What are the symptoms and treatment options for anemia?

Symptoms and Treatment Options for Anemia

Anemia requires prompt identification of symptoms and appropriate treatment based on the underlying cause, with iron deficiency being the most common etiology requiring oral or intravenous iron supplementation. 1, 2

Common Symptoms of Anemia

Symptoms vary based on severity, onset speed, and patient factors:

• Fatigue, weakness, and decreased exercise tolerance 2, 3
• Shortness of breath, especially with exertion 2, 4
• Dizziness, lightheadedness, and palpitations 2, 3
• Pale skin, mucous membranes, and conjunctiva 5, 4
• Cold intolerance and cold extremities 2
• Headache and difficulty concentrating 2, 4
• Chest pain or angina (especially in those with pre-existing cardiovascular disease) 2, 3
• Neurological symptoms in severe cases or specific deficiencies (e.g., vitamin B12 deficiency can cause tingling, numbness, ataxia) 5

In chronic anemia, symptoms may develop gradually and be less pronounced as the body adapts, while acute anemia presents with more dramatic symptoms due to rapid onset 2, 3.

Diagnostic Approach

Initial evaluation should determine if anemia is acute or chronic:

• Complete blood count (CBC) with hemoglobin, hematocrit, and mean corpuscular volume (MCV) 1, 4
• Serum ferritin to assess iron stores (< 15 μg/L confirms iron deficiency) 1
• Additional tests based on MCV classification:
  • Microcytic anemia: iron studies (TIBC, transferrin saturation) 1
  • Macrocytic anemia: vitamin B12 and folate levels 1, 4
  • Normocytic anemia: evaluate for chronic disease, kidney disease, or blood loss 1

Treatment Options Based on Cause

Iron Deficiency Anemia

• Oral iron supplementation:
  • Adults: 60-120 mg elemental iron daily 1
  • Children: 3 mg/kg/day of iron drops 1
  • Continue treatment for 2-3 months after hemoglobin normalizes to replenish stores 1
• Dietary counseling to increase iron-rich foods 1
• For non-responders after 4 weeks, further evaluation with additional tests (MCV, RDW, serum ferritin) 1
• Consider intravenous iron for those who cannot tolerate oral therapy 4
• Investigate underlying cause, especially in men and postmenopausal women (GI evaluation recommended) 1

Vitamin B12 Deficiency (Including Pernicious Anemia)

• Intramuscular vitamin B12 injections:
  • Initial: 100 mcg daily for 6-7 days 6
  • Maintenance: 100 mcg monthly for life in pernicious anemia 6, 5
• Oral supplementation may be sufficient for non-pernicious causes 6

Folate Deficiency

• Oral folate supplementation 1, 4
• Address underlying causes (malabsorption, increased requirements) 1

Anemia of Chronic Disease/Inflammation

• Treat underlying condition 1
• Erythropoiesis stimulating proteins may be considered for symptomatic anemia with hemoglobin below 11 g/dL 1
• Avoid erythropoiesis stimulating proteins for prevention or to reach high hemoglobin targets 1

Acute Blood Loss Anemia

• Blood transfusion for severe symptomatic anemia or hemoglobin < 7-8 g/dL 1, 7
• Identify and address source of bleeding 3, 7

Special Considerations

Pregnant Women

• Screen at first prenatal visit 1
• Start low-dose iron supplementation (30 mg/day) at first prenatal visit 1
• Increase to 60-120 mg/day if anemia develops 1
• Refer to specialist if hemoglobin < 9 g/dL 1

Elderly Patients

• Lower threshold for investigation of GI malignancy with iron deficiency 1, 4
• Consider comorbidities that may exacerbate symptoms 4
• Restrictive transfusion strategy (hemoglobin < 7-8 g/dL) generally preferred 7

Common Pitfalls to Avoid

• Failing to investigate underlying cause, especially in men and postmenopausal women with iron deficiency (may indicate GI malignancy) 1
• Empiric use of nutritional supplements without determining specific deficiency 7
• Overlooking medication effects (e.g., long-term PPI use can impair iron absorption) 1
• Missing non-GI causes of blood loss (e.g., heavy menstruation, frequent blood donation) 1, 4
• Inadequate duration of iron therapy (should continue 2-3 months after hemoglobin normalizes) 1