of the typical OSA patient: A middle-aged obese man who’s fallen asleep in the waiting room. However, there are many other profiles: thin build, women. ... Sleep has a heterogeneous profile, and all profiles need to be known,” said Dr. Mediano. The difficulties in carrying out a sleep study with the various patients are an added problem that the new consensus document also seeks to resolve. “The step we’ve taken is to involve the primary care physician in super-simplified studies to reach more people,” she said. For this, the primary care site must work in coordination with a sleep unit.
“In the super-simplified study, the patient is given a machine to use at home; they hook themselves up to it when they go to sleep. This machine records the number of apnea episodes the patient experiences during the night, as well as the oxygen level. The next day, the patient returns the machine. The data are downloaded to a computer. The software analyzes the breathing pauses that the patient had during the night and automatically gives a series of values that, if very pronounced, as the document indicates, would lead to a diagnosis of OSA. Once diagnosed by a primary care physician, the patient is referred to a sleep unit where treatment can then be assessed,” explained Dr. Mediano.
Different treatments
The new ICD’s approach incorporates therapeutic alternatives as well. Until now, many consensus documents and clinical guidelines have focused on continuous positive airway pressure therapy, in which a machine delivers continuous airflow to help keep the patient’s airway open and unobstructed during sleep. Some guidelines recommend its use, and others do not. “However, in this new document, management of the patient is much more multidisciplinary. What changes, with respect to the treatment, is the philosophy. It’s not one single type of treatment; rather, other therapeutic options are kept in mind,” said Dr. Mediano.
First, treatment of reversible causes of OSA must be offered. The conditions that lead to OSA and that can be reversed are addressed. These include overweight and obesity; heavy drinking; tonsillar hypertrophy, or severe dental or facial alterations, for which surgery can be considered; and gastroesophageal reflux or hypothyroidism, both of which can be treated. “For example, the leading cause of sleep apnea is obesity. If we can get the patient to lose weight, that can end up making the OSA go away. What does the document say? Well, you have to try to implement intensive strategies regarding diet, exercise, etc. And if that’s not enough, you need to consider using drugs or even bariatric surgery,” said Dr. Mediano.
“If there’s no one definitive treatment, we highly recommend that all patients implement hygienic-dietary measures and then assess all the therapeutic options. In some cases, several can be in place at the same time,” she said. Various medical specialists can play a role in the treatment of OSA, said Dr. Mediano. They include otolaryngologists, maxillofacial surgeons, dentists, cardiologists, and neurophysiologists, to mention a few.
A website has been created to explain the ICD. There, visitors will be able to find the most up-to-date version of the ICD as well as related information, news, and materials.
A version of this article appeared on Medscape.com. This article was translated from Univadis Spain.
The Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) has issued a new international consensus document (ICD) on obstructive sleep apnea (OSA). The objective is to improve the diagnosis and treatment of one of the most prevalent sleep disorders.
It provides a series of clinical guidelines to help health care professionals make the best decisions for adult patients with OSA. Notably, the authors propose changing the name from sleep apnea syndrome. In recommending the term OSA, they reintroduce the term “obstructive” – to differentiate the disorder from central sleep apnea – and remove the outdated word “syndrome.”
“The definition has also been changed, as it was a bit vague and difficult to understand. And there are significant changes to the treatment and to the diagnostic algorithms – one for primary care and another for sleep units,” Olga Mediano, MD, said in an interview. She is a SEPAR pulmonologist, first author of the ICD, and the coordinator of SEPAR 2022 Year of Intermediate Respiratory Care Units.
Diagnosis in primary care
The ICD indicates that all levels of care must be involved in the management of OSA, a condition in which complete or partial upper airway blockage occurs during sleep, causing the individual to stop breathing for a few seconds. These pauses, which produce hypoxia and sleep fragmentation, increase the risk of workplace and traffic accidents, affect cardiovascular health, and contribute to uncontrolled or resistant hypertension.
The recommendations in the ICD aim at increasing the role of primary care physicians so as to reduce underdiagnosis of OSA in primary care. “The vast majority of patients with OSA haven’t been diagnosed. In fact, those whom we have diagnosed are the patients with the most severe cases – in other words, patients who present with the most symptoms,” said Dr. Mediano. She explained that many patients with OSA don’t consider it a medical condition, so they do not go to the doctor.
“The other big problem is that, before, there was a preconceived notion of the typical OSA patient: A middle-aged obese man who’s fallen asleep in the waiting room. However, there are many other profiles: thin build, women. ... Sleep has a heterogeneous profile, and all profiles need to be known,” said Dr. Mediano. The difficulties in carrying out a sleep study with the various patients are an added problem that the new consensus document also seeks to resolve. “The step we’ve taken is to involve the primary care physician in super-simplified studies to reach more people,” she said. For this, the primary care site must work in coordination with a sleep unit.
“In the super-simplified study, the patient is given a machine to use at home; they hook themselves up to it when they go to sleep. This machine records the number of apnea episodes the patient experiences during the night, as well as the oxygen level. The next day, the patient returns the machine. The data are downloaded to a computer. The software analyzes the breathing pauses that the patient had during the night and automatically gives a series of values that, if very pronounced, as the document indicates, would lead to a diagnosis of OSA. Once diagnosed by a primary care physician, the patient is referred to a sleep unit where treatment can then be assessed,” explained Dr. Mediano.
Different treatments
The new ICD’s approach incorporates therapeutic alternatives as well. Until now, many consensus documents and clinical guidelines have focused on continuous positive airway pressure therapy, in which a machine delivers continuous airflow to help keep the patient’s airway open and unobstructed during sleep. Some guidelines recommend its use, and others do not. “However, in this new document, management of the patient is much more multidisciplinary. What changes, with respect to the treatment, is the philosophy. It’s not one single type of treatment; rather, other therapeutic options are kept in mind,” said Dr. Mediano.
First, treatment of reversible causes of OSA must be offered. The conditions that lead to OSA and that can be reversed are addressed. These include overweight and obesity; heavy drinking; tonsillar hypertrophy, or severe dental or facial alterations, for which surgery can be considered; and gastroesophageal reflux or hypothyroidism, both of which can be treated. “For example, the leading cause of sleep apnea is obesity. If we can get the patient to lose weight, that can end up making the OSA go away. What does the document say? Well, you have to try to implement intensive strategies regarding diet, exercise, etc. And if that’s not enough, you need to consider using drugs or even bariatric surgery,” said Dr. Mediano.
“If there’s no one definitive treatment, we highly recommend that all patients implement hygienic-dietary measures and then assess all the therapeutic options. In some cases, several can be in place at the same time,” she said. Various medical specialists can play a role in the treatment of OSA, said Dr. Mediano. They include otolaryngologists, maxillofacial surgeons, dentists, cardiologists, and neurophysiologists, to mention a few.
A website has been created to explain the ICD. There, visitors will be able to find the most up-to-date version of the ICD as well as related information, news, and materials.
A version of this article appeared on Medscape.com. This article was translated from Univadis Spain.