What is the treatment for anemia?

Treatment for Anemia

The first-line treatment for anemia is oral iron supplementation with ferrous sulfate 324 mg (65 mg elemental iron) daily or twice daily, administered between meals to maximize absorption, while simultaneously addressing the underlying cause. 1

Diagnosis and Classification

• Anemia is defined as a reduction in hemoglobin concentration below normal levels (less than 12 g/dL in women and less than 13 g/dL in men) 1, 2
• Severity classification:
  • Mild: Hb 10-11.9 g/dL 1, 2
  • Moderate: Hb 8-9.9 g/dL 1, 2
  • Severe: Hb <8.0 g/dL 1, 2
• Diagnostic workup should include peripheral blood smear and assessment for occult blood loss in stool and urine 1

Treatment Algorithm

Step 1: Identify and Treat the Underlying Cause

• Investigate gastrointestinal blood loss in men and postmenopausal women 1, 3
• Screen women during pregnancy and children at one year of age 3
• Consider endoscopy for older patients with suspected iron deficiency anemia to evaluate for gastrointestinal malignancy 4

Step 2: Iron Supplementation

• Oral iron therapy:

  • Ferrous sulfate 324 mg (65 mg elemental iron) daily or twice daily between meals 1, 5
  • Continue treatment for 2-3 months after hemoglobin normalization to replenish iron stores 1
  • Lower-dose formulations may be as effective with fewer adverse effects 4
  • Monitor hemoglobin after 4 weeks of treatment 1

• Parenteral iron therapy is indicated when:

  • Malabsorption is present 1, 6
  • Rapid repletion is needed 1, 6
  • Poor response to oral iron is anticipated 6
  • Patient cannot tolerate oral preparations 3, 7

Step 3: Additional Treatments Based on Severity and Etiology

• Transfusion therapy:

  • Reserved for severe symptomatic anemia (Hb <8 g/dL) or when rapid correction is needed 1, 7, 4
  • Use restrictive transfusion strategy (Hb trigger 7-8 g/dL) to minimize complications 1, 2, 7
  • Consider patient symptoms and preferences along with hemoglobin concentration 7

• Erythropoiesis-stimulating agents (ESAs):

  • Not recommended for mild to moderate anemia with heart disease 1, 2
  • May be appropriate for chemotherapy-induced anemia with Hb ≤10 g/dL 1
  • Consider for anemia of inflammation when combined with iron therapy 8

Special Considerations

Anemia in Heart Disease

• Use restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7-8 g/dL) in hospitalized patients with coronary heart disease 2
• Avoid ESAs in patients with mild to moderate anemia and heart disease due to risks of hypertension and thromboembolism 2

Anemia of Inflammation

• Characterized by hypoferremia and hyperferritinemia 8
• May require combination of iron therapy and erythropoiesis-stimulating agents 8
• Treatment should address the underlying inflammatory condition 8

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 4
• 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
• ESAs carry risks including hypertension, thromboembolism, and potential tumor progression in cancer patients 1, 2
• Transfusions should be used judiciously due to associated risks including iron overload, infection transmission, and immune suppression 1, 7
• Diagnosis of anemia of inflammation with coexisting iron deficiency can be challenging 8