What is the best medication for a patient with hemolytic anemia, presenting with severe anemia (Hb: 68), elevated reticulocytes (4%), low haptoglobin, and high lactate dehydrogenase (LDH), who developed fatigue, abdominal pain, and jaundice after 3 days of hospital admission?

Corticosteroids (Option C)

For this patient with severe hemolytic anemia (Hb 68 g/L) presenting with Grade 3-4 severity, intravenous corticosteroids at 1-2 mg/kg/day are the definitive first-line treatment. 1, 2

Clinical Reasoning

This patient presents with classic laboratory findings of acute hemolytic anemia:

• Severe anemia (Hb 68 g/L, normal >120 g/L) 1
• Elevated reticulocytes (4%) indicating bone marrow response 1, 2
• Low haptoglobin (consumed during hemolysis) 1, 2
• High LDH (released from lysed red blood cells) 1, 2
• Jaundice (from unconjugated bilirubin) 1, 3

The hospital-acquired timing (3 days post-admission) suggests either drug-induced hemolytic anemia or autoimmune hemolytic anemia. 1, 4

Treatment Algorithm

Immediate Management (Grade 3-4 Hemolytic Anemia)

Primary therapy:

• Administer IV methylprednisolone or prednisone 1-2 mg/kg/day immediately 1, 2, 5
• This dosing applies when hemoglobin is <8.0 g/dL (80 g/L) with clinical consequences 1, 5

Supportive measures:

• Folic acid 1 mg daily to support erythropoiesis 1, 2, 5
• RBC transfusion only if symptomatic or to achieve Hb 7-8 g/dL in stable patients 1, 2
• Transfuse minimum units necessary, as transfused cells may also hemolyze 5, 6

Critical workup:

• Obtain hematology consultation urgently 1, 2
• Perform direct antiglobulin test (Coombs) to differentiate immune from non-immune causes 1, 2, 3
• Review medication list for causative drugs (antibiotics, NSAIDs, immunosuppressants) 1, 4
• Examine peripheral blood smear for schistocytes (suggests TMA) or spherocytes (suggests AIHA) 1, 6, 3

Escalation for Refractory Cases

If no improvement after 1-2 weeks of corticosteroids:

• Add IVIG 0.4-1 g/kg/day for 3-5 days 2, 5
• Consider rituximab for steroid-refractory cases 1, 2, 5
• Alternative immunosuppressants: cyclosporine, mycophenolate mofetil, or azathioprine 1, 2, 7

Monitoring Protocol

• Check hemoglobin weekly until steroid tapering begins 1, 2, 5
• Monitor for steroid complications: hyperglycemia, hypertension, mood changes, insomnia 2, 5
• Continue monitoring less frequently after steroid taper completion 1, 2

Why Other Options Are Incorrect

Aspirin (Option A): No role in hemolytic anemia treatment; may worsen bleeding risk if thrombocytopenia develops. 6

Rituximab (Option B): Reserved for refractory cases after corticosteroid failure (no response after 2 weeks), steroid-dependent hemolysis, or recurrent severe hemolysis. 1, 2, 5 Not first-line therapy.

Antibiotics (Option D): Only indicated if infectious cause identified (e.g., Mycoplasma, which itself can cause hemolysis). 5, 4 However, many antibiotics (cephalosporins, penicillins) can actually cause drug-induced hemolytic anemia and should be stopped if suspected. 1, 4

Critical Pitfalls to Avoid

• Do not delay corticosteroids in severe hemolysis, as mortality risk increases with treatment delay 5, 6
• Do not transfuse excessively—use only minimum units needed for symptom relief, as transfused cells will also hemolyze in immune-mediated cases 5, 6
• Do not dismiss drug-induced causes—review all medications started in the past 3 days and consider stopping potential culprits 1, 4, 8
• Do not miss TMA/TTP—if schistocytes present on smear or platelets dropping, urgent ADAMTS13 testing and plasma exchange may be needed instead 1, 6