Pediatr Gastroenterol Hepatol Nutr.  2019 Mar;22(2):152-161. 10.5223/pghn.2019.22.2.152.

Anemia Screening, Prevalence, and Treatment in Pediatric Inflammatory Bowel Disease in the United States, 2010–2014

• Miller SD
• Cuffari C
• Akhuemonkhan E
• Guerrerio
• Lehmann H
• Hutfless S

• KMID: 2440589
• DOI: http://doi.org/10.5223/pghn.2019.22.2.152

Abstract

PURPOSE
We examined the prevalence of anemia, annual screening for anemia, and treatment of anemia with iron among children with inflammatory bowel disease (IBD).
METHODS
A retrospective study of U.S. pediatric patients with IBD was performed in the MarketScan commercial claims database from 2010-2014. Children (ages 1-21) with at least two inpatient or outpatient encounters for IBD who had available lab and pharmacy data were included in the cohort. Anemia was defined using World Health Organization criteria. We used logistic regression to determine differences in screening, incident anemia, and treatment based on age at first IBD encounter and sex.
RESULTS
The cohort (n=2,446) included 1,560 Crohn's disease (CD) and 886 ulcerative colitis (UC). Approximately, 85% of CD and 81% of UC were screened for anemia. Among those screened, 51% with CD and 43% with UC had anemia. Only 24% of anemia patients with CD and 20% with UC were tested for iron deficiency; 85% were iron deficient. Intravenous (IV) iron was used to treat 4% of CD and 4% UC patients overall and 8% of those with anemia.
CONCLUSION
At least 80% of children with IBD were screened for anemia, although most did not receive follow-up tests for iron deficiency. The 43%-50% prevalence of anemia was consistent with prior studies. Under-treatment with IV iron points to a potential target for quality improvement.

Keyword

Crohn disease; Screening; Ulcerative colitis; Anemia; Iron-deficiency

MeSH Terms

Anemia*
Child
Cohort Studies
Colitis, Ulcerative
Crohn Disease
Follow-Up Studies
Humans
Inflammatory Bowel Diseases*
Inpatients
Iron
Logistic Models
Mass Screening*
Outpatients
Pharmacy
Prevalence*
Quality Improvement
Retrospective Studies
United States*
World Health Organization
Iron

Figure

• 

  Fig. 1 Prevalence of screening, anemia and iron deficiency anemia among children with IBD. Results are presented here of the % and number of patients who were screened for anemia with % rounded to 0 decimal places. The number of screened patients was used to determine the % of patients with anemia. The number of anemic patients was used to determine the % of patients with lab evaluation for iron deficiency. The number of patients with sufficient iron data was used to determine the % of iron deficient patients. IBD: inflammatory bowel disease, CD: Crohn's disease, UC: ulcerative colitis.

Reference

1. Benchimol EI, Fortinsky KJ, Gozdyra P, Van den Heuvel M, Van Limbergen J, Griffiths AM. Epidemiology of pediatric inflammatory bowel disease: a systematic review of international trends. Inflamm Bowel Dis. 2011; 17:423–439.

2. Kelsen J, Baldassano RN. Inflammatory bowel disease: the difference between children and adults. Inflamm Bowel Dis. 2008; 14:Suppl 2. S9–S11.

3. Goodhand JR, Kamperidis N, Rao A, Laskaratos F, McDermott A, Wahed M, et al. Prevalence and management of anemia in children, adolescents, and adults with inflammatory bowel disease. Inflamm Bowel Dis. 2012; 18:513–519.

4. Danese S, Hoffman C, Vel S, Greco M, Szabo H, Wilson B, et al. Anaemia from a patient perspective in inflammatory bowel disease: results from the European Federation of Crohn's and Ulcerative Colitis Association's online survey. Eur J Gastroenterol Hepatol. 2014; 26:1385–1391.

5. Wells CW, Lewis S, Barton JR, Corbett S. Effects of changes in hemoglobin level on quality of life and cognitive function in inflammatory bowel disease patients. Inflamm Bowel Dis. 2006; 12:123–130.

6. McCann JC, Ames BN. An overview of evidence for a causal relation between iron deficiency during development and deficits in cognitive or behavioral function. Am J Clin Nutr. 2007; 85:931–945.

7. Dignass AU, Gasche C, Bettenworth D, Birgegård G, Danese S, Gisbert JP, et al. European consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases. J Crohns Colitis. 2015; 9:211–222.

8. Mücke V, Mücke MM, Raine T, Bettenworth D. Diagnosis and treatment of anemia in patients with inflammatory bowel disease. Ann Gastroenterol. 2017; 30:15–22.

9. Gasche C, Berstad A, Befrits R, Beglinger C, Dignass A, Erichsen K, et al. Guidelines on the diagnosis and management of iron deficiency and anemia in inflammatory bowel diseases. Inflamm Bowel Dis. 2007; 13:1545–1553.

10. Alleyne M, Horne MK, Miller JL. Individualized treatment for iron-deficiency anemia in adults. Am J Med. 2008; 121:943–948.

11. World Health Organization. United Nations Children's Fund. United Nations University. Iron deficiency anemia: assessment, prevention and control [Internet]. Geneva: World Health Organization;2001. cited 2017 Oct 22. Available from: http://www.who.int/nutrition/publications/en/ida_assessment_prevention_control.pdf.

12. Rufo PA, Denson LA, Sylvester FA, Szigethy E, Sathya P, Lu Y, et al. Health supervision in the management of children and adolescents with IBD: NASPGHAN recommendations. J Pediatr Gastroenterol Nutr. 2012; 55:93–108.

13. de Silva AD, Tsironi E, Feakins RM, Rampton DS. Efficacy and tolerability of oral iron therapy in inflammatory bowel disease: a prospective, comparative trial. Aliment Pharmacol Ther. 2005; 22:1097–1105.

14. Avni T, Bieber A, Steinmetz T, Leibovici L, Gafter-Gvili A. Treatment of anemia in inflammatory bowel disease--systematic review and meta-analysis. PLoS One. 2013; 8:e75540.

15. Stein RE, Plantz K, Maxwell EC, Mamula P, Baldassano RN. Intravenous iron sucrose for treatment of iron deficiency anemia in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr. 2018; 66:e51–e55.

16. Valério de Azevedo S, Maltez C, Lopes AI. Pediatric Crohn's disease, iron deficiency anemia and intravenous iron treatment: a follow-up study. Scand J Gastroenterol. 2017; 52:29–33.

17. Danko I, Weidkamp M. Correction of iron deficiency anemia with intravenous iron sucrose in children with inflammatory bowel disease. J Pediatr Gastroenterol Nutr. 2016; 63:e107–e111.

18. Sjöberg D, Holmström T, Larsson M, Nielsen AL, Holmquist L, Rönnblom A. Anemia in a population-based IBD cohort (ICURE): still high prevalence after 1 year, especially among pediatric patients. Inflamm Bowel Dis. 2014; 20:2266–2270.

19. Gerasimidis K, Barclay A, Papangelou A, Missiou D, Buchanan E, Tracey C, et al. The epidemiology of anemia in pediatric inflammatory bowel disease: prevalence and associated factors at diagnosis and follow-up and the impact of exclusive enteral nutrition. Inflamm Bowel Dis. 2013; 19:2411–2422.

20. White JM, O'Connor S, Winter HS, Heyman MB, Kirschner BS, Ferry GD, et al. Inflammatory bowel disease in African American children compared with other racial/ethnic groups in a multicenter registry. Clin Gastroenterol Hepatol. 2008; 6:1361–1369.

21. Mack DR, Langton C, Markowitz J, LeLeiko N, Griffiths A, Bousvaros A, et al. Laboratory values for children with newly diagnosed inflammatory bowel disease. Pediatrics. 2007; 119:1113–1119.

22. Howarth LJ, Wiskin AE, Griffiths DM, Afzal NA, Beattie RM. Outcome of childhood ulcerative colitis at 2 years. Acta Paediatr. 2007; 96:1790–1793.

23. Khan K, Schwarzenberg SJ, Sharp H, Greenwood D, Weisdorf-Schindele S. Role of serology and routine laboratory tests in childhood inflammatory bowel disease. Inflamm Bowel Dis. 2002; 8:325–329.

24. Gryboski JD. Crohn's disease in children 10 years old and younger: comparison with ulcerative colitis. J Pediatr Gastroenterol Nutr. 1994; 18:174–182.

25. Revel-Vilk S, Tamary H, Broide E, Zoldan M, Dinari G, Zahavi I, et al. Serum transferrin receptor in children and adolescents with inflammatory bowel disease. Eur J Pediatr. 2000; 159:585–589.

26. Thomas DW, Sinatra FR. Screening laboratory tests for Crohn's disease. West J Med. 1989; 150:163–164.

27. Van Biervliet S, Smets F, Hofmann I, Degreef E, Hauser B, Bontems P, et al. The course of anaemia in children and adolescents with Crohn's disease included in a prospective registry. Int J Colorectal Dis. 2015; 30:51–56.

28. Wiskin AE, Fleming BJ, Wootton SA, Beattie RM. Anaemia and iron deficiency in children with inflammatory bowel disease. J Crohns Colitis. 2012; 6:687–691.

29. Wikholm E, Malmborg P, Forssberg M, Hederos CA, Wikström S. Iron deficiency is common during remission in children with inflammatory bowel disease. Glob Pediatr Health. 2016; 4:2333794X16633672.

30. Burbige EJ, Huang SH, Bayless TM. Clinical manifestations of Crohn's disease in children and adolescents. Pediatrics. 1975; 55:866–871.

31. Beeken WL. Absorptive defects in young people with regional enteritis. Pediatrics. 1973; 52:69–74.

32. Thayu M, Leonard MB, Baldassano RN, Mamula P. Prevalence of anemia in incident pediatric crohn disease: 177. J Pediatr Gastroenterol Nutr. 2005; 41:547–548.

33. Antunes CV, Hallack Neto AE, Nascimento CR, Chebli LA, Moutinho IL, Pinheiro BV, et al. Anemia in inflammatory bowel disease outpatients: prevalence, risk factors, and etiology. BioMed Res Int. 2015; 2015:728925.

34. Filmann N, Rey J, Schneeweiss S, Ardizzone S, Bager P, Bergamaschi G, et al. Prevalence of anemia in inflammatory bowel diseases in European countries: a systematic review and individual patient data meta-analysis. Inflamm Bowel Dis. 2014; 20:936–945.

35. Akhuemonkhan E, Parian A, Miller K, Hanauer S, Hutfless S. Prevalence and screening for anaemia in mild to moderate Crohn's disease and ulcerative colitis in the United States, 2010–2014. BMJ Open Gastroenterol. 2017; 4:e000155.

36. Blumenstein I, Dignass A, Vollmer S, Klemm W, Weber-Mangal S, Stein J. Current practice in the diagnosis and management of IBD-associated anaemia and iron deficiency in Germany: the German AnaemIBD Study. J Crohns Colitis. 2014; 8:1308–1314.

37. Ott C, Liebold A, Takses A, Strauch UG, Obermeier F. High prevalence but insufficient treatment of iron-deficiency anemia in patients with inflammatory bowel disease: results of a population-based cohort. Gastroenterol Res Pract. 2012; 2012:595970.

38. Hansen LG, Stella C. Health research data for the real world: the MarketScan databases [Internet]. Ann Arbor (MI): Truven Health Analytics;2011. cited 2016 Nov 11. Available from: http://truvenhealth.com/portals/0/assets/PH_11238_0612_TEMP_MarketScan_WP_FINAL.pdf.

39. Uhlig HH, Schwerd T, Koletzko S, Shah N, Kammermeier J, Elkadri A, et al. The diagnostic approach to monogenic very early onset inflammatory bowel disease. Gastroenterology. 2014; 147:990–1007.e3.

40. Regenstrief Institute. LOINC and RELMA complete package [Internet]. Indianapolis (IN): Regenstrief Institute;2017. cited 2017 Oct 10. Available from: https://loinc.org/downloads/relma/.