What is the treatment for severe anemia?

Treatment for Severe Anemia

The treatment for severe anemia should include intravenous iron supplementation as first-line therapy, with erythropoiesis-stimulating agents (ESAs) considered when anemia does not improve despite iron therapy and control of underlying inflammation. 1

Diagnostic Evaluation Before Treatment

• Determine the underlying cause of anemia through bone marrow aspiration, biopsy, and cytogenetic analysis in cases where the etiology is unclear 1
• Measure serum erythropoietin levels in all patients with severe anemia (Hb ≤ 10 g/dL) 1
• Assess iron status parameters including serum ferritin and transferrin saturation to distinguish between absolute iron deficiency (serum ferritin < 100 ng/mL) and functional iron deficiency (TSAT < 20% and serum ferritin > 100 ng/mL) 1
• Evaluate for other potential causes of anemia such as vitamin B12 or folate deficiency 2

First-Line Treatment Approach

Iron Supplementation

• For severe anemia with absolute iron deficiency: Administer intravenous iron at doses according to approved product labels until correction of iron deficiency 1
• For severe anemia with functional iron deficiency: Administer 1000 mg of intravenous iron as a single dose or multiple doses according to available formulations 1
• Oral iron therapy (ferrous sulfate 200 mg three times daily) should be limited to patients with mild anemia or those who cannot receive IV iron 1
• Ferrous sulfate tablets typically contain 324mg, providing 65mg of elemental iron per dose 3
• Continue iron supplementation for three months after correction of anemia to replenish iron stores 1

Blood Transfusion

• Reserve red blood cell transfusions for patients with hemoglobin < 7-8 g/dL and/or severe anemia-related symptoms requiring immediate improvement 1
• Use a restrictive transfusion strategy (trigger hemoglobin threshold of 7-8 g/dL) in patients with coronary heart disease 1

Second-Line Treatment Options

Erythropoiesis-Stimulating Agents (ESAs)

• Consider ESAs when anemia does not improve despite intravenous iron therapy and control of inflammation 1
• Administer ESAs as fixed-dose, weekly, subcutaneous treatment at an initial dose in the range of 30,000-80,000 IU recombinant human erythropoietin or up to 300 mg darbepoetin alpha 1
• Always combine ESA therapy with intravenous iron administration to prevent functional iron deficiency 1
• Target hemoglobin levels of 11-13 g/dL to minimize thrombosis risk 1
• Discontinue ESA therapy if no hemoglobin response is observed after 4-8 weeks 1

Treatment Based on Underlying Condition

• For myelodysplastic syndromes (MDS): Consider azacitidine for higher-risk MDS patients not eligible for stem cell transplantation 1
• For chronic myelomonocytic leukemia (CMML): Patients with myelodysplastic CMML and severe anemia should receive erythropoietic stimulating agents if serum erythropoietin ≤ 500 mU/dL 1
• For inflammatory conditions: Target the underlying disease process while providing iron supplementation 4

Monitoring and Follow-up

• Monitor hemoglobin concentration and red cell indices at three-month intervals for one year after normalization, then annually 1
• Provide additional iron supplementation if hemoglobin or MCV falls below normal 1
• Consider further investigation if hemoglobin cannot be maintained despite appropriate therapy 1

Special Considerations

• Iron chelation therapy is strongly recommended for patients with transfusion iron overload who are candidates for allogeneic stem cell transplantation 1
• In non-transplant candidates with lower-risk MDS, iron chelation is recommended for patients with major iron overload (e.g., significantly reduced cardiac T2* on MRI) 1
• Avoid switching from one ESA to another in patients not responding within 4-8 weeks 1
• Consider ascorbic acid supplementation to enhance iron absorption when response to oral iron is poor 1