What is the treatment for anemia?

Treatment of Anemia

The treatment of anemia should be tailored to its specific cause, with oral iron supplementation (ferrous sulfate 324 mg 2-3 times daily) being the first-line treatment for iron deficiency anemia, the most common form of anemia worldwide. 1

Diagnostic Approach to Guide Treatment

Before initiating treatment, it's essential to identify the underlying cause of anemia:

• Iron deficiency anemia

  • Laboratory findings: Low serum iron, low ferritin, low transferrin saturation, elevated total iron binding capacity
  • Common causes: Blood loss, inadequate dietary intake, malabsorption

• Vitamin deficiency anemia

  • B12 deficiency: Macrocytic anemia, neurological symptoms
  • Folate deficiency: Macrocytic anemia without neurological symptoms

• Anemia of chronic disease/inflammation

  • Laboratory findings: Low serum iron, normal/elevated ferritin, low transferrin
  • Associated with chronic inflammation, autoimmune diseases, cancer, kidney failure 2

• Other causes: Hemolytic anemia, aplastic anemia, thalassemia, sideroblastic anemia

Treatment Algorithms by Cause

1. Iron Deficiency Anemia

• First-line: Oral iron supplementation

  • Ferrous sulfate 324 mg (65 mg elemental iron) 2-3 times daily 1
  • Continue therapy for 2-3 months after hemoglobin normalizes to replenish iron stores
  • Take on empty stomach with vitamin C to enhance absorption

• For poor response or intolerance to oral iron:

  • Consider alternative iron formulations
  • Parenteral iron if malabsorption is suspected 1

• Address underlying cause:

  • Investigate and treat source of blood loss
  • Improve dietary iron intake

2. Vitamin B12 Deficiency

• Pernicious anemia:

  • Intramuscular vitamin B12 100 mcg daily for 6-7 days
  • Then every other day for 7 doses
  • Then every 3-4 days for 2-3 weeks
  • Maintenance: 100 mcg monthly for life 3

• Normal intestinal absorption:

  • Initial treatment similar to pernicious anemia depending on severity
  • Transition to oral B12 for chronic treatment 3

3. Folate Deficiency

• Oral folic acid supplementation
• Effective for megaloblastic anemias due to folate deficiency 4
• Particularly important in pregnancy, infancy, and childhood

4. Anemia of Chronic Disease/Inflammation

• Primary approach: Treat underlying condition
• Supplementation with iron, folic acid, and vitamin B12 as needed 2
• Consider erythropoiesis-stimulating agents (ESAs) in specific circumstances
• Important: ESAs should NOT be used in patients with mild to moderate anemia and heart failure or coronary heart disease 5, 1

5. Blood Transfusion Therapy

• Reserved for symptomatic anemia requiring immediate correction
• Use restrictive transfusion strategy (hemoglobin threshold of 7-8 g/dL) in most patients, including those with coronary heart disease 5, 1
• One unit of packed red blood cells typically increases hemoglobin by approximately 1 g/dL 1

Special Considerations

• Elderly patients: More susceptible to adverse effects of anemia; may require earlier intervention 6
• Cardiovascular disease: Use restrictive transfusion strategy (hemoglobin threshold of 7-8 g/dL) 5
• Pregnancy: Higher iron requirements; increased supplementation needed 1

Common Pitfalls to Avoid

• Failing to identify and treat the underlying cause of anemia
• Inappropriate iron supplementation in conditions where iron overload is a risk (e.g., thalassemia, sideroblastic anemia) 1
• Neglecting to continue iron therapy after hemoglobin normalizes (iron stores need replenishment)
• Using ESAs in patients with mild to moderate anemia and heart disease 5
• Transfusing more than the minimum number of RBC units necessary to relieve symptoms or reach safe hemoglobin levels 1