Can a sudden drop in hemoglobin occur in myelodysplastic syndrome (MDS)?

From the Guidelines

Yes, a sudden drop in hemoglobin can occur in myelodysplastic syndrome (MDS). MDS is a group of bone marrow disorders characterized by ineffective blood cell production, and hemoglobin fluctuations are common, with more than 90% of MDS patients presenting with anemia at diagnosis 1. Patients with MDS often experience chronic anemia that gradually worsens over time, but sudden drops can occur due to several mechanisms, including accelerated red blood cell destruction, bleeding episodes, or disease progression with worsening bone marrow failure.

Some key points to consider in MDS patients experiencing a sudden drop in hemoglobin include:

• The development of transfusion dependency, which is associated with a shorter patient survival and an increased risk of conversion to acute myeloid leukemia 1
• The risk of secondary iron overload, defined as a serum ferritin >1,000 ng/mL, which significantly worsens survival 1
• The importance of managing the long-term efficacy of transfusion therapy in relation to the patient's quality of life (QoL) 1
• The potential need for chelation therapy to preserve QoL and organ function, and possibly improve survival 1

In terms of management, regular blood count monitoring is crucial, and patients may require red blood cell transfusions when hemoglobin drops significantly. Some patients may also benefit from erythropoiesis-stimulating agents like epoetin alfa or darbepoetin to stimulate red blood cell production. Any sudden hemoglobin drop in an MDS patient warrants prompt medical evaluation to determine the cause and appropriate intervention.

From the Research

Myelodysplastic Syndrome and Sudden Drop in Hemoglobin

• Myelodysplastic syndromes (MDS) are a heterogeneous group of bone marrow disorders with a highly diverse clinical course 2.
• Anemia is a common comorbidity in MDS, occurring in 80-85% of patients, and can cause fatigue, increase transfusion needs, and reduce quality of life 3.
• A sudden drop in hemoglobin can occur in MDS due to various factors, including disease progression, bleeding, or infection.
• The severity of anemia is an established negative prognostic factor in MDS, with hemoglobin levels lower than 9 g/dL in males and 8 g/dL in females being independently related to reduced overall survival, higher risk of non-leukemic death, and cardiac death 4.

Treatment Options for Anemia in MDS

• Current treatment options for anemia in lower-risk MDS include erythropoiesis-stimulating agents (ESAs), lenalidomide, luspatercept, hypomethylating agents (HMAs), and immunosuppressive therapy (IST) 5.
• ESAs, such as darbepoetin alpha, can increase hemoglobin levels and reduce transfusion needs in some patients with MDS 6, 3.
• Lenalidomide has been shown to be effective in patients with deletion 5q (del5q) syndrome, with both efficacy and durability of response 5.

Clinical Implications

• The treatment of anemia in MDS should be individualized based on the patient's risk stratification, serum erythropoietin level, and presence of specific genetic mutations, such as SF3B1 or ring sideroblasts 5.
• A sudden drop in hemoglobin in a patient with MDS should prompt a thorough evaluation to determine the underlying cause and guide appropriate treatment 2, 4.