What is the treatment for anemia?

Treatment of Anemia

Treat anemia based on its underlying cause: for iron deficiency anemia (the most common type), start oral ferrous sulfate 324 mg (65 mg elemental iron) once or twice daily between meals, continue for 2-3 months after hemoglobin normalizes, and always investigate the source of iron loss. 1, 2

Initial Diagnostic Classification

Before treating, characterize the anemia using:

• Complete blood count with indices to determine mean corpuscular volume (MCV) and classify as microcytic, normocytic, or macrocytic 1, 2
• Peripheral blood smear to confirm red blood cell morphology 1, 2
• Iron studies (ferritin, transferrin, iron saturation) to assess iron status 2
• Stool and urine assessment for occult blood loss 1, 2
• Vitamin B12 and folate levels if macrocytic anemia is present 2

Treatment Algorithm by Etiology

Iron Deficiency Anemia (Most Common)

First-line oral therapy:

• Ferrous sulfate 324 mg (containing 65 mg elemental iron) once or twice daily, taken between meals to maximize absorption 1, 2, 3
• Add ascorbic acid 250-500 mg twice daily to enhance iron absorption 1, 2
• Continue treatment for 2-3 months after hemoglobin normalization to replenish iron stores 1, 2, 4

When to use intravenous iron:

• Oral iron not tolerated 1, 2, 4
• Malabsorption present 1, 2, 4
• Rapid repletion needed 1, 2, 4

Critical step: Investigate and treat the underlying cause of iron loss, particularly gastrointestinal blood loss in men and postmenopausal women 4, 5

Anemia of Chronic Disease/Inflammation

• Treat the underlying inflammatory condition as the primary intervention to enhance iron absorption 1
• Iron supplementation may be appropriate depending on iron studies 6
• Consider erythropoiesis-stimulating agents (ESAs) only in specific situations (see below) 1

Chemotherapy-Induced Anemia

• Screen renal function prior to myelosuppressive chemotherapy 1, 2
• ESAs may be considered when hemoglobin ≤10 g/dl 1, 2, 4
• Evaluate for multiple potential causes before initiating ESAs, including nutritional deficiencies and blood loss 1, 2

Transfusion Strategy

Reserve transfusions for severe symptomatic anemia or when rapid correction is needed: 1, 2, 4

• Use restrictive transfusion threshold of 7-8 g/dl hemoglobin to minimize complications 1, 2, 4
• This restrictive strategy applies to most patients, including those with heart disease 2, 4
• Be aware of complications: iron overload, infection transmission, and immune suppression 1, 2, 4

Monitoring and Follow-Up

For iron deficiency anemia:

• Repeat hemoglobin measurement after 4 weeks of treatment to assess response 1, 2, 4
• Monitor hemoglobin and red blood cell indices every 3 months for 1 year, then annually 1, 2
• Administer additional iron supplementation if hemoglobin or MCV fall below normal 1, 2

Critical Pitfalls to Avoid

Failure to identify and treat the underlying cause leads to recurrence and is the most common error 1, 2, 4

Inappropriate use of erythropoiesis-stimulating agents:

• Avoid ESAs in mild to moderate anemia with congestive heart failure or coronary heart disease 2, 4
• ESAs carry significant risks: hypertension, thromboembolism, and potential tumor progression in cancer patients 1, 2, 4
• Always consider and correct other causes of anemia before initiating ESAs 2

Overreliance on transfusions rather than addressing the underlying cause wastes resources and exposes patients to unnecessary risks 1, 2, 4