Persistent Iron Deficiency Anemia in Patients with Celiac Disease Despite a Gluten-Free Diet

Abstract

Celiac disease (CD) is an autoimmune disorder characterized by intolerance to dietary gluten in genetically predisposed subjects. Iron deficiency anemia (IDA) is a common sign in CD, being the only abnormality in approximately 40% of celiac patients. A multifactorial etiology leads to IDA in CD. The two main causes are the villous atrophy of the mucosa at the site of iron absorption (the duodenum) and the resulting inflammation, which triggers the mechanism that leads to the anemia of chronic disease. Until now, it has been unclear why some patients with CD continue to have IDA despite a careful gluten-free diet (GFD) and the normalization of villous atrophy. Furthermore, some celiac patients are refractory to oral iron supplementation despite the healing of the mucosa, and they thus require periodic intravenous iron administration. The Marsh classification evaluates the degree of inflammation and villous atrophy, but it does not assess the possible persistence of ultrastructural and molecular alterations in enterocytes. The latter was found in CD in remission after adopting a GFD and could be responsible for the persistently reduced absorption of iron and IDA. Even in non-celiac gluten sensitivity, anemia is present in 18.5–22% of patients and appears to be related to ultrastructural and molecular alterations in intestinal microvilli. It is possible that a genetic component may also play a role in IDA. In this review, we evaluate and discuss the main mechanisms of IDA in CD and the possible causes of its persistence after adopting a GFD, as well as their therapeutic implications.

Iron Deficiency Anemia Refractory to Conventional Therapy but Responsive to Feralgine® in a Young Woman with Celiac Disease

“…Depending iron absorption on months necessary for the correction of intestinal mucosa by a good adherence to GFD, correction of IDA necessary result a long time consuming process. 1 , 2 , 4 , 5 …”

“…The option of a new kind of oral iron replacement treatment well tolerated and well absorbed consists in a particular challenge for patients with bowel diseases giving them the possibility of avoiding parenteral therapy. 3 , 4 Iron amino acid chelates showed a good absorption and tolerability. Many clinical trials demonstrated clinical bioequivalence between FS and Ferrous Bysglicinate Chelate (FBC), although administrated at different iron dosage (ratio 4 to 1respectively).…”

Diagnosis and Management of Autoimmune Hemolytic Anemia in Patients with Liver and Bowel Disorders

“…Anemia is a common feature of celiac disease. It is most frequently due to iron deficiency secondary to iron malabsorption [ 141 , 142 ], but folate/vitamin B12 deficiency, blood loss, and inflammation also have a role in its pathogenesis [ 143 , 144 ].…”

Iron Deficiency Anemia in Celiac Disease

“…Schieppattiet al [ 53 ] demonstrated a significant correlation between an increase in hemoglobin concentration and adherence to GFD; Stefanelli et al [ 54 ] and Annibale et al [ 36 ] evidenced a correlation between improving hemoglobin levels and decrease of histological scores of duodenal lesions after starting of a GFD. A normalization of the hemoglobin value was demonstrated after about 6–12 months from the beginning of the GFD alone, following the restoration of the integrity of the intestinal mucosa.…”

“…There are several factors that could explain the reason for the persistence of IDA after the adoption of a GFD and oral iron supplementation: non-adherence to a GFD, the presence of ultrastructural and/or molecular alterations of the enterocytes despite the reformation of the integrity of the duodenal mucosa or the presence of specific genetic factors [ 54 ].…”