What is the management plan for a patient with anemia?

Management Plan for Normocytic Anemia with Elevated RDW and Thrombocytosis

This patient requires immediate investigation for iron deficiency anemia with iron studies (ferritin, transferrin saturation, TIBC) and evaluation for underlying gastrointestinal pathology, as the laboratory findings strongly suggest iron deficiency despite a normal MCV. 1, 2

Initial Diagnostic Workup

Laboratory Assessment Priority

• Obtain iron studies immediately: serum ferritin, transferrin saturation (TSAT), total iron-binding capacity (TIBC), and reticulocyte hemoglobin content if available 1
• The elevated RDW (18.9) with low MCH (25.1) and low MCHC (29.7) indicates early iron deficiency even though MCV remains normal at 84.4 1
• Iron deficiency is confirmed when ferritin <100 μg/L and TSAT <20% 1
• The reactive thrombocytosis (456) further supports iron deficiency as the underlying etiology 1

Additional Testing Required

• Reticulocyte count to assess bone marrow response and distinguish regenerative from non-regenerative anemia 1
• Inflammatory markers (CRP, ESR) to evaluate for anemia of chronic disease 1
• Celiac serology (tissue transglutaminase antibody) particularly important in premenopausal women 1, 2
• Renal function (creatinine) to exclude renal causes 1

Gastrointestinal Evaluation

Urgent Investigation Indicated

Both upper and lower GI tract investigations are recommended for adults with new diagnosis of iron deficiency anemia without obvious explanation. 1, 2

• Upper endoscopy with duodenal biopsies should be performed to evaluate for peptic ulcer disease, gastritis, celiac disease, and upper GI malignancy 1, 2
• Colonoscopy is indicated given the patient's age and unexplained anemia to exclude colorectal pathology 1, 2
• Dual pathology occurs in 10-15% of patients, making complete evaluation of both upper and lower GI tracts essential 1, 2

Important Caveat

• Fecal occult blood testing is of no benefit in the investigation of iron deficiency anemia and should not be used 1

Iron Replacement Therapy

Initiate Treatment Promptly

All patients with iron deficiency anemia should receive iron supplementation to correct anemia and replenish body stores. 1, 2

• Oral iron therapy is first-line treatment, typically ferrous sulfate 325 mg (65 mg elemental iron) two to three times daily 1, 3
• Treatment should continue for three months after correction of anemia to replenish iron stores 2
• Parenteral iron can be used when oral preparations are not tolerated or ineffective 1

Monitoring Response

• Recheck hemoglobin and iron studies in 4-6 weeks to assess response 2, 3
• Failure to respond to iron therapy should prompt further investigation, including small bowel evaluation with capsule endoscopy or enteroscopy 1, 2

Transfusion Considerations

When to Transfuse

Blood transfusions should be reserved for patients with or at risk of cardiovascular instability due to the degree of their anemia. 1

• This patient with hemoglobin 10.3 g/dL does not require transfusion unless symptomatic with cardiovascular compromise 1
• Restrictive transfusion strategy (hemoglobin <7-8 g/dL) is associated with better outcomes than liberal strategy 1, 4
• If transfusion becomes necessary, use single-unit transfusion policy and reassess 1

Critical Red Flags

Situations Requiring Urgent Intervention

• Men with hemoglobin <12 g/dL and postmenopausal women with hemoglobin <10 g/dL should be investigated more urgently, as lower hemoglobin suggests more serious disease 1
• Any patient with hemoglobin <7.5 g/dL or hemodynamic instability requires immediate intervention 1
• Presence of alarm symptoms (weight loss, dysphagia, melena, hematochezia) mandates expedited GI evaluation 1, 2

Common Pitfalls to Avoid

• Do not assume normal MCV excludes iron deficiency: early iron deficiency presents with elevated RDW before MCV drops 1
• Do not delay iron supplementation while awaiting GI investigation results; treatment should begin immediately 1, 2
• Do not stop investigation after finding one source of bleeding: dual pathology is common and complete evaluation is essential 1, 2
• Do not use empiric nutritional supplements without confirming specific deficiency through laboratory testing 4