What is the next step in managing mild anemia in an elderly patient with RBC 3.92, Hb 12.8, and Hct 37.9?

Management of Mild Anemia in an Elderly Patient

Initial Assessment

The next step is to confirm iron deficiency with serum ferritin and transferrin saturation, then initiate oral iron supplementation while considering gastrointestinal investigation based on the patient's clinical status and comorbidities. 1, 2

The hemoglobin of 12.8 g/dL represents mild anemia in an elderly patient (normal is ≥13 g/dL in men, ≥12 g/dL in women by WHO criteria), though this is clinically significant as anemia at any level in elderly patients is associated with worsening physical performance, cognitive decline, increased frailty, and higher mortality risk. 2, 3

Diagnostic Workup

Confirm Iron Deficiency

• Measure serum ferritin - this is the single most powerful test for iron deficiency. 1, 2
• Measure transferrin saturation - values <20% support iron deficiency diagnosis. 2
• In elderly patients with chronic inflammatory conditions, ferritin up to 100 μg/L may still reflect iron deficiency (rather than the typical <30 μg/L cutoff). 2

Additional Initial Tests

• Urinalysis or urine microscopy to exclude renal causes. 1
• Coeliac disease screening (tissue transglutaminase antibodies) - found in 3-5% of iron deficiency anemia cases. 1
• Complete blood count review including MCV and red cell distribution width to help classify the anemia. 1, 4

Treatment Initiation

Start Iron Supplementation

• Begin oral iron immediately - do not defer treatment while awaiting investigations unless colonoscopy is imminent. 1
• Dosing: One tablet daily of ferrous sulfate, fumarate, or gluconate (no more than 100 mg elemental iron daily to minimize side effects in elderly patients). 1, 2
• If not tolerated, reduce to one tablet every other day - intermittent dosing is as effective with fewer side effects. 1, 5
• Monitor hemoglobin response within 2-4 weeks - a rise of ≥10 g/L within 2 weeks is highly suggestive of absolute iron deficiency, even if iron studies are equivocal. 1

Alternative if Oral Iron Fails

• Parenteral iron is a convenient and relatively safe alternative if oral iron is not tolerated or ineffective. 2

Gastrointestinal Investigation

Indications for GI Workup

• Men and postmenopausal women with confirmed iron deficiency anemia should undergo upper and lower GI evaluation as first-line investigation. 1, 2
• Lower hemoglobin levels suggest more serious disease and warrant more urgent investigation. 2

Recommended Approach

• Gastroscopy with small bowel biopsies (to screen for coeliac disease) and colonoscopy should generally be first-line investigations. 1
• CT colonography may be a more attractive alternative to colonoscopy for frail older individuals with significant comorbidities. 1, 2
• The risks and benefits of invasive investigation must be carefully weighed in frail patients. 2

If Initial Endoscopy is Negative

• If bidirectional endoscopy is negative and there is inadequate response to iron replacement or recurrent anemia, capsule endoscopy is the preferred test for examining the small bowel. 1

Key Clinical Pitfalls

• Do not assume dietary deficiency alone - even with a positive dietary history, full GI investigation is still required in elderly patients. 1
• Do not accept minor upper GI lesions (esophagitis, erosions, peptic ulcer) as the sole cause without also investigating the colon, as dual pathology occurs in 10-15% of patients. 1
• Do not withhold iron therapy while awaiting diagnostic workup - treatment should begin immediately. 1
• Monitor for response - if hemoglobin does not rise appropriately with iron therapy, further investigation is mandatory. 1