What is the first line of treatment for a patient diagnosed with anemia?

First-Line Treatment for Anemia

Oral iron supplementation is the first-line treatment for patients diagnosed with anemia, particularly when iron deficiency is confirmed. 1, 2

Diagnosis and Assessment

• Before initiating treatment, confirm iron deficiency through laboratory tests including serum ferritin (cut-off value of 45 mg/dL for diagnosing iron deficiency in individuals with anemia) 1
• In patients with inflammatory conditions, consider transferrin saturation (TfS), with levels below 16% indicating iron deficiency 3
• Ferritin levels <15 μg/L indicate absolute iron deficiency, but in the presence of inflammation, the lower limit should be increased to 100 μg/L 3
• Evaluate other causes of anemia (vitamin deficiency, chronic inflammation, bleeding) before initiating treatment 4

First-Line Treatment Algorithm

Iron Deficiency Anemia

• Oral iron therapy is the first-line approach for most patients with iron deficiency anemia 1, 2, 5
  • Administer oral ferrous sulfate once daily rather than multiple times per day 1
  • Consider every-other-day dosing if daily dosing causes intolerable side effects 1
  • Add vitamin C to improve iron absorption, and take on an empty stomach when possible 1

Special Considerations by Anemia Type

• For anemia in chronic kidney disease:

  • Erythropoiesis-stimulating agents (ESAs) are indicated for treatment of anemia due to CKD 4
  • Evaluate iron status before and during treatment and maintain iron repletion 4
  • Use the lowest dose of ESA sufficient to reduce the need for RBC transfusions 4

• For anemia in myelodysplastic syndromes (MDS):

  • For lower-risk MDS without del(5q): ESAs (recombinant EPO or darbepoetin) are the first-line treatment 3
  • Weekly doses of 30,000-80,000 units of EPO or 150-300 μg of darbepoetin are recommended 3
  • For lower-risk MDS with del(5q): Lenalidomide is recommended after ESA failure 3

When to Consider Alternative Treatments

• Switch to intravenous iron when: 1, 2

  • Patient does not tolerate oral iron
  • Ferritin levels do not improve with a trial of oral iron
  • Patient has a condition in which oral iron is not likely to be absorbed
  • Active inflammation with compromised absorption is present

• Consider RBC transfusions for: 1

  • Hemodynamically unstable patients with acute hemorrhage
  • Symptomatic patients with hemoglobin <10 g/dL
  • Asymptomatic but hemodynamically stable patients with chronic anemia (maintain hemoglobin 7-9 g/dL)

Common Pitfalls and Caveats

• Oral iron supplementation often causes gastrointestinal side effects (nausea, flatulence, diarrhea, gastric erosion), which may limit adherence 3, 1
• In patients with inflammatory bowel disease, oral iron may exacerbate symptoms through generation of reactive oxygen species 3
• ESAs carry risks including increased mortality, myocardial infarction, stroke, and venous thromboembolism when targeting hemoglobin levels >11 g/dL 4
• Failure to identify and treat the underlying cause of anemia may lead to recurrence or poor response to treatment 5, 6
• Concomitant iron deficiency might be present in anemia of chronic disease and could affect the diagnosis and therapeutic protocol 7

Follow-Up and Monitoring

• Monitor hemoglobin levels at least weekly until stable, then monthly for patients on ESAs 4
• For patients with chronic blood loss anemia, regular monitoring of iron stores is necessary to prevent recurrence 1, 2
• Response to oral iron therapy should be evident within 4-8 weeks; if no response, reevaluate diagnosis or consider alternative treatment 5, 6