What is the treatment plan for a patient with anemia, indicated by a low red blood cell count, hemoglobin, and hematocrit?

Management Plan for Normocytic Anemia

This patient requires a comprehensive anemia workup including iron studies (serum ferritin and transferrin saturation), reticulocyte count, vitamin B12, folate, and assessment for occult blood loss or chronic disease before initiating any treatment. 1

Initial Diagnostic Workup

The patient presents with mild normocytic anemia (Hb 10.9 g/dL, MCV 88.2 fL). The normal MCV (80-100 fL) and MCH (27-33 pg) indicate this is not a simple iron, B12, or folate deficiency, which typically present with microcytic or macrocytic patterns. 1

Essential Laboratory Tests Required

• Iron studies: Serum ferritin and transferrin saturation to assess both absolute and functional iron deficiency 1

  • In the absence of inflammation, ferritin <30 μg/L indicates iron deficiency 1
  • With inflammation present, ferritin up to 100 μg/L may still represent iron deficiency 1

• Reticulocyte count: To evaluate bone marrow response and distinguish between production defects versus hemolysis/blood loss 1

  • Low/normal reticulocytes suggest inadequate production (iron deficiency, B12/folate deficiency, chronic disease, or bone marrow dysfunction) 1
  • Elevated reticulocytes suggest hemolysis or acute blood loss 1

• Vitamin B12 and folate levels: Essential to exclude nutritional deficiencies that can present with normocytic anemia early in their course 1

• Inflammatory markers: CRP or ESR to identify anemia of chronic disease 1

• Renal function: Creatinine and BUN, as chronic kidney disease commonly causes normocytic anemia through erythropoietin deficiency 1

• Complete blood count review: Examine white blood cell and platelet counts—abnormalities in multiple cell lines warrant hematology consultation for possible bone marrow pathology 1

Critical Clinical Assessment

• Medication history: Identify drugs that may cause anemia (antibiotics, methotrexate, chemotherapy agents) 2

• Bleeding assessment: Evaluate for gastrointestinal blood loss, menstrual losses, or other occult bleeding sources 1

  • In patients with iron deficiency without obvious blood loss, careful assessment for GI bleeding is mandatory 1

• Chronic disease evaluation: Screen for inflammatory conditions, malignancy, chronic infections, or autoimmune disorders 1

• Dietary history: Assess for vegetarian/vegan diet (B12 deficiency risk) or poor nutritional intake 2

Treatment Algorithm Based on Workup Results

If Iron Deficiency Identified

• Treat iron deficiency regardless of the underlying cause 1
• Oral iron supplementation is first-line for non-dialysis patients 1
• Monitor response with hemoglobin and reticulocyte counts at 5-7 days, then frequently until normalized 2

If B12 or Folate Deficiency Found

• B12 deficiency: Initiate intramuscular cyanocobalamin; patients with pernicious anemia require lifelong monthly injections 2

  • Critical warning: Never give folic acid alone without B12 replacement, as this may correct anemia but allow irreversible neurologic damage to progress 2

• Folate deficiency: Oral folic acid supplementation 1

If Chronic Kidney Disease Present (GFR <30 mL/min/1.73m²)

• Monitor hemoglobin every 3 months 1
• Ensure iron repletion before considering erythropoiesis-stimulating agents (ESAs) 1
• If anemia persists despite iron therapy, consider ESA therapy 1, 3
• ESA caution: Increased risk of thromboembolism, hypertension, and seizures; monitor blood pressure with each dose 3

If Anemia of Chronic Disease

• Address underlying inflammatory condition 1
• Iron supplementation may be beneficial even with elevated ferritin if transferrin saturation is low (functional iron deficiency) 1

Monitoring Strategy

• Reticulocyte response: Should increase to at least twice normal within 5-7 days of appropriate treatment 2
• If reticulocytes fail to increase or hemoglobin doesn't improve, reassess diagnosis and consider complicating factors 2
• Repeat iron studies and nutritional markers if response is inadequate 2

Red Flags Requiring Hematology Referral

• Abnormalities in multiple cell lines (cytopenias) 1
• Lack of response to appropriate therapy 1
• Suspicion of pure red cell aplasia (severe anemia with very low reticulocytes) 3
• Unexplained normocytic anemia after complete workup 1

Common pitfall: Assuming normocytic anemia is simply "anemia of chronic disease" without excluding treatable causes like occult iron deficiency, B12 deficiency, or renal insufficiency. 1, 4