What is the plan of care for a patient with anemia and no signs of bleeding?

Management of Anemia with No Signs of Bleeding

The plan of care for a patient with anemia and no signs of bleeding should begin with identifying the cause through comprehensive laboratory evaluation, followed by targeted treatment with oral iron supplementation for iron deficiency anemia, continuing for 3 months after hemoglobin normalizes to replenish iron stores. 1

Initial Evaluation

Laboratory Assessment

• Complete blood count with MCV to classify anemia
• Iron studies:
  • Serum ferritin (<30 μg/L indicates definitive iron deficiency)
  • Transferrin saturation (<20% suggests iron deficiency)
  • Higher ferritin cutoffs (up to 100 μg/L) should be used in patients with inflammatory conditions 1
• Vitamin B12 and folate levels
• Reticulocyte count to assess bone marrow response

Additional Evaluation Based on Suspected Etiology

• For suspected iron deficiency anemia (especially in men and postmenopausal women):
  • Upper GI endoscopy with small bowel biopsies (to rule out celiac disease)
  • Colonoscopy or double contrast barium enema 2
  • Small bowel evaluation may be necessary in transfusion-dependent cases 2

Treatment Algorithm

For Iron Deficiency Anemia

1. First-line treatment: Oral iron supplementation

   • Ferrous sulfate 324 mg (65 mg elemental iron) once daily 1
   • Alternative-day dosing may improve tolerability
   • Take on empty stomach with vitamin C (500 mg) to enhance absorption
   • Avoid concurrent intake of calcium, tea, coffee, or antacids 1

2. Duration: Continue for 3 months after hemoglobin normalizes to replenish iron stores 2, 1

3. Monitoring:

   • Check hemoglobin after 2-4 weeks of therapy
   • Consider IV iron if hemoglobin increase is <1.0 g/dL at day 14 1
   • Continue monitoring every 4 weeks until hemoglobin normalizes
   • Long-term follow-up with iron studies every 3 months during maintenance phase 1

4. Dietary recommendations:

   • Increase consumption of iron-rich foods (red meat, fish, poultry)
   • Consume vitamin C-rich foods with meals to enhance iron absorption
   • Avoid foods that inhibit iron absorption during meals 1

For Vitamin B12 Deficiency (including Pernicious Anemia)

• Intramuscular vitamin B12 injections 3, 4
• Monthly injections may be required lifelong for pernicious anemia 3
• Monitor for hypokalemia during initial treatment 3

For Other Specific Causes

• Treat underlying conditions (e.g., chronic kidney disease may require erythropoietin therapy) 5
• For anemia due to chronic kidney disease, maintain transferrin saturation ≥20% and serum ferritin ≥100 ng/mL 1

Common Pitfalls to Avoid

1. Premature discontinuation of iron supplementation before iron stores are replenished 1
2. Inadequate monitoring of treatment response 1
3. Accepting upper GI findings (such as erosions or peptic ulcer) as the sole cause of iron deficiency without lower GI evaluation, as dual pathology occurs in 10-15% of patients 2
4. Overlooking occult GI blood loss in men and postmenopausal women with iron deficiency anemia 1
5. Using folic acid alone in patients with vitamin B12 deficiency, which may mask anemia while allowing neurological damage to progress 3

By following this structured approach to evaluation and management, most patients with anemia without signs of bleeding can be effectively diagnosed and treated, improving their morbidity, mortality, and quality of life outcomes.