What is the treatment for anemia?

Treatment for 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 must be continued for 2-3 months after hemoglobin normalization to replenish iron stores. 1, 2

Initial Treatment Approach

Oral Iron Therapy (First-Line)

• Ferrous sulfate 324 mg (65 mg elemental iron) should be administered once or twice daily between meals to maximize absorption 1, 2, 3
• Lower doses may be equally effective and better tolerated in patients experiencing side effects, so consider dose reduction rather than discontinuation 4
• Alternative formulations (ferrous fumarate, ferrous gluconate, or iron suspensions) can be substituted if ferrous sulfate is not tolerated 4
• Adding ascorbic acid 250-500 mg twice daily with iron enhances absorption 4, 2
• Continue treatment for 2-3 months after hemoglobin correction to fully replenish iron stores 4, 1, 2

Monitoring Response

• Repeat hemoglobin measurement after 4 weeks of treatment to assess response 1, 2, 5
• If hemoglobin fails to improve after 4 weeks of adequate oral iron therapy, consider malabsorption or ongoing blood loss 1
• Monitor hemoglobin and red blood cell indices every 3 months for 1 year, then annually 2

Parenteral Iron Therapy (Second-Line)

Intravenous iron is indicated when oral iron is not tolerated, malabsorption is present, or rapid repletion is needed 1, 2, 5

Available IV Iron Preparations

• Iron sucrose (Venofer): 200 mg bolus over 10 minutes 4
• Ferric carboxymaltose (Ferinject): up to 1000 mg over 15 minutes 4
• Iron dextran (Cosmofer): up to 20 mg/kg over 6 hours, but carries 0.6-0.7% risk of serious reactions including fatalities 4

When to Use IV Iron

• Oral iron intolerance despite formulation changes 4, 1, 2
• Malabsorption syndromes 1, 2
• Active inflammatory bowel disease with inflammation 5
• Need for rapid iron repletion 1, 2

Transfusion Therapy

Reserve red blood cell transfusion for severe symptomatic anemia or when rapid correction is needed, using a restrictive strategy with hemoglobin trigger of 7-8 g/dL 1, 2, 5

Transfusion Indications

• Severe anemia (Hb <8.0 g/dL) with symptoms 1
• Hemodynamic instability 6
• Acute coronary syndrome or symptomatic heart disease 2, 5

Important Caveats

• Restrictive transfusion strategy (Hb 7-8 g/dL threshold) minimizes complications including iron overload, infection transmission, and immune suppression 1, 2
• In patients with coronary artery disease, evidence for optimal transfusion thresholds remains limited 7
• Avoid over-reliance on transfusions without addressing the underlying cause 2

Erythropoiesis-Stimulating Agents (ESAs)

ESAs are NOT recommended for mild to moderate anemia with heart disease 1, 2, 5

Limited Appropriate Uses

• Chemotherapy-induced anemia with Hb ≤10 g/dL 1, 2
• Screen renal function before myelosuppressive chemotherapy to identify at-risk patients 2

Critical Safety Concerns

• ESAs carry significant risks including hypertension, thromboembolism, and potential tumor progression in cancer patients 1, 2
• Avoid in patients with congestive heart failure or coronary heart disease with mild-moderate anemia 2, 5

Addressing Underlying Causes

Identifying and treating the underlying cause is essential to prevent recurrence 1, 2

Investigation Requirements

• Men and postmenopausal women with iron deficiency anemia require gastrointestinal evaluation 1, 8
• Perform upper endoscopy and colonoscopy to identify bleeding sources 4
• Test for Helicobacter pylori if anemia persists or recurs after normal endoscopy, and eradicate if present 4
• Consider Giardia lamblia testing if diarrhea is present 4
• Assess for occult blood loss in stool and urine 1

Special Populations

• Screen pregnant women and children at one year of age 8
• In inflammatory bowel disease with active inflammation, use IV iron and treat the underlying inflammation 5

Common Pitfalls to Avoid

• Failing to continue iron therapy for 2-3 months after hemoglobin normalization leads to inadequate store repletion and recurrence 4, 1, 2
• Faecal occult blood testing has no benefit in investigating iron deficiency anemia due to poor sensitivity and specificity 4
• Not investigating the underlying cause in men and postmenopausal women results in missed gastrointestinal malignancies 1, 2, 8
• Using ESAs without considering thromboembolism and tumor progression risks 1, 2
• Administering iron with meals reduces absorption significantly 1, 2