What is the treatment for anemia?

Treatment of Anemia

The treatment of anemia should be tailored to its 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 Testing:

   • Complete blood count (CBC) with differential
   • Reticulocyte count
   • Iron studies (serum ferritin, transferrin saturation)
   • Peripheral blood smear examination 1

2. Classification by MCV:

   • Microcytic (MCV <80 fL): Iron deficiency, thalassemia, anemia of chronic disease
   • Normocytic (MCV 80-100 fL): Acute blood loss, chronic disease, renal disease
   • Macrocytic (MCV >100 fL): B12/folate deficiency, liver disease, alcoholism 1

Treatment Based on Anemia Type

Iron Deficiency Anemia

1. Oral Iron Therapy:

   • First-line treatment: Ferrous sulfate 200 mg twice daily
   • Continue for 3 months after hemoglobin normalizes to replenish stores
   • Add ascorbic acid (250-500 mg twice daily) to enhance absorption 1

2. Intravenous Iron:

   • Indicated for patients with:
     • Inadequate response to oral iron (hemoglobin increase <1.0 g/dL after 14 days)
     • Inflammatory bowel disease or other conditions affecting absorption
     • Intolerance to oral iron 1

3. Monitoring:

   • Repeat CBC in 2-4 weeks to assess response
   • Target hemoglobin rise of ≥10 g/L within 2 weeks indicates good response 1

Vitamin Deficiency Anemia

1. B12 Deficiency:

   • Oral supplementation: 1000-2000 μg daily for 1-2 weeks, then weekly until normalization
   • Intramuscular injection: 1000 μg weekly for 4 weeks, then monthly 1

2. Folate Deficiency:

   • Oral supplementation: 1-5 mg daily for 1-4 months 1

Anemia of Chronic Disease

1. Treat Underlying Condition:

   • Primary approach is to address the underlying chronic disorder 2

2. Iron Therapy:

   • Intravenous iron may benefit patients with functional iron deficiency 3

3. Erythropoiesis-Stimulating Agents (ESAs):

   • CAUTION: ESAs increase the risk of death, myocardial infarction, stroke, and thromboembolism 4
   • Not recommended for patients with mild to moderate anemia and heart disease 5
   • For chronic kidney disease: Use lowest dose sufficient to reduce need for transfusions 4

Cancer-Related Anemia

1. ESAs:

   • Only for anemia due to myelosuppressive chemotherapy
   • Not indicated when anticipated outcome is cure
   • Discontinue following completion of chemotherapy course 5, 4

2. Blood Transfusion:

   • Reserved for symptomatic patients or those with hemodynamically significant anemia 1

Special Populations

Heart Disease Patients

• Use restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7-8 g/dL) 5
• Avoid ESAs in patients with mild to moderate anemia and heart disease 5

Pregnant Women

• Higher iron requirements: 30 mg/day, increasing to 60-120 mg/day for anemia during pregnancy 1

Chronic Kidney Disease

• Regular screening for anemia
• Treatment options include intravenous iron and ESAs for persistent anemia 1, 4

Common Pitfalls to Avoid

1. Diagnostic Errors:

   • Relying solely on MCV without confirming iron status
   • Misinterpreting ferritin levels (may be elevated despite iron deficiency in inflammatory states) 1

2. Treatment Errors:

   • Excessive iron supplementation in conditions with elevated ferritin
   • Overuse of blood transfusions for chronic anemia 3
   • Excessive ESA use increasing risk of adverse cardiovascular events 4

3. Follow-up Failures:

   • Not investigating underlying causes of iron deficiency
   • Inadequate monitoring of response to therapy 1

Remember that anemia is often a symptom of an underlying condition, and identifying and treating the root cause is essential for effective management.