How to manage elevated erythrocytosis in an elderly patient?

Management of Erythrocytosis in a 76-Year-Old Female

Therapeutic phlebotomy is not recommended for this patient with a hemoglobin of 17.2 g/dL (upper normal 14.5 g/dL) as it falls below the threshold requiring intervention, and routine phlebotomies carry risks of iron depletion, decreased oxygen-carrying capacity, and stroke. 1

Initial Assessment

• Evaluate for symptoms of hyperviscosity such as headache, fatigue, or poor concentration 1
• Check hydration status, as dehydration can cause relative erythrocytosis 1
• Assess for potential underlying causes of secondary erythrocytosis 2:
  • Chronic hypoxemia (lung disease, sleep apnea)
  • Cardiovascular disorders (congenital heart disease with right-to-left shunting)
  • Renal disorders (cystic kidney diseases, renal artery stenosis)
  • Medications (androgens, SGLT2 inhibitors)
  • Smoking history (though patient quit in 1974)

Diagnostic Approach

• Measure serum erythropoietin level to distinguish between primary and secondary erythrocytosis 3
• Consider JAK2 mutation analysis (JAK2V617F or exon 12) to rule out polycythemia vera 3
• Evaluate iron status through serum ferritin and transferrin saturation 1
• If secondary erythrocytosis is suspected, consider:
  • Arterial blood gas analysis to assess oxygenation 2
  • Renal ultrasound to evaluate for cystic kidney disease or masses 4
  • Sleep study if obstructive sleep apnea is suspected 4

Management Recommendations

When to Consider Therapeutic Phlebotomy

• Phlebotomy is only indicated when hemoglobin exceeds 20 g/dL and hematocrit exceeds 65% with associated hyperviscosity symptoms and no dehydration 1, 5
• This patient's hemoglobin of 17.2 g/dL does not meet criteria for therapeutic phlebotomy 1

Appropriate Management for This Patient

• Ensure adequate hydration, as dehydration can exacerbate erythrocytosis 1
• Identify and treat any underlying cause of secondary erythrocytosis 2
• If polycythemia vera is diagnosed, consider aspirin therapy and targeted management 1, 6
• Monitor hemoglobin and hematocrit levels periodically 5
• Avoid routine phlebotomies due to risk of iron depletion, which can paradoxically worsen symptoms by reducing oxygen-carrying capacity and red cell deformability 1

Special Considerations for Elderly Patients

• Assess cardiovascular risk factors, as erythrocytosis increases risk of thrombotic events 6, 7
• Consider low-dose aspirin if there are no contraindications, especially if secondary to myeloproliferative disorders 1
• Evaluate renal function, as kidney disease can contribute to erythrocytosis in older adults 4

Monitoring Recommendations

• Regular follow-up with complete blood counts to monitor hemoglobin and hematocrit 5
• Periodic assessment of iron status to avoid iron deficiency 1
• Monitor for symptoms of hyperviscosity or thrombotic complications 1

Common Pitfalls to Avoid

• Performing routine phlebotomies without meeting established criteria (Hgb >20 g/dL, Hct >65%) 1
• Failing to identify underlying causes of secondary erythrocytosis 2
• Creating iron deficiency through excessive phlebotomy, which can paradoxically worsen symptoms 1
• Overlooking the possibility of polycythemia vera, which requires specific management 3