What is the appropriate management for a patient with severe anemia (Hemoglobin (Hb) level of 8)?

Management of Hemoglobin 8 g/dL

For a patient with hemoglobin of 8 g/dL (moderate anemia), immediate management depends critically on symptom severity and cardiovascular comorbidities: symptomatic patients or those with cardiovascular disease should receive red blood cell transfusion, while asymptomatic patients without significant comorbidities can be observed with urgent workup to identify and treat the underlying cause. 1, 2

Risk Stratification and Immediate Management

The decision to transfuse should not be based solely on the hemoglobin threshold but rather on three clinical categories 1:

• Asymptomatic without significant comorbidities: Observation with periodic reevaluation is appropriate 1
• Asymptomatic with cardiovascular disease or high-risk comorbidities: Red blood cell transfusion should be strongly considered, as patients with cardiovascular disease may benefit from a liberal transfusion strategy 2
• Symptomatic patients (weakness, fatigue, shortness of breath, chest pain, dizziness): Transfusion is indicated 1

Key principle: Patients with acute-onset anemia are more likely to be symptomatic because physiologic compensatory mechanisms (increased cardiac output, altered blood viscosity, enhanced oxygen extraction) require time to develop 1

Transfusion Guidelines

When transfusion is indicated 1:

• Target hemoglobin: 7-8 g/dL in stable, non-cardiac inpatients; transfuse only the minimum units necessary to relieve symptoms 1
• Expected response: Each unit of packed red blood cells (300 mL) increases hemoglobin by approximately 1 g/dL in a normal-sized adult without ongoing blood loss 1
• For cardiovascular disease: Consider transfusion threshold of <8.5 g/dL if symptomatic 2

Essential Diagnostic Workup

Before or concurrent with treatment, identify the underlying cause 1, 2:

• Complete blood count with reticulocyte count and peripheral blood smear 2, 3
• Iron studies: serum iron, ferritin, transferrin saturation, total iron-binding capacity 2, 4
• Renal function assessment (creatinine, estimated GFR) 1
• Vitamin B12 and folate levels 4, 3
• Assessment for occult blood loss, particularly gastrointestinal sources 1, 4
• C-reactive protein to evaluate for chronic inflammation 2

Critical caveat: In older adults with iron deficiency anemia, endoscopy is warranted to evaluate for gastrointestinal malignancy, as 60-70% will have an identifiable GI bleeding source 5, 4

Cause-Specific Treatment

Iron Deficiency Anemia

• Oral iron supplementation is first-line: ferrous sulfate 1 tablet 2-3 times daily (do not crush or chew) 6
• Lower-dose formulations may be equally effective with fewer adverse effects 4
• Intravenous iron is preferred for severe anemia with iron deficiency or functional iron deficiency 2
• Hemoglobin normalization typically occurs by 8 weeks 4
• Failure to respond: Evaluate for non-adherence, malabsorption, ongoing blood loss, or systemic disease 5

Cancer-Related Anemia

• Erythropoiesis-stimulating agents (ESAs) may be considered if hemoglobin <10 g/dL in patients receiving chemotherapy 2
• ESAs are a long-term management decision given potential risks 1
• All correctable causes of anemia should be addressed before ESA use 1

Nutritional Deficiencies

• Vitamin B12 deficiency: Oral vitamin B12 can be as effective as intramuscular administration 5
• Folate supplementation: 1 mg daily if deficiency identified 1

Monitoring Strategy

• Initial phase: Monitor hemoglobin at 2-4 week intervals after initiating treatment 2
• During steroid taper (if applicable for immune-mediated causes): Weekly hemoglobin monitoring until taper complete 1
• Response assessment: Improvement in hemoglobin levels and resolution of symptoms 2

Common Pitfalls to Avoid

• Never treat anemia empirically without identifying the underlying cause 2, 7
• Do not delay transfusion in symptomatic patients with severe anemia, especially those with cardiovascular disease 2
• Avoid excessive transfusion: Use restrictive strategy (hemoglobin 6-8 g/dL threshold) in stable patients without cardiac disease, as this is associated with better outcomes than liberal transfusion 7
• Do not overlook occult blood loss, particularly in older adults with iron deficiency 2, 4
• Do not initiate ESAs in non-chemotherapy patients or without adequate iron supplementation 2