What is the framework for the workup of anemia?

From the Guidelines

The most effective framework for the workup of anemia is the GOVMEME approach, which includes getting a complete blood count (CBC) with reticulocyte count, observing red blood cell (RBC) indices and peripheral smear, checking vitamin B12 and folate levels, performing microcytosis workup, evaluating for blood loss, considering marrow examination, and excluding other causes. This approach is supported by the most recent and highest quality study, which emphasizes the importance of a comprehensive evaluation of potential causes of anemia, including nutritional deficiencies, blood loss, bone marrow disorders, and systemic diseases that can affect red blood cell production or survival 1.

Key Components of the GOVMEME Framework

• G: Get a complete blood count (CBC) with reticulocyte count to assess the severity of anemia and reticulocyte production
• O: Observe red blood cell (RBC) indices and peripheral smear to characterize the type of anemia (microcytic, normocytic, or macrocytic)
• V: Check vitamin B12 and folate levels to rule out deficiencies that can cause anemia
• M: Perform microcytosis workup (iron studies, hemoglobin electrophoresis) to diagnose iron deficiency or other causes of microcytic anemia
• E: Evaluate for blood loss (occult blood test, endoscopy if indicated) to identify potential sources of bleeding
• M: Consider marrow examination if diagnosis remains unclear after above steps to rule out bone marrow disorders
• E: Exclude other causes (thyroid function, renal function, liver tests) to identify underlying systemic diseases that may be contributing to anemia

Implementation of the GOVMEME Framework

1. Order CBC with reticulocyte count and review results to assess the severity of anemia and reticulocyte production
2. Examine RBC morphology on peripheral smear to characterize the type of anemia
3. Check vitamin B12, folate, iron studies, and hemoglobin electrophoresis to rule out deficiencies and diagnose iron deficiency or other causes of microcytic anemia
4. Perform stool occult blood test and consider endoscopy if positive to identify potential sources of bleeding
5. Consider bone marrow biopsy if diagnosis remains unclear after above steps to rule out bone marrow disorders
6. Check thyroid, renal, and liver function tests to identify underlying systemic diseases that may be contributing to anemia

This systematic approach ensures a comprehensive evaluation of potential causes of anemia, including nutritional deficiencies, blood loss, bone marrow disorders, and systemic diseases that can affect red blood cell production or survival, and is supported by the most recent and highest quality study 1.

From the Research

Framework for the Workup of Anemia

The framework for the workup of anemia involves a stepwise approach to diagnose the underlying cause of anemia. The following steps are involved:

• Initial laboratory evaluation: complete blood count (CBC) and reticulocyte count 2, 3, 4, 5, 6
• Categorization of anemia: microcytic, macrocytic, or normocytic, with or without reticulocytosis 2, 3, 5, 6
• Examination of the peripheral smear and specific tests to confirm the diagnosis 2, 3, 5

Laboratory Tests

The following laboratory tests are used to diagnose the cause of anemia:

• Serum iron level, total iron-binding capacity, and serum ferritin level to separate microcytic anemias 2
• Erythrocyte size-distribution width to distinguish iron deficiency from thalassemia minor 2
• Hemoglobin electrophoresis to diagnose hemoglobinopathies 2
• Vitamin B12 and folic acid levels to diagnose macrocytic anemia 3
• Reticulocyte indices, such as reticulocyte hemoglobin content and mean reticulocyte volume, to diagnose iron-deficient erythropoiesis 5

Algorithmic Approach

An algorithmic approach can be used to analyze the cause of anemia, which accepts input parameters from a CBC test, such as mean corpuscular volume, red cell distribution width, and reticulocyte count, and generates a probable etiology of the anemia 4. This approach can also automatically order reflex tests needed to confirm the diagnosis.

Classification of Anemia

Anemia can be classified into three patterns: microcytic, normocytic, and macrocytic, based on morphological and kinetic classifications 5. The clinical usefulness of old and new parameters, such as mean cell volume, red blood cell distribution width, and reticulocyte indices, can be used to diagnose and treat anemia 5.