What is the treatment for anemia?

Treatment of Anemia

For iron deficiency anemia, start oral ferrous sulfate 324 mg (65 mg elemental iron) once or twice daily between meals for 2-3 months after hemoglobin normalizes; switch to intravenous iron if oral therapy fails, malabsorption exists, or rapid correction is needed. 1, 2

Initial Diagnostic Workup

Before initiating treatment, obtain the following to identify the underlying cause:

• Complete blood count with red cell indices (MCV, MCH, MCHC) to classify anemia morphologically 1, 2
• Peripheral blood smear to confirm RBC morphology and identify specific abnormalities 1, 3
• Iron studies: serum ferritin, transferrin saturation, and serum iron 2
• Stool and urine assessment for occult blood loss 1, 2
• Vitamin B12 and folate levels if macrocytic anemia is present 2
• Renal function testing, particularly in patients with chronic disease 2

Treatment Algorithm by Etiology

Iron Deficiency Anemia (Most Common Cause)

Oral Iron Therapy (First-Line):

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

Intravenous Iron Therapy (Second-Line):

Switch to IV iron when: 1, 2, 3

• Oral iron is not tolerated (common gastrointestinal side effects)
• Malabsorption is present (inflammatory bowel disease, celiac disease)
• Rapid iron repletion is needed
• Active inflammation exists (particularly in inflammatory bowel disease patients) 3, 5

Anemia of Chronic Disease in Cardiovascular Patients

This population requires a fundamentally different approach:

• Intravenous iron is first-line therapy, not oral supplementation, because it bypasses hepcidin-mediated blockade of intestinal iron absorption 1
• For heart failure patients with reduced ejection fraction and iron deficiency, administer ferric carboxymaltose 200 mg weekly until ferritin >500 ng/mL, then 200 mg monthly for maintenance 1
• IV iron improves exercise capacity, NYHA functional class, and quality of life in approximately 50% of patients compared to 28% with placebo 1
• Avoid erythropoiesis-stimulating agents (ESAs) entirely in patients with mild to moderate anemia and congestive heart failure or coronary heart disease 6, 1, 2

The evidence here is particularly strong: the American College of Physicians provides a strong recommendation with moderate-quality evidence against ESA use in this population due to risks without proven mortality benefit 6.

Transfusion Strategy

Use a restrictive approach in all hospitalized patients, especially those with heart disease:

• Transfuse only when hemoglobin falls below 7-8 g/dL 6, 1, 2, 3
• Reserve transfusion for severe symptomatic anemia or when rapid correction is essential 1, 2
• This restrictive strategy reduces complications including iron overload, infection transmission, and immune suppression 1, 2

The 2013 American College of Physicians guideline specifically addresses patients with coronary heart disease, providing a weak recommendation with low-quality evidence for this restrictive threshold, but it remains the standard of care 6.

Monitoring Protocol

For Iron Deficiency Anemia:

• Repeat hemoglobin measurement at 4 weeks after initiating treatment 1, 2, 3
• Monitor hemoglobin and red cell indices every 3 months for the first year 1, 2
• Continue annual monitoring thereafter 1, 2
• Administer additional iron if hemoglobin or MCV falls below normal 1, 2

Special Population Considerations

Inflammatory Bowel Disease:

• Prefer intravenous iron when active inflammation is present 1, 3, 5
• Treat underlying inflammation to enhance iron absorption and reduce ongoing depletion 3

Cancer-Related Anemia:

• Evaluate for multiple causes: chemotherapy effects, nutritional deficiencies, bone marrow infiltration 1, 3
• ESAs may be considered for chemotherapy-induced anemia with Hb ≤10 g/dL, but use cautiously due to thromboembolism risk 2

Pregnancy and Children:

• Screen pregnant women routinely 7
• Screen children at one year of age 7

Critical Pitfalls to Avoid

• Never use ESAs in heart disease patients with mild-moderate anemia - this carries a strong recommendation against use due to lack of benefit and potential harm 6, 1, 2
• Don't stop iron therapy when hemoglobin normalizes - continue for 2-3 additional months to replenish stores 1, 2, 3
• Don't rely on oral iron in inflammatory bowel disease with active inflammation - use IV iron instead 1, 3
• Don't transfuse liberally in cardiac patients - the restrictive threshold of 7-8 g/dL is safer 6, 1, 2
• Always identify and treat the underlying cause - supplementation alone without addressing etiology leads to recurrence 2