What is the first line treatment for anemia?

First-Line Treatment for Anemia

The first-line treatment for anemia depends on the underlying cause, with erythropoiesis-stimulating agents (ESAs) being the first choice for anemia in most lower-risk myelodysplastic syndrome (MDS) without del(5q), while iron supplementation is the primary treatment for iron deficiency anemia. 1

Diagnostic Approach to Determine Treatment

Before initiating treatment, it's crucial to identify the specific cause of anemia:

1. Complete blood count with differential

   • Microcytic anemia (MCV <80 fL): Suggests iron deficiency, thalassemia
   • Normocytic anemia (MCV 80-100 fL): May indicate anemia of inflammation, MDS
   • Macrocytic anemia (MCV >100 fL): Consider B12/folate deficiency, MDS

2. Iron studies

   • Serum ferritin, iron, TIBC, transferrin saturation
   • Low ferritin (<30 ng/mL) confirms iron deficiency

3. Additional testing based on clinical suspicion

   • B12 and folate levels
   • Reticulocyte count
   • Bone marrow examination (if MDS suspected)

Treatment Algorithm by Etiology

1. Iron Deficiency Anemia

• First-line: Oral iron supplementation
  • Ferrous sulfate 325 mg (65 mg elemental iron) 1-3 times daily
  • Continue for 3-6 months after hemoglobin normalizes to replenish stores
• For poor response/intolerance: IV iron formulations
• Identify and treat underlying cause (bleeding, malabsorption, etc.)

2. Myelodysplastic Syndrome (MDS)

• Lower-risk MDS without del(5q):

  • First-line: Erythropoiesis-stimulating agents (ESAs)
    • EPO 30,000-80,000 units weekly or darbepoetin 150-300 μg weekly 1
    • Best response when baseline EPO <500 U/L and limited transfusion requirements
    • Response evaluation after 8-12 weeks
  • Add G-CSF to improve efficacy if needed 1

• Lower-risk MDS with del(5q):

  • First-line: Lenalidomide 10 mg/day for 3 weeks every 4 weeks 1
    • 60-65% response rate with 2-2.5 years median duration of transfusion independence
    • Monitor for neutropenia and thrombocytopenia

3. Vitamin B12 Deficiency

• First-line: Vitamin B12 replacement
  • Initial: 1000 μg IM daily for 7 days
  • Then: 1000 μg IM weekly for 4 weeks
  • Maintenance: 1000 μg IM monthly 2

4. Anemia of Inflammation/Chronic Disease

• First-line: Treat underlying inflammatory condition
• Consider ESAs if persistent anemia despite treatment of underlying condition

Special Considerations

Transfusion Therapy

• Reserved for symptomatic anemia or hemoglobin <7-8 g/dL
• Target hemoglobin 7-9 g/dL in most cases (higher in patients with cardiac disease)
• Consider iron chelation in transfusion-dependent patients to prevent iron overload 1

Monitoring Response

• Hemoglobin/hematocrit at regular intervals (2-4 weeks initially)
• Iron studies to assess replenishment of iron stores
• For MDS: Bone marrow examination to evaluate response after 6 cycles of treatment 3

Common Pitfalls to Avoid

1. Treating anemia without identifying the cause

   • Always determine etiology before initiating specific therapy

2. Overlooking concurrent conditions

   • Iron deficiency can coexist with other causes of anemia

3. Inadequate iron dosing or duration

   • Continue iron therapy for 3-6 months after hemoglobin normalizes

4. Failure to investigate iron deficiency

   • Always seek source of blood loss in adults with iron deficiency

5. Inappropriate ESA use

   • ESAs should be used primarily for specific indications like MDS or anemia of chronic kidney disease, not for all types of anemia

By following this structured approach to anemia treatment based on the underlying cause, clinicians can effectively manage this common condition and improve patient outcomes.