What is the management plan for a 65-year-old female with anemia (previous Packed Cell Volume (PCV) of 20)?

Management of Anemia in a 65-Year-Old Female with PCV of 20

The management of a 65-year-old female with severe anemia (PCV 20) should include immediate diagnostic workup to identify the underlying cause, iron supplementation therapy, and consideration for blood transfusion based on her clinical status and hemoglobin level.

Initial Assessment and Diagnosis

• Iron deficiency anemia (IDA) occurs in 2-5% of adult men and post-menopausal women in the developed world and requires thorough investigation 1
• A PCV of 20 corresponds to a severely low hemoglobin level (approximately 6-7 g/dL), which warrants urgent evaluation and treatment 1
• Serum ferritin is the most powerful test for diagnosing iron deficiency, with levels <12 μg/dL being diagnostic 1
• Additional testing should include complete blood count with red cell indices, reticulocyte count, iron studies (transferrin saturation, total iron binding capacity), vitamin B12 and folate levels 1
• In cases where anemia of chronic disease may coexist with iron deficiency, serum transferrin receptor activity measurement can be helpful 2

Gastrointestinal Evaluation

• In post-menopausal women, gastrointestinal blood loss is the most common cause of IDA, necessitating thorough GI investigation 1
• Upper GI endoscopy with small bowel biopsies should be performed, as 2-3% of patients with IDA have celiac disease 1
• Lower GI tract examination (colonoscopy or barium enema) is essential as dual pathology occurs in 10-15% of patients 1
• Common GI causes include colonic cancer/polyps, gastric cancer, angiodysplasia, peptic ulcer disease, and inflammatory bowel disease 1
• NSAID use should be noted and discontinued whenever possible as it's a common cause of occult GI blood loss 1

Treatment Approach

Iron Supplementation

• All patients should receive iron supplementation to correct anemia and replenish body stores 1
• Oral iron therapy should be initiated with ferrous sulfate 200 mg three times daily, or equivalent ferrous gluconate or ferrous fumarate 1
• Iron supplementation should be continued for three months after correction of anemia to replenish iron stores 1
• The hemoglobin concentration should rise by approximately 2 g/dL after 3-4 weeks of oral iron therapy 1
• Failure to respond to oral iron may indicate poor compliance, misdiagnosis, continued blood loss, or malabsorption 1

Parenteral Iron Therapy

• Intravenous iron should be considered when there is intolerance to at least two oral preparations or non-compliance 1
• In patients with inflammatory bowel disease and moderate to severe IDA (Hb <100 g/L), intravenous iron is indicated for those intolerant to oral iron 1
• Parenteral iron therapy is more expensive and may cause anaphylactic reactions, but may be necessary in cases of severe malabsorption 1, 3

Blood Transfusion

• Blood transfusion should be considered when hemoglobin decreases to less than 7.5 g/dL and/or there are clinical symptoms and/or no response to other therapeutic measures 1
• Transfusion of 2-3 units of packed cells is recommended to address an acute episode while avoiding complications from volume overload 1
• Do not transfuse more than the minimum number of RBC units necessary to relieve symptoms or return the patient to a safe hemoglobin range (7-8 g/dL) 1

Follow-up and Monitoring

• Once normal, the hemoglobin concentration and red cell indices should be monitored at three-month intervals for one year and then after a further year 1
• Additional oral iron should be given if the hemoglobin or MCV falls below normal 1
• Further investigation is only necessary if the hemoglobin and MCV cannot be maintained with iron supplementation 1
• In patients with inflammatory bowel disease and IDA, monitoring should occur every 3 months for at least a year after correction, and periodically thereafter 1

Special Considerations

• The appropriateness of investigating patients with severe co-morbidity or advanced age should be carefully considered, especially if the results would not influence management 1
• If anemia persists despite appropriate therapy, consider additional causes such as vitamin B12 deficiency, folate deficiency, or myelodysplastic syndrome, particularly common in elderly patients 4
• In cases of vitamin B12 deficiency, oral supplementation is usually effective, though intramuscular injection (100 mcg daily for 6-7 days followed by maintenance therapy) may be required in cases of pernicious anemia 5