Iron deficiency without anemia

[soccerusa]

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So just starting in an academic hybrid job seeing both heme and onc but largely only heme referrals in the first few weeks. I've been essentially overrun with patients getting sent for IV iron from PCPs/midlevels. About half of them do not have anemia. Are people giving IV iron as a standard in patients with a normal hemoglobin? Some of these patients haven't given oral iron a real try.

I don't want to burn all my referral bridges right away but it seems excessive to give across the board.

Thoughts?

 

[bobsmith]

There's pretty good data to support treating symptomatic patients with iron deficiency even without anemia (PMID: 21705493 for example)

I usually do ask that they try oral iron first

And then if they don't tolerate oral iron, or if it's ineffective, I don't really have qualms about giving IV iron.

...and so I give a lot of IV iron. But it's a quick visit, patients often feel better and the $ / quality of life improvement is probably better than a lot of drugs we give in our field

 

[gutonc]

So just starting in an academic hybrid job seeing both heme and onc but largely only heme referrals in the first few weeks. I've been essentially overrun with patients getting sent for IV iron from PCPs/midlevels. About half of them do not have anemia. Are people giving IV iron as a standard in patients with a normal hemoglobin? Some of these patients haven't given oral iron a real try.

I don't want to burn all my referral bridges right away but it seems excessive to give across the board.

Thoughts?

I used to be like this

There's pretty good data to support treating symptomatic patients with iron deficiency even without anemia (PMID: 21705493 for example)

I usually do ask that they try oral iron first

And then if they don't tolerate oral iron, or if it's ineffective, I don't really have qualms about giving IV iron.

...and so I give a lot of IV iron. But it's a quick visit, patients often feel better and the $ / quality of life improvement is probably better than a lot of drugs we give in our field

And now I'm like this.

Agree. And I don't even fight it anymore. I give them a gram of InFed, tell them to take some oral iron, repeat labs in 3 mos and d/c back to PCP.

 

[HemeOncHopeful19]

I do the same just give the iron and move on. Oh and make sure you document you told them to go get scoped (they won’t half the time) to protect yourself down the road.

You can do whatever you want though you’re not gonna burn your referral bridge in an Academic hybrid job they are just clicking a nameless “refer to Big U down the road” button

 

[gutonc]

I do the same just give the iron and move on. Oh and make sure you document you told them to go get scoped (they won’t half the time) to protect yourself down the road.

I'll put the referral in myself just to CYA. I'll also do my $10K anemia workup panel too. If the referring's aren't going to put an ounce of thought into it, I'm not going to bother either.

 

[bobsmith]

I'll also do my $10K anemia workup panel too. If the referring's aren't going to put an ounce of thought into it, I'm not going to bother either.

Haha I haven't gotten quite this cynical yet, but ask me again in a few years...

 

[VA Hopeful Dr]

I'll put the referral in myself just to CYA. I'll also do my $10K anemia workup panel too. If the referring's aren't going to put an ounce of thought into it, I'm not going to bother either.

I way over order and over test. An unpleasant, but ultimately dismissed, medical board complaint will do that to you. Medical judgement doesn't mean anything anymore and no one is giving me a medal for trying to control costs for the patient.

 

[gutonc]

Haha I haven't gotten quite this cynical yet, but ask me again in a few years...

It's not cynical, it's practical. At least where I am, once people refer to me, they forget the problem even existed. So if I'm stuck with it, I'm just going to figure it out and either treat 'em or street 'em.

I also have a lot of people who drive 1-3h to see me (that is the distance to the next nearest hem/onc in any direction from here), and doing a piecemeal workup can be a hardship on them. So I have an anemia order set that includes about 15 different labs and referrals for EGD/colo in it. I draw the labs after the visit, tell them I'll call with any red flag results and have them schedule follow up after their endoscopy. Obviously if I find an alternative explanation in the labs (AIHA, myeloma, CKD4 with undetectable epo level that nobody caught before), I'll have them hold on the endoscopy. But IMO, if you're going to work something up, work it up.