What is the appropriate management for a patient with anemia?

Management of Normocytic Anemia with Hemoglobin 8.3 g/dL

This patient requires immediate iron status evaluation (ferritin and transferrin saturation) and should receive oral iron supplementation to correct anemia and replenish stores, with consideration for transfusion only if cardiovascular instability develops. 1

Initial Assessment and Iron Evaluation

All patients with anemia must have iron status evaluated before and during treatment. 2 Specifically measure:

• Serum ferritin (iron deficiency if <100 mcg/L) 2
• Transferrin saturation (TSAT) (iron deficiency if <20%) 1, 2
• These parameters guide whether iron supplementation is needed even with normocytic indices 1

The normocytic MCV (96 fL) does not exclude iron deficiency—functional iron deficiency can occur with normal MCV, particularly in inflammatory states where ferritin acts as an acute phase reactant. 1

Iron Supplementation Strategy

Initiate oral iron therapy immediately with ferrous sulfate 200 mg three times daily as first-line treatment. 1 This approach:

• Corrects anemia and replenishes body stores 1
• Should continue for 3 months after hemoglobin correction to replenish iron stores 1
• Hemoglobin should rise by 2 g/dL after 3-4 weeks of treatment 1

If oral iron is not tolerated after trying at least two different oral preparations, consider parenteral iron. 1 Intravenous iron is appropriate when:

• TSAT ≤30% and ferritin ≤500 ng/mL 1
• Oral iron causes gastrointestinal intolerance 1
• Faster correction is needed 1

Transfusion Threshold

Blood transfusions should be reserved for patients with or at risk of cardiovascular instability. 1 Specific guidance:

• Avoid transfusion when possible to minimize risks of allosensitization and transfusion-related complications 1
• Consider transfusion when hemoglobin <7.5 g/dL AND clinical symptoms are present 1
• With hemoglobin 8.3 g/dL, transfusion is not indicated unless the patient has hemodynamic instability, active ischemic heart disease, or severe symptomatic anemia 1, 3
• A restrictive transfusion strategy (hemoglobin <6-8 g/dL threshold) is associated with better outcomes than liberal transfusion 3

Monitoring and Follow-up

Monitor hemoglobin weekly until stable, then at least monthly. 2 Specific monitoring includes:

• Hemoglobin concentration should be checked weekly after initiating iron therapy until stable 2
• Once normalized, recheck at 3-month intervals for one year, then annually 1
• If hemoglobin or MCV falls below normal during follow-up, restart oral iron and recheck ferritin 1

Failure to respond (hemoglobin increase <2 g/dL after 3-4 weeks) suggests:

• Poor compliance with oral iron 1
• Continued blood loss 1
• Malabsorption 1
• Alternative diagnosis requiring further investigation 1

Additional Diagnostic Considerations

Screen for coeliac disease in all premenopausal women with iron deficiency anemia using tissue transglutaminase (tTG) antibody. 1

Evaluate for gastrointestinal blood loss if:

• Male patient or postmenopausal female 1
• Hemoglobin cannot be maintained with iron supplementation 1
• Age >45 years warrants upper and lower GI investigation 1

Do not use faecal occult blood testing—it is insensitive and non-specific for investigating iron deficiency anemia. 1

Common Pitfalls to Avoid

• Do not delay iron supplementation while awaiting further workup—all patients with anemia should receive iron therapy to correct anemia and replenish stores 1
• Do not transfuse based solely on hemoglobin level—clinical stability and symptoms determine transfusion need 1, 3
• Do not use erythropoiesis-stimulating agents (ESAs) without clear indication (chronic kidney disease, chemotherapy-induced anemia, or HIV/zidovudine-related anemia), as they increase cardiovascular risks and mortality 2
• Do not assume normal MCV excludes iron deficiency—check iron studies in all cases 1