What is the treatment for anemia?

Treatment of Anemia

The treatment of anemia should be directed at the underlying cause, with oral iron supplementation (ferrous sulfate 324 mg daily or twice daily) as first-line therapy for iron deficiency anemia, continuing for 2-3 months after hemoglobin normalization to replenish iron stores. 1

Diagnostic Approach

• Anemia is defined as a reduction in hemoglobin concentration below normal levels 1
• Severity classification:
  • Mild: Hb ≤11.9 g/dl and ≥10 g/dl 1
  • Moderate: Hb ≤9.9 and ≥8.0 g/dl 1
  • Severe: Hb <8.0 g/dl 1
• Initial workup should include:
  • Complete blood count with red cell indices 2
  • Iron studies (serum ferritin, transferrin saturation) 2
  • Peripheral blood smear 1
  • Assessment for occult blood loss 1, 3

Treatment Approach Based on Cause

Iron Deficiency Anemia

• Oral iron supplementation: Ferrous sulfate 324 mg (65 mg elemental iron) daily or twice daily between meals 1, 4
• Continue treatment for 2-3 months after hemoglobin normalization 1, 5
• Investigate underlying cause, particularly gastrointestinal blood loss in men and postmenopausal women 1, 3
• For patients with confirmed iron deficiency without obvious non-GI cause, both upper and lower GI tract investigations are recommended 2

Parenteral Iron Therapy

• Indicated when:
  • Oral iron is not tolerated 1, 6
  • Malabsorption is present 1
  • Rapid repletion is needed 1, 7
  • Conditions such as gastric bypass, heavy uterine bleeding, inflammatory bowel disease 6

Transfusion Therapy

• Reserved for severe symptomatic anemia or when rapid correction is needed 1
• Use restrictive transfusion strategy (hemoglobin trigger 7-8 g/dL) to minimize complications 8, 1, 7
• The American College of Physicians recommends a restrictive red blood cell transfusion strategy in hospitalized patients with coronary heart disease 8

Anemia of Inflammation

• Treat the underlying inflammatory condition 9
• Iron therapy may be beneficial even with elevated ferritin levels due to functional iron deficiency 9
• Combination of iron therapy and erythropoiesis-stimulating agents may improve anemia in selected patients 9

Special Considerations

Erythropoiesis-Stimulating Agents (ESAs)

• Not recommended for patients with mild to moderate anemia and congestive heart failure or coronary heart disease 8, 1
• May be appropriate for chemotherapy-induced anemia with Hb ≤10 g/dl 1
• Carry risks including hypertension, thromboembolism, and potential tumor progression in cancer patients 1

Anemia in Older Adults

• Associated with increased morbidity and mortality 5
• Often asymptomatic and discovered incidentally 5
• Common causes include nutritional deficiency, chronic kidney disease, chronic inflammation, and occult blood loss 5

Monitoring and Follow-up

• For iron deficiency anemia: Repeat hemoglobin measurement after 4 weeks of treatment 1
• Normalization of hemoglobin typically occurs by eight weeks after treatment in most patients 5
• Regular assessment of iron status and hemoglobin levels based on the underlying condition 1

Pitfalls and Caveats

• Failure to identify and treat the underlying cause can lead to recurrence 1
• Transfusions should be used judiciously due to associated risks 1, 7
• No single test is diagnostic of iron deficiency unless the serum ferritin is low or the percent transferrin saturation is low with an elevated total iron binding capacity 6
• Oral iron has many unpleasant side effects, resulting in low patient adherence; lower-dose formulations may be as effective with fewer adverse effects 5, 6