Treatment Options for Low Hemoglobin, RBC, and WBC Count
The first step in managing a patient with low hemoglobin (H&H), red blood cell (RBC) count, and white blood cell (WBC) count is to identify and treat the underlying cause through appropriate diagnostic testing before initiating specific therapies.
Initial Diagnostic Workup
- A thorough diagnostic evaluation should include:
- Complete drug exposure history to identify medication-related causes 1
- Careful review of peripheral blood smear and possibly bone marrow examination 1
- Assessment for iron, folate, and vitamin B12 deficiency 1
- Evaluation for occult blood loss and renal insufficiency 1
- Coombs testing for patients with suspected autoimmune hemolytic anemia, especially those with chronic lymphocytic leukemia or non-Hodgkin's lymphoma 1
- Evaluation for infectious causes of cytopenia 1
- Assessment for bone marrow failure syndromes 1
Treatment Based on Underlying Cause
Iron Deficiency Anemia
- Oral iron supplementation (ferrous sulfate 200 mg three times daily, ferrous gluconate, or ferrous fumarate) 1
- Continue iron therapy for three months after correction of anemia to replenish iron stores 1
- Consider adding ascorbic acid to enhance iron absorption 1
Chemotherapy-Associated Anemia
- For patients with hemoglobin approaching or below 10 g/dL, erythropoiesis-stimulating agents (ESAs) such as epoetin or darbepoetin are recommended treatment options to increase hemoglobin and decrease transfusion requirements 1
- Red blood cell transfusion is also an option depending on the severity of anemia or clinical circumstances 1
- Use ESAs with caution in patients with high risk of thromboembolic events 1
Transfusion Therapy
- For hemodynamically stable patients with no extenuating circumstances (such as myocardial ischemia, severe hypoxemia, or acute hemorrhage), RBC transfusion is recommended only when hemoglobin concentration decreases to < 7.0 g/dL 1
- Avoid transfusing more than the minimum number of RBC units necessary to relieve symptoms or return hemoglobin to a safe range (7-8 g/dL in stable, non-cardiac patients) 1
Immune-Related Cytopenias
- For Grade 2 immune-related cytopenias: Hold immune checkpoint inhibitors and consider prednisone 0.5-1 mg/kg/day 1
- For Grade 3-4 immune-related cytopenias: Permanently discontinue immune checkpoint inhibitors, administer prednisone 1-2 mg/kg/day, and consider hematology consultation 1
- For severe refractory cases, consider rituximab, IVIG, cyclosporine, infliximab, mycophenolate mofetil, or anti-thymocyte globulin 1
Bone Marrow Failure
- For suspected bone marrow failure syndromes, hematology consultation is essential 1
- Consider evaluation for hematopoietic stem cell transplantation in appropriate candidates 1
Special Considerations
- Avoid erythropoietin for treatment of anemia associated with sepsis 1
- In patients with sepsis, RBC transfusion should occur only when hemoglobin concentration decreases to < 7.0 g/dL 1
- For patients with methemoglobinemia (a rare cause of functional anemia):
Monitoring Response to Treatment
- Monitor hemoglobin levels weekly until stable, then less frequently 1
- For patients on iron therapy, continue monitoring for at least one year after normalization 1
- If hemoglobin or MCV falls below normal during follow-up, additional oral iron should be given 1
Pitfalls to Avoid
- Do not rely solely on hemoglobin concentration as a "transfusion trigger"; consider the patient's clinical condition 1
- Beware of spurious low blood counts due to sample collection issues (EDTA-induced agglutination, lipemia, cryoglobulins) 2
- Do not use erythropoietin in patients with hemoglobin levels >10 g/dL due to increased risk of thromboembolic events 1
- Avoid invasive procedures in patients with coagulopathy until it is corrected 1
- Consider that multiple myeloma patients treated with thalidomide or lenalidomide plus corticosteroids are at particularly increased risk for thromboembolic events if given ESAs 1