Ironic considerations in Mediterranean anemia
ANASTASIOS DRACOPOULOS, MD, of Toronto, ON, asks, "Is iron therapy indicated in patients who have Mediterranean anemia with very low mean corpuscular/cell volume (MCV) but low-normal iron levels? Is folic acid supplementation required?"
Mediterranean anemias, or thalassemias, are all associated with very low MCV, but this doesn't indicate iron deficiency. In uncomplicated conditions, especially thalassemia major or intermedia, serum ferritin is generally high, unless the patient has an infection, inflammation or connective tissue disorder, in which case, serum iron may be low. But you can't use that as evidence of iron deficiency unless the total iron binding capacity is high and the iron saturation is less than 16%. If serum ferritin is low or low normal, however, you have to assume that iron deficiency is present and you could give the patient a trial of iron therapy to see if the hemoglobin increases. The individual should also be investigated to find the source of blood loss. Avoid long-term use of iron, however. Once the deficiency is corrected and bleeding has stopped, treatment should be discontinued because patients with thalassemia major or intermedia are at risk of developing iron overload, even if they don't receive iron therapy. In the past, folic acid supplementation was recommended for thalassemia major or any chronic hemolytic anemia in order to ensure an adequate supply of folate for increased red cell production. These days, grain products are fortified with this vitamin, so most patients have enough. If their dietary folate is quite low, though, or hemolytic anemia is very severe, it's prudent to give additional folic acid. MS