A Study to Compare Liposomal Iron With Ferrous Ascorbate in the Treatment of Iron Deficiency Anemia in Children

Effect of Ferrous Ascorbate Versus Liposomal Iron on Hemoglobin Concentration and Iron Indices in 6 to 59 Months Age Children With Nutritional Iron-Deficiency Anemia: A Double-blinded Single Centre Randomized Clinical Trial

This trial is designed to compare the efficacy of ferrous ascorbate versus liposomal iron for the treatment of nutritional iron deficiency anemia (IDA) amongst 6 to 59 months age children as determined by the increase in hemoglobin concentration and change in iron indices after 12 weeks of treatment. This study will be a randomized double-blinded single-center study done at the outpatient department of the Department of Pediatrics. All the children between 6 months to 59 months with nutritional IDA will be enrolled in the study. Written informed consent will be taken from the caregiver. At baseline detailed history will be taken and a complete physical examination will be done. Complete blood count (CBC), Peripheral smear, corrected reticulocyte count, Serum iron, Serum ferritin, and serum Total iron binding capacity(TIBC) will be done at baseline. Transferrin saturation will be calculated with the formula Serum Iron/ TIBC ×100. C Reactive Protein (CRP) and alpha1- acid glycoprotein (AGP) will be done to look for inflammation. Eligible subjects would be randomized in a 1:1 ratio by computerized software to receive either ferrous ascorbate or liposomal iron. Subjects in the ferrous ascorbate group would be given the drug at a dose of 3mg/kg/day OD of elemental iron. Subjects in the liposomal group would be given 1mg/kg/day OD of liposomal iron. Follow-up visits would be done at 4 and 12 weeks. Follow-up at 4 weeks is required to check the initial response to treatment and identify nonresponders and at 12 weeks is required to see the final response and thus decide upon continuation or discontinuation of treatment. In the follow-up visit at 4 and 12 weeks, CBC, Iron profile (Iron, Ferritin, and TIBC), CRP, and AGP will be done. Corrected Reticulocyte will be done at 4 weeks only. Any adverse effects of therapy will be noted. Adherence to therapy will be checked by measuring the volume of unused medicine in the bottle at each visit. All the statistically analyzed continuous data will be presented as mean ± standard deviation (SD). The categorical data will be reported as a percentage. Student's t-tests will be used to compare means. The χ2 test will be used to compare categorical outcomes, including the proportion of patients with dropouts, adverse effects, and adherence measures. The percentage volume of unused study medication returned at each visit will be compared using the Wilcoxon rank sign test. p<0.05 will be considered statistically significant.

1. Research Hypothesis: Liposomal iron preparation is equally effective and more tolerable than ferrous ascorbate in treating iron deficiency anemia in 6 to 59 months age children.

2. Background & Rationale of the study: Iron deficiency anemia (IDA) is highly prevalent worldwide with underdeveloped and developing countries being most affected. As per the recent NFHS-5 data, 67.1% of 6 to 59 months of age children are anemic in India. About 1/3rd under 5 children reportedly have iron deficiency anemia in India. Poor breastfeeding practices, untimely and improper complementary feeding, predominant milk-based diet, recurrent infections, and low socio-economic status are some of the common risk factors for IDA. Children under 5 years of age are more vulnerable to IDA because of their rapid growth and increased requirement. IDA leads to both short and long-term morbidities including poor appetite, irritability, recurrent infections, and neurodevelopment impairment. Prevention, early diagnosis, and early intervention are keys to managing IDA and thus preventing complications. Ferrous sulphate, ferrous ascorbate, carbonyl iron, polysaccharide iron complex, and liposomal iron are some of the iron preparations which are used as per the personal choice of the treating pediatrician. Poor palatability, untoward gastrointestinal side effects, and staining of teeth are some of the factors which negatively impact compliance with iron therapy. Therefore newer iron preparations need to be explored which can counteract these side effects. Liposomal iron, a form of ferric pyrophosphate is transported within a phospholipid membrane, absorbed by the intestinal M cells, reaches to the liver directly through lymphatics, and is finally released. Due to this mechanism, liposomal iron has been reported to have better bioavailability than traditional iron preparations thus requiring lesser doses and producing fewer adverse effects. Liposomal iron has reportedly been used successfully in the adult population including pregnant females and chronic kidney disease patients. A recent multicentre study has reported that liposomal iron is being used widely in children for IDA. Liposomal iron is given in droplet dispenser form thus facilitating the administration of precise doses in young children. Thus it can be hypothesized that liposomal iron is equally effective as ferrous salts and have better tolerability. However, there is a paucity of studies in the literature on liposomal iron for the treatment of IDA in children. As per our knowledge, there are no randomized controlled trials in the under-5 children group comparing liposomal iron with any other iron preparation. Since ferrous ascorbate is one of the most commonly prescribed iron preparations, therefore this trial would be designed to compare the efficacy of ferrous ascorbate with liposomal iron. The dose of Ferrous ascorbate would be 3mg/kg once daily dosing and the dose of liposomal iron would be 1mg/kg once a day. The dose of drugs was decided as per the WHO recommendations, pediatric textbooks, and recent trials.

3. Preliminary work done if any: No

4. The relevance and the expected outcome of the proposed study: Iron deficiency anemia is highly prevalent in under 5 children in India. Prevention, early diagnosis, and early intervention are the key to managing IDA. Several iron preparations are available across the world. Liposomal iron preparation is expected not to be inferior to commonly used ferrous ascorbate in treating iron deficiency anemia in children. Liposomal iron is also less likely to have common adverse effects associated with other commonly used iron preparations and thus reducing the rate of discontinuation of the medicine.

5. Specific objectives

   Primary objective:

   a. To compare the efficacy of ferrous ascorbate versus liposomal iron for the treatment of nutritional IDA amongst 6 to 59 months age children as determined by the increase in hemoglobin concentration after 12 weeks of treatment

   Secondary objective:

   1. To compare the change in other laboratory parameters of IDA- MCV, corrected reticulocyte count, serum iron, serum ferritin (corrected for markers of inflammation), TIBC, and transferrin saturation between ferrous ascorbate and liposomal iron group.
   2. To compare the adverse effects of drugs between the two groups
   3. To compare the adherence to drugs amongst study subjects in the two groups.

6. Work plan methodology/experimental design to accomplish the stated aim including the sample size (Patient/Control/Volunteers) and source of volunteers/Control:

Study population: children from 6 to 59 months of age attending OPD (outpatient department) of the Pediatrics Department with IDA.

Study design: This study is a randomized, controlled, double-blinded single-center trial to compare the efficacy of ferrous ascorbate versus liposomal iron for the treatment of nutritional IDA in 6 to 59 months age children.

Study setting: outpatient department of Pediatrics of the institute Consent: Written informed consent would be taken from the caregiver

Study protocol:

• Laboratory definition of Anemia: Hemoglobin <11g/dl (as per WHO definition).
• Laboratory definition of IDA:

S No.

Laboratory Tests Performed

Definition of IDA 1. Hemoglobin concentration < 11 gm/dl 2. Mean cell volume (MCV) < 70 µg/dL 3. Serum iron < 30 µg/dL 4a. Serum ferritin (after applying correction factor for CRP and AGP ) ≤ 12 ng/ml 5. Total iron binding capacity (TIBC) > 425 µg/dL 6. Transferrin saturation(Iron×100/TIBC) <16% 7. Corrected reticulocyte count <0.5%

For enrolment in the study patient should have criteria 1& 2 and atleast one of 3,4,5,6

• Correction of Serum Ferritin as per markers of inflammation

Individuals will be categorised into four groups based on their CRP and AGP concentrations:

1. an apparently healthy reference group: (CRP ≤ 5 mg L-1 and AGP ≤ 1gL-1);

2. an incubation group (CRP > 5 mg L-1 and AGP ≤ 1gL-1);

3. an early convalescence group (CRP > 5 mg L-1 and AGP > 1gL-1); and

4. a late convalescence group (CRP ≤ 5 mg L-1 and AGP > 1gL-1). Individual serum ferritin concentrations will then be adjusted by using the relevant, group-specific correction factor(CF) as a multiplier and repeating the calculation . For the incubation group a CF of 0.77 will be used, and for the early and late convalescence groups CFs of 0.53 and 0.75 will be used, respectively.

   • Baseline assessment:

     1. History and physical examination: detailed history including demography, dietary intake of child, any other factors predisposing to IDA, any recent blood transfusion or recent iron therapy, any chronic illness, history of recurrent infections, irritability, poor appetite or any other complication of IDA, history of hypersensitivity to iron would be taken. Complete physical examination including vitals, anthropometry, general and systemic examination would be done.
     2. Laboratory investigations: Complete blood count (CBC), corrected reticulocyte count, Iron Profile (Serum iron, Serum ferritin, serum TIBC) , CRP, AGP and general blood picture.

   • Treatment interventions:

     1. Eligible subjects would be randomized in a 1:1 ratio by computerized software to receive either ferrous ascorbate or liposomal iron.
     2. Subjects in the ferrous ascorbate group would be given drug in dose of 3mg/kg/day OD of elemental iron. Subjects in the liposomal group would be given 1mg/kg/day OD of liposomal iron. In both groups medicine would be given at bedtime. To increase compliance to drug potential negative effects of discontinuing therapy would be clearly explained to the care givers. They would also be told about potential adverse effects of the drug. Strict instructions would be given to caregivers to keep the medicine out of reach of children.
     3. Subjects would be advised to restrict milk intake to less than 500ml and give iron rich foods as per IYCF guidelines.
     4. Follow up visit would be done at 4 and 12 weeks (+2 days). In the follow up visit following points would be noted

   • Any intercurrent illness

   • Any adverse effects of therapy like altered taste, nausea, vomiting, constipation, diarrhea, teeth staining, black stools, abdominal pain

   • Adherence to therapy would be checked by measuring the volume of unused medicine in the bottle at each visit.

   • Dietary history of child will be noted

   • Laboratory studies : CBC, corrected retic count (only at 4 weeks), Iron Profile (serum ferritin, serum iron, TIBC), CRP and AGP.

     5. If at 4 weeks hemoglobin doesn't begin to rise then adherence to drug would be rechecked and re ensured. For such patients repeat hemoglobin will be done at 8 weeks. If hemoglobin rise is <0.5 gm/dl then it would be labeled as treatment failure and that case would be discontinued from study.

     c. Sample size: The sample size calculation is done based on a non-inferiority parallel design. Considering a desired power of 80 %, allocation ratio of 1:1, probability of Type I error of 5 %, common SD for a baseline of 2 g/dl, and the expected clinically relevant difference of 2 g/dl, it was found that a minimum sample of 40 subjects in each arm was sufficient to provide statistically significant results. Considering the dropout rate of 20%, the sample size will be 48 in each group with a total sample size of 96.

     d. Allocation of intervention: randomization of subjects in either group would be done using computerized software in 1:1 ratio. Sequentially numbered opaque sealed envelopes (SNOSE) would be used to effectively conceal the randomization sequence. Subjects and researcher would be blinded to the allocation. Each subject will be given the assigned medicine sufficient for duration of 12 weeks.

     e. Data collection, management and analysis: Clinical information would be collected in the pre tested structured proforma. Details included would be: name, gender, religion, date of birth, current medications, patient's medical and hospitalization history; family history, dietary history, socio economic history, physical examination and laboratory results. Weight and length/height of the subject would be documented. Contact numbers of the primary caregivers will be collected. Amount of unused medicine being brought at each visit will be noted. Data thus collected will be entered in excel sheet. All the statistically analyzed continuous data will be presented as mean ± standard deviation (SD), unless stated otherwise. The categorical data will be reported as a percentage. Student's t tests will be used to compare means. The χ2 test will be used to compare categorical outcomes, including the proportion of patients with dropouts, adverse effects, and adherence measures. The percentage volume of unused study medication returned at each visit will be compared using the Wilcoxon rank sign test. p<0.05 will be considered statistically significant

Inclusion Criteria:

Children in the age group 6 to 59 months with Nutritional Iron Deficiency Anaemia as confirmed by hematological parameters

Exclusion Criteria:

1. Subjects with other causes of anemia(hemolytic anemia, bone marrow failure) as evidenced by clinical symptoms and signs and or laboratory values
2. Subjects with ongoing blood loss
3. Subjects who have received any iron therapy or blood transfusion in the past 3 months
4. Subjects with disease interfering with iron absorption e.g. Inflammatory bowel disease, celiac disease, bowel surgery, chronic gastrointestinal infection
5. Subjects with serious chronic medical conditions like chronic kidney disease, congenital heart disease, and chronic lung disease.
6. Subjects with prior history of allergy to iron preparations