What are the treatment options for anemia?

Treatment Options for Anemia

The treatment of anemia should be tailored to the underlying cause, with iron supplementation being the first-line therapy for iron deficiency anemia, erythropoiesis-stimulating agents for anemia related to chronic kidney disease or chemotherapy, and vitamin supplementation for deficiency-related anemias.

Initial Evaluation

Before initiating treatment, a thorough diagnostic workup is essential:

• Complete blood count with RDW and reticulocyte count
• Iron studies (serum iron, ferritin, transferrin saturation)
• Vitamin B12 and folate levels
• Inflammatory markers (CRP, ESR)
• Peripheral blood smear review
• Additional testing based on clinical suspicion:
  • Hemoglobin electrophoresis for suspected thalassemia
  • Serum haptoglobin, LDH, and bilirubin to rule out hemolysis
  • Bone marrow examination in selected cases

Treatment Algorithm by Anemia Type

1. Iron Deficiency Anemia

• First-line: Oral iron supplementation

  • Ferrous sulfate 325 mg (65 mg elemental iron) three times daily
  • Continue for 3 months after hemoglobin normalization to replenish stores 1
  • Take between meals with vitamin C to enhance absorption

• For poor response, intolerance, or malabsorption:

  • Intravenous iron formulations (iron sucrose, ferric carboxymaltose)
  • Reserved for severe anemia (Hb <7 g/dL) or symptomatic patients 1

2. Vitamin Deficiency Anemias

• B12 Deficiency:

  • For pernicious anemia: Intramuscular vitamin B12 100 mcg daily for 6-7 days, then alternate days for 7 doses, then every 3-4 days for 2-3 weeks, followed by 100 mcg monthly for life 2
  • For normal intestinal absorption: Oral B12 supplementation after initial parenteral treatment

• Folate Deficiency:

  • Oral folic acid 1-5 mg daily until resolution

3. Anemia of Chronic Disease/Inflammation

• Primary approach: Treat underlying condition 1
• For persistent anemia:
  • Consider IV iron if ferritin <100 μg/L with inflammation 1
  • Oral iron is less effective in inflammatory states 1
  • ESA therapy may be considered if inadequate response to iron and optimized disease treatment 1

4. Chemotherapy-Induced Anemia

• For Hb <10 g/dL:

  • Erythropoiesis-stimulating agents (epoetin alfa or darbepoetin) 3
  • RBC transfusion depending on severity and clinical circumstances 3
  • Carefully weigh thromboembolism risks when considering ESAs 3

• For Hb between 10-12 g/dL:

  • Clinical judgment should guide whether to use ESAs or wait until Hb falls closer to 10 g/dL 3

5. Genetic Disorders of Iron Metabolism or Heme Synthesis

• SLC11A2 defects: Oral iron supplementation, EPO, and/or erythrocyte transfusions 3
• STEAP3 defects: Erythrocyte transfusions with EPO; iron chelation for systemic iron loading 3
• SLC25A38 defects: Hematopoietic stem cell transplantation; symptomatic treatment with transfusions and chelation 3
• ALAS2 defects (XLSA): Pyridoxine trial (50-200 mg/day); manage both anemia and iron overload 3

6. Severe Symptomatic Anemia

• RBC transfusion considerations:
  • Generally recommended for Hb <7 g/dL in stable patients 4
  • Higher threshold (8 g/dL) may be appropriate for patients with cardiovascular disease 4
  • Transfusion should be guided by symptoms and patient preferences in conjunction with Hb levels 4

Special Considerations

Anemia in Cancer Patients

• Before using ESAs, rule out other causes of anemia 3
• ESAs are indicated for chemotherapy-induced anemia, not for patients receiving hormonal agents, biologics, or radiotherapy alone 5
• ESAs are not indicated when the anticipated outcome of chemotherapy is cure 5
• Monitor for thromboembolism risk, especially in patients with prior history, recent surgery, or prolonged immobilization 3

Anemia in Inflammatory Bowel Disease

• Often multifactorial and may require combination therapy 1
• IV iron preferred over oral in active inflammation 1

Pediatric Considerations

• Screen high-risk infants for anemia between 9-12 months, 6 months later, and annually from ages 2-5 years 3
• For iron deficiency anemia in children, prescribe 3 mg/kg/day of iron drops between meals 3
• Recheck hemoglobin after 4 weeks of treatment; an increase of ≥1 g/dL confirms iron deficiency 3

Common Pitfalls to Avoid

1. Failure to identify the underlying cause before initiating treatment
2. Overlooking iron deficiency in inflammatory states (ferritin may appear normal)
3. Inappropriate use of ESAs in patients with cancer when transfusion is more appropriate
4. Inadequate duration of iron therapy (should continue for 3 months after hemoglobin normalizes)
5. Neglecting to monitor for iron overload in patients receiving chronic transfusions or iron therapy
6. Assuming oral iron is effective in all cases (IV iron may be necessary with inflammation or malabsorption)

By systematically identifying the underlying cause and applying evidence-based treatment strategies, most forms of anemia can be effectively managed to improve patient outcomes, reduce morbidity, and enhance quality of life.