How to treat anemia?

Treatment of Anemia: Comprehensive Management Approach

The most effective treatment for anemia requires identifying and treating the underlying cause while providing iron supplementation to correct deficiency and replenish body stores. 1

Diagnosis and Evaluation

Before initiating treatment, proper diagnosis is essential:

• Laboratory assessment:

  • Complete blood count (CBC) with hemoglobin, hematocrit, MCV, RDW
  • Serum ferritin (most powerful test for iron deficiency)
  • Transferrin saturation and iron-binding capacity
  • Consider B12 and folate levels if macrocytic or normocytic anemia

• Differential diagnosis parameters:

  Parameter	Iron Deficiency	Thalassemia Trait	Anemia of Chronic Disease
  MCV	Low	Very low (<70 fl)	Low/Normal
  RDW	High (>14%)	Normal (≤14%)	Normal/Slightly elevated
  Ferritin	Low (<30 μg/L)	Normal	Normal/High
  TSAT	Low	Normal	Low
  RBC count	Normal/Low	Normal/High	Normal/Low

Treatment Algorithm

1. Iron Deficiency Anemia (Most Common Type)

• Oral Iron Therapy:

  • Ferrous sulfate 200 mg three times daily (provides 60-120 mg elemental iron/day) 1
  • Alternative preparations if not tolerated: ferrous gluconate or ferrous fumarate
  • Continue for 3 months after hemoglobin normalizes to replenish iron stores 1, 2
  • Consider adding ascorbic acid (250-500 mg twice daily) to enhance iron absorption 1

• Parenteral Iron (for patients with:)

  • Intolerance to oral preparations
  • Poor absorption
  • Ongoing blood loss
  • Chronic inflammatory conditions
  • Options include:
    • Iron sucrose (Venofer): 200 mg over 10 minutes
    • Ferric carboxymaltose (Ferinject): 1000 mg over 15 minutes
    • Iron dextran (Cosmofer): 20 mg/kg over 6 hours 1

2. Vitamin B12 Deficiency

• For pernicious anemia: Parenteral 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 3
• For normal intestinal absorption: Oral B12 supplementation after initial parenteral treatment 3

3. Anemia of Chronic Disease

• Treat underlying inflammatory condition
• Iron supplementation if concurrent iron deficiency exists
• Consider erythropoiesis-stimulating agents (ESAs) only when absolutely necessary 2

4. Blood Transfusions

• Reserved for severe anemia (Hb <7 g/dL)
• Use restrictive transfusion strategy (trigger hemoglobin threshold of 7-8 g/dL) in patients with coronary heart disease 1

Special Considerations

Gender and Age-Specific Recommendations

• Women of childbearing age:

  • Screen annually if risk factors present
  • Treat with 60-120 mg/day of iron 1
  • Follow up after 4 weeks to assess response

• Pregnant women:

  • Start low-dose (30 mg/day) iron supplements at first prenatal visit
  • Increase to 60-120 mg/day if anemia develops
  • If Hb <9.0 g/dL, refer to physician familiar with anemia during pregnancy 1

• Men and postmenopausal women:

  • Gastrointestinal evaluation (upper and lower endoscopy) is essential as anemia often indicates GI blood loss or malignancy 1

Monitoring Response

• Check hemoglobin weekly until stable, then monthly

• Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of treatment

• If no response after 4 weeks despite compliance:

  • Reassess diagnosis
  • Consider additional testing (MCV, RDW, serum ferritin)
  • Evaluate for malabsorption or ongoing blood loss 1, 2

• After normalization, monitor hemoglobin and red cell indices every three months for one year, then after another year 1

Common Pitfalls to Avoid

1. Accepting a positive dietary history as the sole cause of iron deficiency without GI investigation
2. Inadequate duration of iron therapy (must continue for 3 months after normalization)
3. Misinterpreting ferritin levels in the presence of inflammation
4. Using ESAs in patients with mild to moderate anemia and heart disease (increased mortality risk) 1
5. Deferring iron replacement while awaiting investigations
6. Failing to investigate men and postmenopausal women with iron deficiency anemia for gastrointestinal causes 1, 2

Contraindications and Cautions

• ESAs increase risk of death, myocardial infarction, stroke, and thromboembolism when targeting hemoglobin >11 g/dL 4
• Parenteral iron can cause anaphylactic reactions; resuscitation facilities should be available 1
• Multiple-dose vials containing benzyl alcohol should not be used in neonates, infants, pregnant women, and lactating women 4

By following this comprehensive approach to anemia management, focusing on identifying and treating the underlying cause while providing appropriate iron supplementation, most patients can achieve normal hemoglobin levels and improved quality of life.