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Perioperative Iron Plus BOC Improves Outcomes in Patients Undergoing Gynecologic Procedures

Study results being presented at the 2019 ASH Annual Meeting & Exposition suggest that combining perioperative iron with blood optimization compound (BOC) can lead to improved patient outcomes.

“Perioperative red blood cell (RBC) transfusion is associated with poor patient outcomes. RBC transfusion rates have been decreasing across different types of surgeries as a result of implementing patient blood management (PBM) strategies; while RBC transfusion rates in gynecologic surgeries have remained static,” explained Emily Sirotich, BSc, McMaster University, Hamilton, Ontario, Canada, and colleagues.

“Women are at increased risk of anemia, specifically iron deficiency anemia from gynecologic blood loss putting them at increased risk of requiring perioperative RBC transfusion. PBM encourages preoperative iron supplementation to optimize patients’ hemoglobin (Hb) levels; however, evidence specific to gynecological procedures is lacking,” they continued.

Ms Sirotich conducted a systematic review to evaluate whether the perioperative use of iron supplementation affects patient outcomes in women undergoing gynecologic procedures compared with placebo, standard care, or lack of treatment altogether.

Using the Cochrane Risk of Bias tool, investigators collected randomized controlled trial data comparing patients undergoing gynecologic procedures perioperatively provided with iron supplementation or a comparator. Studies were found via MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science, with additional records collected from theses, conference proceedings, and grey literature.

Study data were pooled via the random-effects (DerSimonian and Laird) method of meta-analysis and assessed using the GRADE approach.

Although 11 trials met inclusion criteria, two were excluded and seven were ultimately deemed appropriate for meta-analysis (n=447). Notably, iron supplementation was used in both arms of these studies, which included four comparing iron plus erythropoietin stimulating agents with iron alone and three comparing iron plus gonadotropin-releasing hormone analogue/agonist with iron alone.mAccording to Ms Sirotich and colleagues, six trials had overall low risk for bias and one had a high risk for bias.

When iron was combined with BOC vs administered alone, RBC transfusions were significantly reduced during the perioperative period (risk ratio [RR], 0.33; 95% CI, 0.16-0.70; P = .003). This combination was also tied to a significantly higher median preoperative Hb level of 12.87g/dL (95% CI, 11.13-14.61 g/dL) vs Δ1.16 g/dL (95% CI, 1.01-1.31g/dL; P <.00001) in those given oral iron alone.

“Among 336 women in six randomized controlled trials, women who had taken a BOC in addition to iron had a postoperative Hb of 11.53g/dl. This was significantly higher than those who took iron supplements alone,” Ms Sirotich and colleagues reported.

Although patients in five studies (n=289) had adverse events (AEs), it was determined that BOC did not yield a statistically significant impact on AE incidence (RR, 0.98; 95% CI, 0.83-1.17; P = .85).

“Perioperative use of iron in combination with a BOC in women undergoing gynecological procedures may reduce the need for perioperative RBC transfusions and improve preoperative Hb levels with high certainty of evidence. There was very low certainty of evidence for the impact of iron plus BOC on postoperative Hb levels and the number of AEs,” Ms Sirotich and colleagues said, adding that further research is required to address the role perioperative iron supplementation plays in gynecologic procedures.

“The results of this systematic review suggest that the use of perioperative iron with BOC may improve patient outcomes. Lack of randomized controlled trials comparing iron to placebo is a limitation. Analysis of existing observational studies may offer additional data to supplement the results of this meta-analysis,” they concluded. —Hina Porcelli

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