When should I consider referring a patient with iron deficiency anaemia for further investigation or specialist input?

You should consider referring a patient with iron deficiency anaemia for further investigation or specialist input in several specific circumstances:

• Urgent Referral for Suspected Cancer:
  • Urgently refer people with iron deficiency anaemia using a suspected cancer pathway for colorectal cancer if they have a faecal immunochemical testing (FIT) result of at least 10 micrograms of haemoglobin per gram of faeces ¹,²,³.
  • For women aged over 55 years with postmenopausal bleeding, refer urgently using a suspected cancer pathway for an appointment within 2 weeks ¹,².
  • For women aged under 55 years with postmenopausal bleeding, consider referring urgently using a suspected cancer pathway for an appointment within 2 weeks ¹,².
• Referral to Gastroenterology:
  • Refer all men and postmenopausal women with iron deficiency anaemia, unless they have overt non-gastrointestinal bleeding ¹,².
  • Men with a haemoglobin (Hb) level less than 120 g/L and postmenopausal women with an Hb level less than 100 g/L should be investigated more urgently, as lower Hb levels may suggest more serious disease ¹,².
  • Refer all people aged 50 years or over with marked anaemia, or a significant family history of colorectal carcinoma, even if coeliac disease is found ¹,².
  • Refer premenopausal women (under 50 years) if they have colonic symptoms, a strong family history of gastrointestinal cancer (two affected first-degree relatives or one first-degree relative affected before age 50), persistent iron deficiency anaemia despite treatment, or if they do not menstruate (e.g., following hysterectomy) ¹,².
  • If coeliac serology is positive, refer to gastroenterology ¹,².
• Referral to Gynaecology:
  • Refer women if menorrhagia is unresponsive to medical management ¹,².
  • Refer women if there is postmenopausal bleeding ¹,².
• Referral to Obstetrics:
  • Refer pregnant women if there are significant symptoms and/or severe anaemia (haemoglobin less than 70 g/L), if pregnancy is at advanced gestation (over 34 weeks), or if there is failure to respond to a trial of oral iron ¹,².
• Other Specialist Referrals:
  • Arrange referral if the person has profound anaemia with signs of heart failure ¹,².
  • Arrange referral if the person is unable to tolerate, or is not responding to, oral iron treatment ¹,².
  • Arrange referral if the person has initially responded to iron treatment but develops anaemia again without an obvious underlying cause ¹,².
  • Arrange referral when the type of anaemia is in doubt ¹,².
  • Arrange referral when further haematological investigations are required that cannot be carried out in primary care (such as bone marrow examination or an investigation of bleeding state) ¹,².

  It is important to note that treatment with iron replacement therapy should not be deferred while awaiting investigations for iron deficiency anaemia, unless colonoscopy is imminent ¹,².