Tiredness in a Man with Iron Deficiency and Red Flags
A 58-year-old man attends with six weeks of tiredness and breathlessness climbing stairs. He takes aspirin 75 mg daily (started five years ago after a transient ischaemic attack), atorvastatin and ramipril. He has never had bowel cancer screening. He denies visible rectal bleeding, but mentions his stools have become 'narrower' and he feels bloated after meals, and he has lost 3 kg without trying. Examination: pale conjunctivae, no lymphadenopathy, abdomen soft with no mass, no hepatosplenomegaly; rectal examination shows no palpable mass and no visible blood on the glove. Haemoglobin 104 g/L, MCV 74 fL, ferritin 8 µg/L, platelets 420 × 10⁹/L, creatinine normal, coeliac serology pending.
1. He asks whether he can 'just take iron tablets'. Is empirical iron alone acceptable here, and what is your investigation plan?
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No - not on its own. Iron deficiency anaemia in a man over 50 is a red flag in itself, and here it is compounded by unintentional weight loss, a change in stool calibre and bloating. Treating the haemoglobin without finding the lesion risks missing a colorectal cancer and delays diagnosis at a curable stage.
Plan:
- Refer on the suspected-cancer pathway for colonoscopy. Give both oral iron and the referral on the same day; do not let a 'wait for the iron response' interval stand in for investigation.
- Also consider upper GI endoscopy - he is on aspirin, and a proximal lesion is a real possibility; many pathways scope both ends in a man with iron deficiency anaemia.
- Check coeliac serology (already pending) and review aspirin as a contributor.
- FIT is not a substitute for endoscopy in a symptomatic patient with documented iron deficiency anaemia.
- Confirm with repeat ferritin only if diagnosis is uncertain; here the ferritin of 8 with microcytosis is diagnostic.
Frame it for him: 'The iron will help your energy, but it will not tell us why you are losing blood - that is what the camera test is for.'
2. He asks whether he should stop his aspirin while waiting for the tests. How do you decide, and what do you advise?
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Continue the aspirin. Reasons:
- It is being taken for secondary prevention after a TIA; stopping it exposes him to recurrent ischaemic stroke, which is a greater immediate harm than the bleeding risk.
- Aspirin may unmask or worsen GI blood loss, but it does not cause iron deficiency by itself - stopping it does not remove the need for endoscopy, so there is no diagnostic gain.
- The likely finding (ulcer, erosions) can be managed with acid suppression and, if needed, a switch to a PPI plus antiplatelet strategy after the scope.
Exceptions that would change my advice: active GI bleeding with haemodynamic compromise, or a plan for immediate high-risk intervention where the endoscopist requests it.
Do: add a PPI if he has dyspepsia, check for H. pylori at endoscopy, and document the reasoning in the notes so a later clinician does not stop the aspirin reflexively.
3. How will you prescribe iron, follow him up, and decide whether he needs a transfusion?
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Prescribing: oral ferrous sulphate (or fumarate) - often better tolerated and equally absorbed on alternate days, which reduces hepcidin-driven block. Take with vitamin C or on an empty stomach if tolerated; warn about black stools and constipation; avoid tea, coffee, calcium and antacids around the dose.
Monitoring: repeat full blood count at 4 weeks. A rise of ~10–20 g/L in haemoglobin is expected; a reticulocyte response comes earlier. If there is no response, consider adherence, ongoing blood loss, malabsorption (coeliac) or the wrong diagnosis. Continue iron for about 3 months after haemoglobin normalises to refill stores, then recheck.
Transfusion: not indicated in a stable, asymptomatic-to-mildly-symptomatic man at 104 g/L. Transfuse for haemodynamic instability, ongoing brisk bleeding, ischaemic cardiac symptoms, or a haemoglobin falling towards 70–80 g/L (threshold higher with cardiac disease). Transfusion here would mask the trend, add risk, and delay the diagnosis without improving his outcome.
Safety-net: return immediately for black or bloody stools, dizziness, chest pain or breathlessness at rest.