Mechanism of iron deficiency anemia and treatment with integrated traditional Chinese and western medicine

Jiu-Wei Li

1 Shandong University of Traditional Chinese Medicine, Second Clinical Medical Colleg, Jinan, China

Abstract Iron-deficiency anemia (IDA) is one of the most common anemia diseases in China, and its patients are mostly children and women of childbearing age.Among the four major anemia, IDA belongs to benign anemia, which presents as a series of compensatory symptoms due to iron deficiency affecting hemoglobin synthesis.The insufficient oxygen supply of cells and tissues in the human body is closely related to iron and hemoglobin.However, there is a lack of systematic research on the treatment of IDA with integrated traditional Chinese and western medicine and its mechanism.This paper explores the mechanism of integrated traditional Chinese and western medicine for IDA in order to lay a theoretical foundation for the treatment of IDA with integrated traditional Chinese and western medicine.

Keywords: Iron-deficiency anemia; traditional Chinese and western medicine; iron; menstruation

Introduction

Iron-deficiency anemia (IDA) is the most common type of anemia, which is benign and has a higher incidence in women of child-bearing age and infants.IDA is a microcytic hypochromic anemia in which the supply and demand of iron in the body are unbalanced,resulting in the lack of stored iron in the body and affecting the synthesis of hemoglobin in red blood cells [1].The clinical manifestations of IDA are mainly divided into two parts.One is the manifestations of the primary disease that causes IDA, such as peptic ulcer,melena caused by tumors, and menorrhagia in women;the other is nutritional disorders of various tissues,such as dizziness, fatigue, tiredness, abnormal mental behavior, chapped mouth corners, brittle nails and reverse nails, hair becomes brittle and breaks, etc [2].

Iron is a necessary trace element for cells to maintain normal physiological functions.The negative balance of iron in the body is the root cause of iron deficiency anemia.Then, how is iron metabolized and out of balance in the body? The metabolic process of iron in the human body can be summarized into six parts:source, absorption, transport, distribution, storage and excretion.Once some of them are disorders, the body will suffer from iron imbalance leading to the clinical manifestations of iron deficiency [2].

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IDA is a typical microcytic hypochromic anemia in which erythrocyte hypochromatism and small-cell character are due to unimpaired cell production and insufficient hemoglobin synthesis.IDA is confirmed when blood routine tests show a decrease in the mean volume of red blood cells, hemoglobin, and red blood cells, as well as a decrease in serum iron, serum ferritin,or a lack of iron stored in bone marrow smear.

Iron imbalances can be caused by a variety of causes,main shows are: inadequate intake of iron (food iron deficiency), short supply (pregnant woman),malabsorption (gastrointestinal disease), transshipment dysfunction (no transferrin hematic disease, liver disease, chronic inflammation), lost too much (various blood loss), the use of barriers (iron young granulocyte anemia, lead poisoning, chronic anemia), etc [3].

In China, the onset of IDA seriously affects people's quality of life, ability to work and fertility.However,most clinicians have indulged in the treatment of IDA only in the mode of iron supplementation, causing that the primary disease of iron deficiency cannot be controlled and treated comprehensively.Therefore,the key to the treatment of IDA is to regulate the body fundamentally through traditional Chinese medicine and to standardize the treatment of IDA with integrated Chinese and Western medicine.

For the treatment of IDA, western medicine focuses on improving the objective indicators, mainly to supplement the easily absorbed ferrous, including ferrous sulfate, ferrous dextran, ferrous gluconate,ferrous fumarate, ferrous succinate, etc.Treatment with iron should be continued for at least 4-6 months after hemoglobin returns to normal and should be discontinued when ferritin returns to normal [4].

Eradicating the cause is the key to the treatment of IDA.In general, it can be quickly corrected by supplementing sufficient iron.However, the prognosis of IDA does not depend on itself, but on cause.Traditional Chinese medicine (TCM) focuses on replenishing qi to invigorate the spleen, which can comprehensively condition the body, treat IDA from origin, and reduce complications such as iron overload caused by iron supplementation.

Although there is no disease name for IDA in the medical literature of China, it belongs to the categories of "chlorosis", "deficiency", "yellow swelling", and"deficiency" according to its syndrome characteristics[5].Hemorrhagic anemia, IDA, and massive anemia in a broad sense are manifested in the subjective symptoms of qi deficiency in TCM.qi deficiency refers to a series of pathological changes and syndromes caused by insufficient vitality, and we generally believe that male vitality is more abundant than females, so the normal value of male hemoglobin is higher than females.Hemoglobin transports oxygen to the human body, represents a substance necessary for human body functions, and is closely related to "qi".Therefore,anemia is manifested as a group of symptoms of qi deficiency, such as dizziness, headache, fatigue,shortness of breath after exercise, palpitations, and pale complexion in IDA.Anemia in modern medicine is not the same as blood deficiency in TCM.Blood deficiency refers specifically anemia that lacks trace elements in modern medicine, such as megaloblastic anemia.Therefore, in the treatment of iron deficiency anemia in traditional Chinese medicine, qi should be supplemented first.

Due to lack of hemoglobin, patients with IDA have reduced red blood cell oxygen-carrying capacity, and the body exhibits a series of compensatory symptoms,such as fatigue, rapid heartbeat, shortness of breath,shortness of breath after activity, etc.Laboratory examinations show a compensatory increase in bone marrow hematopoietic function, or accompanied by an increase in platelets, different from the chlorosis of hemolytic anemia and the dark complexion of aplastic anemia, the face of IDA is pale with redness in the middle [6].

1.Anemia emphasizes etiological diagnosis

After a clear diagnosis, must be found the cause of iron deficiency.Failure to pay attention to this principle will delay the treatment of serious diseases with IDA as the initial manifestation, and cause adverse consequences to the patient.The decrease in iron storage in the body is mainly caused by chronic blood loss from the gastrointestinal tract and female genitalia.The former is rare, so women are more likely to develop than men.The key point is to find the cause of anemia.If a IDA male patient comes to see a doctor, treated directly without finding the cause, and the anemia is corrected,but it is later discovered that the anemia is caused by intestinal tumors.It will cover up and delay the diagnosis of the tumor, and with this treatment, the correction of anemia is only temporary.As the tumor grows, the anemia cannot be truly improved.In this sense, IDA is chronic hemorrhagic anemia.We must find the cause of blood loss, and then treat it according to different reasons, such as hemorrhoid bleeding,gastrointestinal bleeding, tumor bleeding and other symptomatic treatments.

70% of IDA is caused by chronic hemorrhagic anemia,and women's excessive menstrual flow occupies most of them.Chong is a sea of blood and Ren is responsible for palace.Regulating Chong Ren is one of the main methods of regulating menstruation.

In the Qing Dynasty, Xu Da-chun's "Miscellaneous Diseases - Blood Evidence" states, "Blood is the essence of water and grain." It can be seen that insufficient absorption of water and grain essence is an important cause of blood deficiency diseases, so it is believed that the disease is located in the middle jiao spleen, stomach and kidney, and the basic pathogenesis is weakness of the spleen and stomach and deficiency of both qi and blood.The kidney is the root of the innate nature, the kidney collects essence, essence and blood are of the same origin, blood is transformed by essence, if the kidney is deficient, essence does not transform blood, resulting in blood deficiency.If the kidney is deficient, the essence does not transform into blood, resulting in blood deficiency.If the spleen and stomach are weak, the qi and blood will lack biochemical sources."Lingshu · Determination of qi"said that "the middle coke receives gas and takes juice,changes and turns red, is called blood." The "Spleen and Stomach Theory" says: "If the spleen and stomach are insufficient, all are blood diseases.It can be seen that kidney deficiency is the root cause, the spleen and stomach is the key, the liver does not nourish the blood.Benefiting qi and strengthening the Spleen, nourishing Blood and softening the Liver is the fundamental treatment for IDA.

2.The body is deficient in iron, not in iron alone, but in easily absorbed ferrous ions and trace elements that promote iron absorption

Some trace elements can promote the absorption of iron, such as like magnesium, calcium and phosphorus can affect the absorption of iron [7].These minerals containing trace elements are mostly heavy metals.In terms of Chinese medicine, the liver collects blood, and the drugs of heavy town can calm the liver, therefore,can promote the absorption of iron.Therefore,the treatment of iron deficiency anemia should be supplemented to promote the blood of the internal organs are returned to the Chong pulse, and Chong for the blood of the five organs and six bowels of the sea,so the scriptures say that the Tai Chong pulse, then the menstrual events to time, this can be seen Chong pulse for the menstruation of the book also ".And Ren has"the sea of yin pulse" of the name.Where the body's yin liquid (including the absorption of trace elements,like copper green, ochre, sunshine, soap alum,manganese, etc..

3.Regulation of iron in the body

The regulation of iron by the body has a dual mechanism, from individual cells to the body's overall water, to ensure that iron levels are maintained within an optimal range for normal physiological processes.Hepcidin, the core hormone that regulates iron, controls dietary iron absorption, storage and tissue iron distribution by acting on the iron pump protein Ferroportin, which internalizes and degrades Ferroportin, thereby reducing the transport of iron from the small intestine, macrophages and liver to the blood[8].Studies have shown that the Chinese herb Jixueteng(Caulis Spatholobi)inhibits Hepcidin expression [9].

The development of iron deficiency goes through three stages in an orderly manner, namely, iron storage reduction (IDS), iron deficiency in erythropoiesis (IDE)and IDA, in the first two stages, although the body is iron deficient, the Hb level is still within the normal range, and the symptoms are hidden and not easily detected and paid attention to, which is often referred to as the hidden iron deficiency stage or subclinical iron deficiency stage [10].

4.Treatment of iron deficiency anemia

What the human body can absorb is ferrous i on,for example, the Ferroids, iron-dextrin, iron lactate contained ferrous ion and these drugs are more often taken with Vit C.Because iron can be easier absorbed in acidic environment, and vitamin C can promote the absorption of iron in the intestine.It can convert ferric iron absorbed difficulty into ferrous iron absorbed easily, and can also make plasma ferritin ferric iron reduction to liver ferritin ferric iron.Therefore, in the traditional Chinese medicine treatment of iron deficiency anemia, acid drugs were often compatible,such as: Zaoren(Semen Ziziphi Spinosae), Jiaoshanzha(Fructus Crataegi), Shanyurou(Fructus Corni),Wuweizi(Fructus Schisandra Chinensis), and so on.

In the treatment of iron deficiency anemia, more attention should be paid in nourishing the liver and kidney and fixing Chong Ren.In iron deficiency anemia, the relationship between the liver and blood is the closest: the liver stores blood, has the function of storing blood and regulating blood volume.Although the heart is the main blood vessel, it is the heart through blood vessels to transport qi and blood around the body.The liver hides the blood, the kidney hides the essence, the liver and kidney are homologous, Yi(liver) and Gui (kidney) share the same source, the sperm blood is alternate.If the liver and kidney are not solid and insufficient, add the drugs of softening liver,regulating liver and kidney, such as: Jixueteng(Caulis Spatholobi), Ciwujia(Radix et Caulis Acanthopanacis Senticosi), Fupenzi(Acanthopanax), Hanliancao(Fructus Rubi and Lotus herb).

Anemia in western medicine equals qi deficiency in traditional Chinese medicine, while blood deficiency in traditional Chinese medicine is lack of trace elements,such as megaloblastic anemia, iron deficiency anemia and anemic disease in a broad sense.Macroscopically showed qi deficiency in traditional Chinese medicine.Anemia shows a group of symptoms of qi deficiency,such as fatigue, pallor, dizziness, loss of appetite and lethargy, etc., but there is no red tongue less moss, dry tongue and so on.

For women, iron deficiency anemia is not nutritional anemia, but chronic hemorrhagic anemia.Menstruation is the main cause of female anemia, and chronic hemorrhagic anemia is caused by excessive menstrual blood volume.If a woman in childbearing age comes to see a doctor, with a small cell low pigment anemia,diagnosed iron deficiency anemia, first interrogation should pay attention to ask: is menstrual quantity more? Is anemia in menstruation when perhaps after menstruation aggravate? What is the color and texture of menstruation? So that determine whether menstruation is the cause of iron deficiency anemia in patients.

Menstruation is the main cause of anemia in women,which leads to another important treatment idea of traditional Chinese medicine for iron deficiency anemia- regulating thoroughfare and conception vessels.

"LingshuWuyin Wuwei" points out: "Chongmai and Renmai, are started in the womb, upward along the back of the spine inside, is the sea of meridians.As Jingyue's Complete Works·the Woman Rules said: "Vital channel is illed full which is the fundamental of menstruation，the function of five viscera and six entrails is the required environment of yin blood?However, essence, blood, body fluid) are owned by the Renmai, The qi and blood of Renmai are smooth,indicating that the Yin fluid is exuberant, and the blood of the Chong Channel is exuberant, so it can regulate the menstrual blood.Conversely, lose balance between Chongmai and Renmai causes menstruation disorder,one of the manifestations is heavy menstrual flow,and then cause iron deficiency anemia.Another way to regulate menstruation is to replenish qi and nourish blood."qi as the commander of blood "" blood is the mother of qi ", qi can generate blood, qi flourishing is blood filling, qi deficiency is less blood.Therefore,in the clinical treatment of iron deficiency anemia,often with qi drugs, qi is the power of tonifying blood;qi can control the blood, and the fixation effect of qi makes the blood normally circulate in the vessels instead of escaping outside the meridians.When qi cannot control the blood, the symptoms of bleeding may appear.Therefore, in the treatment, the method of supplementing qi and controlling the blood must be used to achieve the purpose of hemostasis.Qi governing blood is actually the function of spleen regulating blood."All blood is concentrated in the spleen" The commonly used prescriptions in clinic are Guchong Decoction, Buzhong Yiqi Decoction, and Taishan Panshi Powder.Commonly used drugs are Shengma(Rhizoma Cimicifugae), Xiangfu(Rhizoma Cyperi), Chuanduan(Radix Dipsaci), Zhumagen(Radix Boehmeriae), Xianhecao(Herba Agrimoniae),Huangqi(Radix Astragali), and Baizhu(Rhizoma Atractylodis Macrocephalae).Kidney is the congenital root, congenital lack of endowment, acquired malnutrition, spleen and kidney yang deficiency, warm and nourishing are not allowed, essence and blood are not born, blood and qi, one is Yin and the other is Yang,mutual root mutual use, qi is the handsome of blood,blood is the mother of qi, blood deficiency can cause qi deficiency, qi deficiency can cause blood deficiency, qi and blood deficiency over time, leading to anemia.

Furthermore, tumors can also cause more bleeding,female uterine fibroids can cause more menstrual blood, male intestinal tumors will cause bleeding,which leads to the occurrence of anemia.Therefore,it is important to find the cause of anemia.If a patient with anemia comes to the clinic, male, is diagnosed with iron deficiency anemia, directly treated without finding the cause, and the anemia is corrected, but it is later found to be anemia caused by intestinal tumors,which will mask and delay the diagnosis of tumors.In this way of treatment, the correction of anemia is only temporary.With the growth of tumors, anemia cannot be truly improved.In this sense, we say that iron deficiency anemia is chronic hemorrhagic anemia, we must find the cause of blood loss, and then according to different causes, such as: hemorrhoid bleeding,gastrointestinal bleeding, tumor bleeding and other symptomatic treatment.Men have high hemoglobin,which is sufficient qi; women have low hemoglobin,which is qi deficiency.

If the liver is bitter and urgent, it can be soothed by urgent food.Attention should be paid to the use of soothing drugs in the treatment of iron deficiency anemia.Such as Gancao(Radix Glycyrrhizae),Huangqi(Radix Astragali), Danggui(Radix Angelicae Sinensis), Baizhu(Rhizoma Atractylodis Macrocephalae), Ejiao(Colla Corii Asini), Shanyao(Rhizoma Dioscoreae), Baibiandou(Men Lablab Album)and so on.At the same time, these drugs are also drugs for tonifying qi and nourishing blood.

Iron deficiency anemia has some symptoms, one of which is dysphagia (Plummer 2 Vinson syndrome).that is, there is a sense of choking when eating, which can be dialectically classified as disharmony between the liver and spleen, Chong Ren imbalance and deficiency of both qi and blood.Patients with qi deficiency are treated with Shenxu Peiqi decoction, in which there are important town, iron supplement and qi-tonifying medicine, which accords with not only the dialectics of traditional Chinese medicine, but also the basic principles of western medicine.

For some patients with low iron deficiency anemia,we should pay attention to its compensatory anemia,because of its long-term chronic anemia, the body has tolerated anemia compensation, or the reduction of red blood cells can not compensate for long-term chronic blood loss, leading to the decrease of platelets and white blood cells, be careful not to be misdiagnosed as MDS.

In short, for the TCM treatment of iron deficiency anemia, we should tonify both qi and blood, regulate the liver and kidney, consolidate Chong Ren, and pay attention to the application of important town and acid medicine.

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