What is the first line treatment for anemia?

First-Line Treatment for Anemia

The first-line treatment for anemia should be oral iron supplementation for patients with iron deficiency anemia who have mild anemia, clinically inactive disease, and no previous intolerance to oral iron. 1

Diagnostic Approach Before Treatment

• Complete initial workup including complete blood count, serum ferritin, and C-reactive protein to distinguish between iron deficiency anemia and anemia of chronic disease 2, 1
• In patients without inflammation, serum ferritin <30 μg/L indicates iron deficiency, while in patients with inflammation, serum ferritin up to 100 μg/L may still be consistent with iron deficiency 3, 1
• If serum ferritin is between 30-100 μg/L with inflammation present, a combination of iron deficiency and anemia of chronic disease is likely 3
• Evaluate for other causes of anemia if there is inadequate response to iron replacement 3

Treatment Algorithm Based on Anemia Type

Iron Deficiency Anemia

• First-line treatment: Oral iron supplementation at 100-200 mg elemental iron daily 1, 4
  • Lower doses (100 mg daily) may be sufficient for asymptomatic patients 5
  • Higher doses (200 mg daily) recommended for symptomatic or severe anemia 5
  • Consider alternate-day dosing if side effects occur 5
• Duration: 3-6 months to achieve therapeutic goals (normalize hemoglobin and replenish iron stores) 4
• Monitoring: Check hemoglobin response after 4 weeks of treatment 1, 6
  • If hemoglobin increases <1.0 g/dL at day 14, consider switching to IV iron 6

When to Use Intravenous Iron Instead

• Consider IV iron as first-line treatment in patients with: 3, 1
  • Clinically active inflammatory disease
  • Previous intolerance to oral iron
  • Hemoglobin below 10 g/dL
  • Need for erythropoiesis-stimulating agents
  • Malabsorption conditions
  • When rapid correction of anemia is needed

Anemia of Chronic Disease

• Address the underlying inflammatory condition 2
• Provide comprehensive nutritional support 2
• Consider IV iron if inflammation is active 3, 2
• For severe cases, consider erythropoiesis-stimulating agents (ESAs) like epoetin alfa, but use with caution due to risks 7

Anemia in Specific Conditions

• Inflammatory Bowel Disease: IV iron preferred even in mild anemia due to potential exacerbation of inflammation with oral iron 1
• Chronic Kidney Disease: Initial dose of ESAs 50-100 Units/kg three times weekly, after ensuring adequate iron stores 7
• Cancer-related anemia: ESAs at 40,000 Units weekly or 150 Units/kg three times weekly, only for chemotherapy-induced anemia 7

Monitoring and Follow-up

• Check iron status and hemoglobin every 6-12 months for patients in remission or with mild disease 2, 1
• More frequent monitoring (every 3 months) for patients with active disease 1
• After successful treatment with IV iron, initiate re-treatment when serum ferritin drops below 100 μg/L or hemoglobin falls below gender-specific thresholds 3

Important Cautions

• ESAs increase risk of death, myocardial infarction, stroke, and thromboembolism when targeting hemoglobin >11 g/dL 7
• ESAs are not indicated for cancer patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure 7
• Evaluate iron status before and during treatment with ESAs and maintain iron repletion 7
• Oral iron may cause gastrointestinal side effects that reduce compliance; consider dose reduction or alternate-day dosing if this occurs 8, 5