What is the appropriate management for a patient with anemia, as indicated by low hemoglobin and hematocrit levels?

Management of Anemia Based on CBC Findings

The appropriate management for this patient with mild anemia (low hemoglobin and hematocrit) is to confirm iron deficiency with iron studies and initiate oral iron supplementation with ferrous sulfate 324 mg (65 mg elemental iron) daily while investigating underlying causes. 1

Interpretation of CBC Results

The patient's CBC shows:

• Hemoglobin: 12.2 g/dL (low; normal range 13.5-17.0 g/dL)
• Hematocrit: 37.1% (low; normal range 40.0-53.0%)
• RBC: 3.84 m/mm³ (low; normal range 4.30-6.00 m/mm³)
• Normal MCV (96.6 fL), MCH (31.8 pg), MCHC (32.9 g/dL), and RDW
• Normal WBC and platelets

This pattern represents a normocytic, normochromic anemia, which requires further evaluation.

Diagnostic Approach

1. Confirm Iron Deficiency

• Obtain iron studies including:
  • Serum ferritin (most useful marker for iron deficiency) 1
  • Transferrin saturation (TSAT) 1, 2
  • Serum iron and TIBC 1

2. Additional Testing

• Screen for coeliac disease (recommended for all patients with confirmed IDA) 1
• Consider vitamin B12 and folate levels (to rule out mixed deficiencies) 2
• Reticulocyte count (to assess bone marrow response) 1, 2
• CRP/ESR (to assess for inflammation/chronic disease) 2

Treatment Algorithm

Initial Treatment

1. Start oral iron supplementation:

   • Ferrous sulfate 324 mg (65 mg elemental iron) once daily 3
   • Take on empty stomach with vitamin C to enhance absorption
   • If not tolerated, consider:
     • Reduced dosing (every other day)
     • Alternative preparations (ferrous gluconate or fumarate)
     • Parenteral iron if oral preparations fail 1

2. Monitor response:

   • Check hemoglobin after 4 weeks of therapy 1, 2
   • A good response (Hb rise ≥10 g/L within 2 weeks) confirms iron deficiency 1
   • Continue iron therapy for at least 3 months after hemoglobin normalizes to replenish stores 2

Investigation of Underlying Cause

For male patients with confirmed IDA:

• Upper and lower GI investigations are recommended 1
• Gastroscopy and colonoscopy should be first-line GI investigations 1
• CT colonography is a reasonable alternative if colonoscopy is not suitable 1

Special Considerations

• Avoid premature discontinuation of iron therapy - continue for 3 months after hemoglobin normalizes to replenish iron stores 2
• Consider parenteral iron if oral therapy fails, is not tolerated, or if there is ongoing blood loss 1, 2
• Investigate recurrent anemia - if anemia recurs after successful treatment, further investigation of the small bowel and renal tract may be needed 1
• Limited blood transfusion may be required for symptomatic severe anemia, but iron replacement is still necessary post-transfusion 1

Common Pitfalls to Avoid

• Relying solely on MCV - normal MCV does not rule out iron deficiency, especially in mixed deficiencies 2
• Failing to investigate the underlying cause - especially important in male patients 1
• Stopping iron therapy too early - continue for 3 months after hemoglobin normalizes 2
• Overlooking mixed nutritional deficiencies - consider B12/folate deficiency coexisting with iron deficiency 2

By following this structured approach to diagnosis and management, you can effectively treat the anemia while identifying and addressing its underlying cause.