What is the treatment for anemia?

Treatment of Anemia

The treatment of anemia should focus on identifying and addressing the underlying cause, with oral iron supplementation (ferrous sulfate 324 mg daily or twice daily) as first-line therapy for iron deficiency anemia, continuing for 2-3 months after hemoglobin normalization to replenish iron stores. 1, 2, 3

Diagnostic Classification

• Anemia is defined as a reduction in hemoglobin concentration, red-cell count, or packed cell volume below normal levels 1
• Severity classification:
  • Mild: Hemoglobin ≤11.9 g/dL and ≥10 g/dL 1, 2
  • Moderate: Hemoglobin ≤9.9 and ≥8.0 g/dL 1, 2
  • Severe: Hemoglobin <8.0 g/dL 1, 2
• Initial assessment should include complete blood count with indices and peripheral blood smear to characterize the type of anemia (microcytic, normocytic, or macrocytic) 1

Treatment Based on Type of Anemia

Iron Deficiency Anemia

• Oral iron supplementation is the first-line therapy 1, 2, 3
  • Ferrous sulfate 324 mg (containing 65 mg elemental iron) daily or twice daily 4
  • Administer between meals to maximize absorption 2
• Continue iron treatment for 2-3 months after hemoglobin normalization to replenish iron stores 2, 3
• Intravenous iron therapy is indicated when:
  • Oral iron is not tolerated 1
  • Malabsorption is present 1, 2
  • Rapid repletion is needed 1, 2
  • In patients with inflammatory bowel disease and active inflammation 1

Anemia of Chronic Disease

• Treat the underlying inflammatory condition to enhance iron absorption and reduce iron depletion 1
• In patients with inflammatory bowel disease and iron deficiency anemia, intravenous iron therapy is recommended 1
• Erythropoiesis-stimulating agents (ESAs) may be considered in specific situations, such as chemotherapy-induced anemia 1, 2

Transfusion Therapy

• The American College of Physicians recommends a restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7-8 g/dL) in hospitalized patients with coronary heart disease 5, 1
• Packed red cell transfusions are indicated when hemoglobin decreases to less than 7.5 g/dL and/or clinical symptoms are present 1
• Low-quality evidence shows that liberal RBC transfusions were associated with reduced cardiovascular events, although the data were not statistically significant 5

Special Considerations

Heart Disease

• Use a restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7-8 g/dL) in patients with heart disease 5, 1
• The American College of Physicians strongly recommends against the use of erythropoiesis-stimulating agents in patients with mild to moderate anemia and congestive heart failure or coronary heart disease 5, 1

Cancer-Related Anemia

• Evaluate for multiple potential causes of anemia, including chemotherapy effects, nutritional deficiencies, and bone marrow infiltration 1
• ESAs may be considered for chemotherapy-induced anemia with appropriate hemoglobin thresholds 1, 2

Monitoring and Follow-up

• Repeat hemoglobin measurement after 4 weeks of treatment for iron deficiency anemia 1, 2
• Continue iron treatment for 2-3 months after correction of anemia to replenish stores 1, 2, 3
• Monitor hemoglobin levels and red blood cell indices every 3 months for 1 year and then annually 3

Potential Pitfalls and Caveats

• Failure to identify and treat the underlying cause can lead to recurrence of anemia 2
• ESAs carry risks including hypertension, thromboembolism, and potential tumor progression in cancer patients 2
• Transfusions should be used judiciously due to associated risks including iron overload, infection transmission, and immune suppression 2, 6
• In men and postmenopausal women with iron deficiency anemia, gastrointestinal endoscopy is warranted to evaluate for malignancy 7, 8