What is the recommended treatment for anemia with a hemoglobin (Hb) level of 85g/L?

Treatment of Anemia with Hemoglobin 85 g/L

Iron supplementation is the appropriate first-line treatment for anemia with hemoglobin of 85 g/L (8.5 g/dL), but only after evaluating and correcting the underlying cause and confirming iron deficiency or functional iron deficiency. 1

Initial Evaluation Required

Before initiating any treatment, perform a comprehensive workup to identify the cause of anemia 1:

• Measure iron studies: serum iron, transferrin saturation (TSAT), and ferritin levels 1
• Check reticulocyte count to assess bone marrow response 1
• Evaluate vitamin B12 and folate levels, particularly if macrocytosis is present 1
• Assess renal function as chronic kidney disease can cause anemia 1
• Test for occult blood loss in stool and urine 1
• Consider C-reactive protein to identify inflammation contributing to anemia of chronic disease 1

Iron Supplementation Strategy

Oral Iron Therapy

Start with oral iron supplementation as first-line therapy if iron deficiency is confirmed (ferritin <100 ng/mL or TSAT <20%) 1:

• Dose: 60-120 mg of elemental iron daily 1
• Standard formulation: Ferrous sulfate 324 mg tablets contain 65 mg elemental iron 2
• Duration: Continue for 2-3 months after hemoglobin normalizes to replenish iron stores 1, 3

Monitoring Response

Reassess hemoglobin after 4 weeks of oral iron therapy 1:

• Expected response: Hemoglobin should increase by ≥1.0 g/dL 1, 4
• If hemoglobin increases <1.0 g/dL at 14 days: This predicts poor overall response to oral iron (sensitivity 90.1%, specificity 79.3%) and indicates need to transition to intravenous iron 4
• If no response after 4 weeks despite compliance: Perform additional testing including MCV, RDW, and repeat ferritin 1

Intravenous Iron Indications

Transition to intravenous iron in the following situations 5, 4:

• Inadequate response to oral iron after 4 weeks (hemoglobin increase <1.0 g/dL) 4
• Intolerance to oral iron preparations 5, 3
• Malabsorption conditions preventing oral iron absorption 5
• Ongoing blood loss exceeding intestinal iron absorption capacity 5
• Functional iron deficiency (ferritin >100 ng/mL but TSAT <20%) 1

Context-Specific Considerations

If Patient Has Cancer on Chemotherapy

At hemoglobin 85 g/L (8.5 g/dL), this falls into grade 3 anemia (6.5 to <8.0 g/dL per NCI-CTCAE) 1:

• Correct iron deficiency first before considering erythropoiesis-stimulating agents (ESAs) 1
• ESAs may be considered only if on active chemotherapy and after iron repletion, with target hemoglobin not exceeding 12 g/dL 1
• Monitor for functional iron deficiency: ferritin >100 ng/mL and TSAT <20% indicates need for iron supplementation even with ESA therapy 1

If Patient Has Chronic Kidney Disease

For CKD patients with hemoglobin 85 g/L (8.5 g/dL) 1:

• Iron supplementation is essential before and during ESA therapy 1
• Target hemoglobin: 100-120 g/L (10-12 g/dL), aiming for 110 g/L 1
• Do not target hemoglobin >130 g/L due to increased mortality risk and thrombotic complications 1

If Patient Has Inflammatory Bowel Disease

For IBD patients 1:

• Intravenous iron is preferred over oral iron due to better efficacy and tolerability 1
• Optimize IBD treatment first as disease activity contributes to anemia of chronic disease 1
• Consider ESAs only if inadequate response to IV iron despite optimized IBD therapy, targeting hemoglobin ≤12 g/dL 1

Red Blood Cell Transfusion Threshold

Transfusion is generally indicated when 1:

• Hemoglobin falls below 7.0-7.5 g/dL 1
• Clinical symptoms of severe anemia are present (hemodynamic instability, angina, severe dyspnea) 1
• Patient has significant comorbidities (ischemic heart disease, advanced age) that increase risk from anemia 1

At hemoglobin 85 g/L (8.5 g/dL), transfusion is not routinely indicated unless symptomatic or high-risk comorbidities exist 1. Follow transfusion with intravenous iron supplementation to prevent recurrent anemia 1.

Common Pitfalls to Avoid

• Do not start ESAs without first correcting iron deficiency, as this reduces ESA effectiveness and increases costs 1
• Do not continue oral iron beyond 4 weeks without documented response, as this delays appropriate transition to IV iron 4
• Do not target hemoglobin >12 g/dL with ESAs due to increased thrombotic risk and mortality 1
• Do not use ESAs in cancer patients not receiving chemotherapy due to increased thrombotic risk and decreased survival 1