What is the initial treatment for chronic blood loss anemia?

Initial Treatment for Chronic Blood Loss Anemia

The initial treatment for chronic blood loss anemia is oral iron supplementation, with ferrous sulfate being the preferred formulation due to its low cost and effectiveness. 1

Diagnosis and Assessment

• Before initiating treatment, confirm iron deficiency anemia through laboratory tests including serum ferritin (with a cut-off value of 45 mg/dL recommended for diagnosing iron deficiency in individuals with anemia) 1
• Evaluate for the source of chronic blood loss, as identifying and addressing the underlying cause is essential for successful management 2
• Consider transferrin saturation, soluble transferrin receptor, or reticulocyte hemoglobin equivalent tests in patients with inflammatory conditions who may have iron deficiency despite ferritin levels >45 mg/dL 1

Oral Iron Therapy Protocol

• First-line approach: Oral ferrous sulfate, which is the least expensive iron formulation with comparable efficacy to other preparations 1
• Dosing recommendations:
  • Administer once daily rather than multiple times per day 1
  • Consider every-other-day dosing if daily dosing causes intolerable side effects, as this may provide similar absorption rates 1
  • Add vitamin C to improve iron absorption 1
  • Take on an empty stomach when possible for better absorption 1

Special Considerations for Specific Conditions

• Portal hypertensive gastropathy: Begin with oral iron supplements to replenish iron stores; consider IV iron therapy for patients with ongoing bleeding who don't respond to oral iron 1
• Inflammatory bowel disease: Determine whether anemia is due to inadequate intake/absorption or iron loss; treat active inflammation to enhance iron absorption 1
• Post-bariatric surgery: Intravenous iron therapy is recommended due to likely disruption of duodenal iron absorption 1
• Celiac disease: Ensure adherence to a gluten-free diet to improve iron absorption while supplementing with oral iron 1

When to Switch to Intravenous Iron

Intravenous iron should be used when:

• Patient does not tolerate oral iron 1
• Ferritin levels do not improve with a trial of oral iron 1
• Patient has a condition in which oral iron is not likely to be absorbed 1
• Severe anemia is present requiring rapid correction 3
• Gastrointestinal blood loss exceeds intestinal ability to absorb iron (e.g., intestinal angiodysplasia) 2
• Active inflammation with compromised absorption is present (e.g., in IBD) 1

Intravenous Iron Administration

• Prefer IV iron formulations that can replace iron deficits with 1-2 infusions rather than those requiring multiple infusions 1
• Be aware that all IV iron formulations have similar risk profiles 1
• True anaphylaxis with IV iron is rare; most reactions are complement activation-related pseudo-allergies that should be treated as such 1

Red Blood Cell Transfusions

• Reserve transfusions for:
  • Hemodynamically unstable patients with acute hemorrhage 1
  • Symptomatic patients (tachycardia, tachypnea, postural hypotension) with hemoglobin <10 g/dL 1
  • Asymptomatic but hemodynamically stable patients with chronic anemia: maintain hemoglobin 7-9 g/dL 1
  • Patients with acute coronary syndromes: maintain hemoglobin around 10 g/dL 1

Common Pitfalls and Caveats

• Failure to identify and treat the underlying cause of chronic blood loss will result in continued anemia despite iron supplementation 2
• Oral iron supplementation often causes gastrointestinal side effects (constipation in 12%, diarrhea in 8%, nausea in 11%), which may limit adherence 1
• Iron deficiency anemia that does not respond to oral supplementation requires further investigation, not just increased dosing 4
• Patients with anemia of chronic disease may be misdiagnosed as having iron deficiency anemia; careful laboratory evaluation is needed to differentiate these conditions 5