What is the treatment for anemia?

Treatment of Anemia

Oral iron supplementation with ferrous sulfate 324 mg (65 mg elemental iron) daily or twice daily between meals is the first-line treatment for iron deficiency anemia, which is the most common cause of anemia. 1, 2

Initial Diagnostic Workup

Before initiating treatment, identify the type and underlying cause of anemia:

• Obtain complete blood count with indices, peripheral blood smear, iron studies (ferritin, transferrin, iron saturation), and assess for occult blood loss in stool and urine 1, 2
• Check vitamin B12 and folate levels to rule out deficiencies 2
• In men and postmenopausal women with iron deficiency anemia, investigate for gastrointestinal blood loss with endoscopy 1, 3

Treatment Algorithm by Severity and Type

Iron Deficiency Anemia (Most Common)

Oral Iron Therapy:

• Ferrous sulfate 324 mg (65 mg elemental iron) daily or twice daily, administered between meals to maximize absorption 1, 2, 4
• Add ascorbic acid 250-500 mg twice daily to improve iron absorption 2
• Continue treatment for 2-3 months after hemoglobin normalization to replenish iron stores 1, 2
• Repeat hemoglobin measurement after 4 weeks to assess response 1, 2

Parenteral Iron Therapy:

• Indicated when oral iron is not tolerated, malabsorption is present, or rapid repletion is needed 1, 2

Anemia of Chronic Disease

• Treatment requires control of the underlying inflammatory condition 5
• Intravenous iron may be considered in specific contexts 6

Chemotherapy-Induced Anemia

• Erythropoiesis-stimulating agents (ESAs) may be considered when hemoglobin ≤10 g/dL 1, 2
• Use ESAs cautiously due to risks of thromboembolism, hypertension, and potential tumor progression 1, 2

Transfusion Strategy

Use a restrictive transfusion approach with hemoglobin trigger of 7-8 g/dL in most patients, including those with coronary heart disease 1, 7, 2

• Reserve transfusion for severe symptomatic anemia or when rapid correction is needed 1, 2
• This restrictive strategy minimizes complications including iron overload, infection transmission, and immune suppression 1, 2

Special Population: Heart Disease Patients

• The American College of Physicians strongly recommends against using ESAs in patients with mild to moderate anemia and heart disease 7, 2
• Use restrictive transfusion strategy (hemoglobin threshold 7-8 g/dL) in hospitalized patients with coronary heart disease 7, 2
• Anemia severity classification: mild (Hb 10-11.9 g/dL), moderate (Hb 8-9.9 g/dL), severe (Hb <8.0 g/dL) 7

Critical Pitfalls to Avoid

• Failure to identify and treat the underlying cause leads to recurrence 1, 2
• Do not overlook gastrointestinal malignancy in men and postmenopausal women with iron deficiency 3, 8
• Avoid overreliance on transfusions rather than addressing the root cause 2
• Do not use ESAs in mild to moderate anemia with heart disease due to increased risks of hypertension and thromboembolism 7, 2

Monitoring

• For iron deficiency anemia: Check hemoglobin after 4 weeks of treatment 1, 2
• Monitor hemoglobin levels and red blood cell indices every 3 months for 1 year, then annually 2
• Administer additional iron supplementation if hemoglobin or MCV fall below normal 2
• Normalization of hemoglobin typically occurs by 8 weeks in most patients responding to oral iron 8