What is the best medication for a patient with hemolytic anemia, characterized by severe anemia (Hb: 68), elevated reticulocytes (4%), low haptoglobin, and high lactate dehydrogenase (LDH), who developed fatigue, abdominal pain, and jaundice after 3 days of hospital admission?

Corticosteroids (Option C) is the Best Treatment

For this patient with severe hemolytic anemia (Hb 68 g/L, elevated reticulocytes, low haptoglobin, high LDH), intravenous corticosteroids at 1-2 mg/kg/day should be initiated immediately as first-line therapy. 1, 2

Clinical Presentation Analysis

This patient developed acute hemolytic anemia after 3 days of hospital admission, presenting with:

• Severe anemia (Hb 68 g/L, normal >120 g/L) - Grade 3-4 severity 1, 2
• Active hemolysis markers: elevated reticulocytes (4%), low haptoglobin, elevated LDH 1, 3, 4
• Clinical symptoms: fatigue, abdominal pain, jaundice (yellowish eyes) 3, 4

The timing (3 days post-admission) and laboratory pattern strongly suggest drug-induced or autoimmune hemolytic anemia, both of which respond to corticosteroids. 5, 1

Why Corticosteroids Are the Correct Answer

Immediate Treatment Protocol

For Grade 3-4 hemolytic anemia (Hb <80 g/L), IV methylprednisolone 1-2 mg/kg/day is the established first-line treatment. 1, 2 This patient's hemoglobin of 68 g/L clearly meets Grade 3-4 criteria. 1

• Response rate: 70-80% for autoimmune hemolytic anemia 1
• Time to response: Parenteral corticosteroids achieve 81.6% response rate versus only 41.7% with oral prednisolone alone 6
• Mechanism: Suppresses antibody-mediated red cell destruction and reduces phagocytosis by the reticuloendothelial system 5, 1

Supporting Evidence Hierarchy

The most recent guideline evidence (2025) from the American Society of Clinical Oncology explicitly recommends IV methylprednisolone 1-2 mg/kg/day for severe hemolytic anemia as first-line therapy. 1 This is reinforced by 2021 ASCO guidelines for immune-related hemolytic anemia. 5

A 2021 clinical study demonstrated that intravenous corticosteroids are superior to oral prednisolone for initial response in severe cases, with multivariate analysis proving predictivity for response. 6

Why the Other Options Are Incorrect

Aspirin (Option A) - Contraindicated

• No role in hemolytic anemia treatment 5, 1
• Aspirin is used for platelet disorders (ITP), not hemolytic anemia 5
• Could worsen bleeding risk if thrombocytopenia develops 5

Rituximab (Option B) - Second-Line Only

• Reserved for steroid-refractory or relapsed cases 1, 7
• Dose: 375 mg/m² weekly for 4 weeks 1
• Used only after 1-2 weeks of failed corticosteroid therapy 1, 2
• Not appropriate as initial treatment in acute presentation 1

Antibiotics (Option D) - Not First-Line

• Only indicated if infectious hemolysis is confirmed (e.g., Mycoplasma, malaria) 2, 8, 9
• Even in Mycoplasma-associated hemolytic anemia, corticosteroids remain the primary treatment for the hemolysis itself 2
• This patient's presentation (hospital-acquired, 3 days post-admission) suggests drug-induced rather than infectious etiology 5, 1

Complete Treatment Algorithm

Immediate Management (First 24-48 Hours)

1. Start IV methylprednisolone 1-2 mg/kg/day 1, 2
2. Add folic acid 1 mg daily to support erythropoiesis 1, 2
3. Transfuse RBCs only if symptomatic or Hb <70-80 g/L 1, 2
4. Discontinue any potentially causative medications 5, 1

Diagnostic Workup (Concurrent with Treatment)

• Direct antiglobulin test (Coombs test) to confirm immune-mediated hemolysis 1, 3, 4
• Review medication list for drug-induced causes 5, 1
• Monitor daily: CBC, LDH, haptoglobin, reticulocyte count 2

Escalation Strategy (If No Response in 1-2 Weeks)

• Add IVIG 0.4-1 g/kg/day for 3-5 days 1, 7, 2
• Consider rituximab 375 mg/m² weekly for 4 weeks 1
• Alternative immunosuppressants: cyclosporine, mycophenolate mofetil, azathioprine 1, 2

Steroid Tapering

• Continue high-dose steroids for at least 5 weeks 1
• Taper gradually over 4-5 weeks once Hb improves 1
• Monitor hemoglobin weekly during tapering 1, 2

Critical Pitfalls to Avoid

Do not delay corticosteroid initiation while awaiting diagnostic test results - this increases morbidity and mortality. 2 Treatment should begin immediately based on clinical and basic laboratory findings. 1, 2

Do not over-transfuse - target Hb 70-80 g/L only, as excessive transfusion can paradoxically worsen hemolysis in certain cases. 1, 7, 2

Do not use rituximab as first-line therapy - it is reserved for steroid-refractory cases and takes 1-8 weeks to work. 5, 1 In acute severe hemolysis, corticosteroids work faster and more reliably. 1, 6

Monitor for steroid complications: hyperglycemia, hypertension, mood changes, insomnia, fluid retention. 1