How do you treat anemia?

Treatment of Anemia

The treatment of anemia should be based on the underlying cause, with iron supplementation being the first-line therapy for iron deficiency anemia, which is the most common type of anemia worldwide. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Initial laboratory evaluation:

   • Complete blood count with MCV
   • Peripheral blood smear
   • Complete iron studies (serum ferritin, transferrin saturation)
   • Inflammatory markers (CRP)

2. Diagnostic criteria for iron deficiency:

   • Serum ferritin <15 μg/L confirms iron deficiency
   • Serum ferritin 15-45 μg/L suggests possible iron deficiency
   • Serum ferritin >150 μg/L rules out iron deficiency 1

3. Differential diagnosis:

   • Low ferritin indicates iron deficiency anemia
   • High ferritin with low transferrin saturation suggests anemia of chronic disease
   • Very low MCV with normal/high ferritin suggests thalassemia 1

Treatment Algorithm

1. Iron Deficiency Anemia

First-line treatment:

• Oral iron therapy: Ferrous sulfate 200 mg three times daily (65 mg elemental iron per dose) 2
• Alternative oral preparations include ferrous gluconate and ferrous fumarate 2
• Continue treatment for 3 months after correction of anemia to replenish iron stores 2
• Consider adding ascorbic acid to enhance iron absorption when response is poor 2

For non-responders or intolerant patients:

• If no response after 4 weeks (Hb increase <1 g/dL) despite compliance, further evaluate with MCV, RDW, and serum ferritin 2
• Consider parenteral iron for patients with:
  • Intolerance to at least two oral preparations
  • Non-compliance
  • Malabsorption
  • Blood losses exceeding oral replacement capacity 2

2. Anemia in Chronic Kidney Disease

• Use a restrictive red blood cell transfusion strategy (trigger Hb 7-8 g/dL) 2
• Avoid erythropoiesis-stimulating agents (ESAs) in patients with mild to moderate anemia and heart disease 2
• For patients requiring ESAs:
  • Initial dose: 50-100 Units/kg three times weekly 3
  • Target Hb should not exceed 11 g/dL due to increased cardiovascular risks 3
  • Ensure adequate iron stores before and during ESA therapy 3

3. Cancer-Related Anemia

• For patients receiving palliative chemotherapy with Hb <10 g/dL:

  • Consider ESA therapy (epoetin alfa 40,000 Units weekly or 150 Units/kg three times weekly) 2, 3
  • ESAs are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure 3
  • Monitor Hb weekly initially and adjust dose accordingly 2

• For patients not candidates for ESA therapy:

  • Consider red cell transfusion for symptomatic anemia 2
  • Consider intravenous iron supplementation 2

4. Iron Refractory Iron Deficiency Anemia (IRIDA)

• Initial treatment with oral iron or oral iron combined with ascorbic acid 2
• If inadequate response, use intravenous iron supplementation 2
• Calculate total IV iron dose based on formulas of body iron deficit 2
• Monitor serum ferritin levels to avoid exceeding 500 μg/L 2

Special Populations

Pregnant Women

• Start oral, low-dose (30 mg/day) iron supplements at first prenatal visit 2
• For anemia during pregnancy, increase to 60-120 mg/day of iron 2
• Screen for anemia at first prenatal care visit 2

Postmenopausal Women and Men

• No routine screening for iron deficiency recommended 2
• Fully evaluate any detected iron deficiency or anemia for its cause 2

Monitoring and Follow-up

• Monitor hemoglobin and red cell indices at 3-month intervals for one year after normalization, then after another year 2
• Provide additional oral iron if hemoglobin or MCV falls below normal 2
• Further investigation is only necessary if hemoglobin and MCV cannot be maintained with supplementation 2

Common Pitfalls to Avoid

1. Misinterpreting ferritin levels - Ferritin is an acute phase reactant and may be elevated despite iron deficiency in inflammatory states 1

2. Inadequate duration of therapy - Failure to continue iron therapy for 3 months after normalization of hemoglobin leads to recurrence 2

3. Overlooking underlying causes - Persistent or recurrent iron deficiency anemia requires investigation for ongoing blood loss, particularly from the gastrointestinal tract 2

4. Excessive ESA use - Using ESAs to target hemoglobin >11 g/dL increases risk of death, myocardial infarction, stroke, and thromboembolism 3

5. Inappropriate transfusion - Transfusing based on arbitrary hemoglobin thresholds rather than symptoms increases risks without clear benefit 2