What is the treatment for anemia?

Treatment for Anemia

The treatment for anemia should be targeted to the underlying cause, with oral iron supplementation (ferrous sulfate 200 mg three times daily) being the first-line treatment for iron deficiency anemia, continuing for three months after correction of anemia to replenish iron stores. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis of the type of anemia is essential:

• Initial testing should include:

  • Complete blood count (CBC) with differential
  • Iron studies: serum ferritin, transferrin saturation, serum iron, and total iron-binding capacity
  • Additional tests based on clinical suspicion: B12, folate, inflammatory markers 2

• Laboratory patterns:

  Parameter	Iron Deficiency	Anemia of Chronic Disease	Thalassemia
  MCV	Low (<80 fL)	Low or normal	Very low
  Ferritin	Low (<15 μg/L)	Normal or high (>100 μg/L)	Normal
  TSAT	Low	Low	Normal
  RDW	Elevated	Normal or slightly elevated	Normal 2

Treatment Based on Anemia Type

1. Iron Deficiency Anemia

• First-line treatment: Oral iron supplementation

  • Ferrous sulfate 200 mg three times daily
  • Continue for 3 months after hemoglobin normalizes 1, 2
  • Adding ascorbic acid (vitamin C) enhances iron absorption 1, 2

• Intravenous iron indicated for:

  • Inadequate response to oral iron (hemoglobin increase <1.0 g/dL after 14 days)
  • Inflammatory bowel disease or conditions affecting absorption
  • Intolerance to oral iron 2

• Investigation: All men and post-menopausal women with iron deficiency anemia should undergo upper gastrointestinal endoscopy and colonoscopy to exclude gastrointestinal malignancy 1

2. Vitamin B12 Deficiency Anemia

• Pernicious anemia: Parenteral vitamin B12 (cyanocobalamin)

  • Initial: 100 mcg daily for 6-7 days intramuscularly
  • Followed by 100 mcg monthly for life 3

• Normal intestinal absorption: Oral B12 preparation for chronic treatment 3

3. Folate Deficiency Anemia

• Oral folic acid supplementation for megaloblastic anemias due to folate deficiency 4

4. Anemia of Chronic Disease

• Primary treatment focuses on the underlying condition
• Iron supplementation generally not beneficial as iron stores are usually normal 5
• In cases with concurrent iron deficiency, iron therapy may be considered 6

5. Anemia in Heart Disease

• Restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7-8 g/dL) in hospitalized patients with coronary heart disease 1
• Avoid erythropoiesis-stimulating agents in patients with mild to moderate anemia and heart disease 1

Blood Transfusion Considerations

• Reserve for symptomatic patients or those with hemodynamically significant anemia
• Target hemoglobin levels:

  • 7 g/dL in stable patients without cardiac disease

  • 8 g/dL in patients with cardiac disease or active bleeding 2, 7

• Transfusion decisions should be guided by patient symptoms and preferences in conjunction with hemoglobin concentration 7

Monitoring and Follow-up

• Repeat CBC in 2-4 weeks to assess response to therapy
• Target hemoglobin rise of ≥10 g/L within 2 weeks indicates good response to iron therapy
• Once normal, monitor hemoglobin and red cell indices at three-month intervals for one year, then after another year 1, 2

Common Pitfalls to Avoid

• Failing to investigate the underlying cause, especially in men and post-menopausal women
• Relying solely on MCV or MCH without confirming iron status
• Misinterpreting ferritin levels in the presence of inflammation
• Excessive iron supplementation in patients with thalassemia
• Excessive use of erythropoiesis-stimulating agents, which can increase risk of death and cardiovascular events 2

Remember that iron deficiency does not usually return in most patients in whom a cause is not found after appropriate investigation 1. However, persistent or recurrent anemia warrants further evaluation.