What is the treatment for anemia?

Treatment of Anemia

The treatment of anemia depends fundamentally on the underlying etiology, with iron deficiency anemia treated primarily with oral ferrous sulfate 324 mg (65 mg elemental iron) daily or twice daily, while patients with heart disease require restrictive transfusion strategies (hemoglobin threshold 7-8 g/dL) and should avoid erythropoiesis-stimulating agents. 1, 2

Initial Diagnostic Workup

Before initiating treatment, characterize the anemia type through:

• Complete blood count with indices and mean corpuscular volume (MCV) to classify as microcytic, normocytic, or macrocytic 1, 2
• Peripheral blood smear to confirm red blood cell morphology 1, 3
• Iron studies including ferritin, transferrin, and iron saturation 2
• Assessment for occult blood loss in stool and urine 1, 3
• Vitamin B12 and folate levels when macrocytic anemia is present 2

Treatment Algorithm by Etiology

Iron Deficiency Anemia

First-line therapy is oral iron supplementation:

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

Intravenous iron therapy is indicated when:

• Oral iron is not tolerated due to gastrointestinal side effects 1, 2
• Malabsorption is present (such as inflammatory bowel disease with active inflammation) 1, 3
• Rapid repletion is needed 1, 2

Anemia of Chronic Disease in Cardiovascular Patients

This represents a critical clinical scenario with specific management:

• Intravenous iron is the recommended first-line treatment 1
• Ferric carboxymaltose 200 mg weekly until ferritin >500 ng/mL, then 200 mg monthly for maintenance 1
• IV iron bypasses hepcidin-mediated blockade of intestinal absorption, making it superior to oral supplementation 1
• This improves exercise capacity, NYHA functional class, and quality of life scores 1
• Erythropoiesis-stimulating agents should be avoided in patients with mild to moderate anemia and congestive heart failure or coronary heart disease 5, 1, 2

The evidence here is particularly strong: the American College of Physicians provides a strong recommendation with moderate-quality evidence against ESAs in this population 5, while the European Society of Cardiology gives a IIA level recommendation for IV iron therapy in heart failure patients with reduced ejection fraction and iron deficiency 1.

Transfusion Therapy

Use a restrictive transfusion strategy:

• Trigger hemoglobin threshold of 7-8 g/dL in hospitalized patients, particularly those with coronary heart disease 5, 1, 2
• Reserve transfusion only for severe symptomatic anemia or when rapid correction is needed 1, 2
• This approach minimizes risks including iron overload, infection transmission, and immune suppression 1, 2

The American College of Physicians provides this as a weak recommendation with low-quality evidence, but it represents the current standard of care 5. Low-quality evidence showed that liberal transfusions were associated with reduced cardiovascular events, but this was not statistically significant 5.

Monitoring and Follow-up

For iron deficiency anemia:

• Repeat hemoglobin measurement after 4 weeks of treatment to assess response 1, 2, 3
• Monitor hemoglobin levels 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

Special Populations

Cancer-Related Anemia

• Evaluate for multiple potential causes including chemotherapy effects, nutritional deficiencies, and bone marrow infiltration 1, 3
• Erythropoiesis-stimulating agents may be considered for chemotherapy-induced anemia with hemoglobin ≤10 g/dL 2
• Use ESAs cautiously due to risks of thromboembolism and potential tumor progression 2

Inflammatory Bowel Disease

• Intravenous iron therapy is recommended with active inflammation rather than oral supplementation 1, 3
• Treat the underlying inflammatory condition to enhance iron absorption 3

Critical Pitfalls to Avoid

Failure to identify the underlying cause leads to recurrence 2. In men and postmenopausal women with iron deficiency anemia, gastrointestinal endoscopy is mandatory to evaluate for occult bleeding 6. The most common cause in elderly patients is gastrointestinal bleeding, including angiodysplasia of the colon 7.

Do not use ESAs in heart disease patients with mild to moderate anemia 5, 1, 2. This represents a strong recommendation based on moderate-quality evidence showing no benefit and potential harm 5.

Avoid over-reliance on transfusions rather than addressing the underlying cause 2. The restrictive transfusion strategy (7-8 g/dL threshold) has become standard practice based on evidence showing no mortality benefit with higher thresholds 5.