Symptoms and Treatment Options for Anemia
Symptoms of Anemia
Anemia presents with a range of symptoms that vary based on severity, chronicity, and underlying cause, with fatigue being the most common manifestation. 1
- Common symptoms include fatigue, weakness, shortness of breath, lightheadedness, difficulty concentrating, and exercise intolerance 1, 2
- Physical manifestations may include pallor, tachycardia, and in severe cases, heart failure 3
- Specific symptoms of iron deficiency anemia may include angular stomatitis, glossitis, koilonychia (spoon-shaped nails), restless legs syndrome (affecting 32-40% of patients), pica (craving for non-food items like ice, affecting 40-50%), and blue sclerae 3, 1
- Acute anemia typically presents with symptoms related to blood loss, while chronic anemia may develop gradually with worsening fatigue, dyspnea, and lightheadedness 4, 2
- Symptoms are often more pronounced with rapid onset of anemia compared to slowly developing anemia, which may be asymptomatic and discovered incidentally 5, 2
Diagnostic Approach
- Initial evaluation should include a complete blood count (CBC) with hemoglobin, hematocrit, and mean corpuscular volume (MCV) 6, 7
- Anemia severity is classified as mild (Hb ≥10 g/dl to ≤11.9 g/dl), moderate (Hb ≥8.0 g/dl to ≤9.9 g/dl), and severe (Hb <8.0 g/dl) 7
- Further workup should include iron studies (serum ferritin, transferrin saturation), assessment for inflammation (ESR, CRP), and peripheral blood smear 7
- Serum ferritin below 15-30 μg/L confirms iron deficiency, though this may be falsely elevated in inflammatory states 6, 7, 1
- Additional testing may include reticulocyte count, vitamin B12 and folate levels, and tests for hemolysis (lactate dehydrogenase, haptoglobin, bilirubin) 5
Treatment Options Based on Anemia Type
Iron Deficiency Anemia
- Oral iron supplementation is first-line therapy for most patients with iron deficiency anemia 6, 7
- Recommended dosage is 60-120 mg elemental iron daily (e.g., ferrous sulfate 324 mg daily or twice daily) 6, 7
- Treatment should continue for 2-3 months after hemoglobin normalizes to replenish iron stores 6, 1
- Lower-dose formulations or alternate-day dosing may be as effective with fewer side effects 2
- Intravenous iron is indicated for patients with:
Anemia of Chronic Disease/Inflammation
- Treatment should focus on addressing the underlying condition 6, 7
- In inflammatory states such as active IBD, intravenous iron may be preferred over oral iron 7
Chemotherapy-Induced Anemia
- Erythropoiesis-stimulating agents (ESAs) may be used for chemotherapy-induced anemia with Hb ≤10 g/dl 7
- ESAs should be avoided for mild to moderate anemia with heart disease due to increased risks 7
Severe Symptomatic Anemia
- Blood transfusion may be considered for symptomatic patients with hemoglobin levels of 8 g/dL or less 2
- A restrictive transfusion strategy (transfusing only when Hb <6-8 g/dL) is associated with better outcomes than liberal transfusion 8
Special Considerations
Pregnancy
- Screening for anemia is recommended at the first prenatal visit 6
- Low-dose iron supplementation (30 mg/day) is recommended at the first prenatal visit 6, 7
- If anemia develops during pregnancy, increase iron supplementation to 60-120 mg/day 6, 7
Elderly Patients
- Anemia in older adults is associated with increased morbidity and mortality 2
- In elderly patients with iron deficiency anemia, endoscopic evaluation is warranted to rule out gastrointestinal malignancy 2
Common Pitfalls and Caveats
- Failure to identify and treat the underlying cause can lead to recurrence of anemia 7
- Ferritin is an acute phase reactant that may be falsely elevated in inflammatory states, potentially masking iron deficiency 7, 1
- ESAs carry risks including hypertension, thromboembolism, and potential tumor progression in cancer patients 7
- Empiric use of nutritional supplements to treat anemia of uncertain etiology is discouraged 8
- Monitoring is essential, with repeat hemoglobin measurement after 4 weeks of treatment 7