What is the treatment for anemia?

Treatment of Anemia

The treatment of anemia should be directed at the underlying cause, with oral iron supplementation (ferrous sulfate 324 mg, 2-3 times daily) as first-line therapy for iron deficiency anemia, continuing for 2-3 months after hemoglobin normalizes to replenish iron stores. 1

Diagnostic Approach to Guide Treatment

Before initiating treatment, proper diagnosis is essential:

• Laboratory evaluation should include:

  • Complete blood count with hemoglobin, hematocrit, MCV, RDW
  • Iron studies (serum iron, ferritin, transferrin saturation)
  • Reticulocyte count
  • Vitamin B12 and folate levels if indicated 1

• Classification by MCV helps direct treatment:

  • Microcytic (low MCV): Consider iron deficiency, thalassemia, sideroblastic anemia
  • Normocytic: Consider anemia of chronic disease, hemolysis, acute blood loss
  • Macrocytic (high MCV): Consider B12/folate deficiency, medications, liver disease

Treatment Options Based on Etiology

1. Iron Deficiency Anemia

• First-line therapy: Oral iron supplementation

  • Ferrous sulfate 324 mg (65 mg elemental iron) 2-3 times daily
  • Continue for 2-3 months after hemoglobin normalizes 1
  • For children: 3 mg/kg/day of elemental iron 1

• Alternative options if oral therapy fails:

  • Different iron formulations (ferrous gluconate, ferrous fumarate)
  • Parenteral iron for malabsorption cases or intolerance to oral therapy 1

2. Sideroblastic Anemia

• X-linked sideroblastic anemia (XLSA):

  • Initial treatment with pyridoxine 50-200 mg/day
  • Maintenance dose of 10-100 mg/day if responsive 1

• SLC25A38 defects:

  • Hematopoietic stem cell transplantation (HSCT) as curative option
  • Symptomatic treatment with erythrocyte transfusions and chelation therapy 1

3. Anemia of Chronic Disease/Inflammation

• Primary approach: Treat underlying condition
• Erythropoiesis-stimulating agents (ESAs) considerations:
  • Use only when hemoglobin <10 g/dL and specific criteria are met
  • Strong recommendation against using ESAs in patients with mild to moderate anemia and heart failure 1
  • ESAs increase risk of death, myocardial infarction, stroke, and venous thromboembolism 2

4. Blood Transfusion Therapy

• Indications: Symptomatic anemia requiring immediate correction 1
• Dosing: One unit of packed red blood cells typically increases hemoglobin by approximately 1 g/dL 1
• Threshold recommendations:
  • Use restrictive transfusion strategy (hemoglobin threshold of 7-8 g/dL) in most patients
  • This includes patients with coronary heart disease 1

Special Considerations

Pregnancy

• Higher iron requirements necessitate increased supplementation 1

Elderly or Cardiovascular Disease Patients

• Lower threshold for intervention due to higher risk of complications 1

Cancer Patients

• ESAs should be considered only if hemoglobin <10 g/dL and planned chemotherapy for at least 2 more months
• ESAs are not indicated when the anticipated outcome is cure 1, 2
• ESAs shortened overall survival and/or increased tumor progression risk in multiple cancer types 2

Common Pitfalls to Avoid

• Inappropriate iron supplementation in conditions like thalassemia trait or sideroblastic anemia, where iron overload is a risk 1
• Neglecting family screening in hereditary conditions like thalassemia or sideroblastic anemia 1
• Failing to monitor for iron overload during treatment, especially with transfusions or in certain genetic disorders 1
• Not addressing the underlying cause of anemia, leading to treatment failure
• Using ESAs inappropriately without considering their significant cardiovascular risks 2

Monitoring During Treatment

• Weekly hemoglobin monitoring after initiation of therapy and after each dose adjustment until stable 2
• Iron status evaluation before and during treatment 2
• Supplemental iron therapy when serum ferritin is less than 100 mcg/L or transferrin saturation less than 20% 2