From the Guidelines
Hemolytic anemia requires immediate attention to prevent morbidity and mortality, and treatment should be guided by the underlying cause, with a focus on reducing hemolysis and improving quality of life. The management of hemolytic anemia involves a comprehensive approach, including supportive care, treatment of the underlying cause, and monitoring for potential complications.
Causes and Clinical Presentation
Hemolytic anemia can be inherited, such as pyruvate kinase deficiency, or acquired, like autoimmune hemolytic anemia 1. The clinical presentation varies widely, ranging from mild anemia to life-threatening conditions, with symptoms including jaundice, pallor, and fatigue.
Treatment Approach
For autoimmune hemolytic anemia, first-line treatment typically includes prednisone at 1-2 mg/kg/day for 3-4 weeks, followed by a slow taper 1. In severe cases, intravenous immunoglobulin (IVIG) at 1 g/kg for 2 days may be needed. For patients who don't respond to steroids, rituximab (375 mg/m² weekly for 4 weeks) is often effective.
Supportive Care
Supportive care includes folic acid supplementation (1 mg daily) to support increased red cell production and blood transfusions for severe anemia with hemoglobin below 7 g/dL. Patients should be monitored with regular complete blood counts, reticulocyte counts, and liver function tests.
Complications and Prevention
The destruction of red blood cells releases hemoglobin, which can damage the kidneys, so maintaining adequate hydration is essential. Understanding the specific mechanism of hemolysis guides treatment—intravascular hemolysis (within blood vessels) often requires more urgent intervention than extravascular hemolysis (in the spleen or liver) 1.
Specific Considerations
In patients with sickle cell disease, hemolytic transfusion reactions (HTRs) can occur, and immunosuppressive therapy should be initiated promptly in patients with life-threatening hemolysis, with first-line agents including IVIg and high-dose steroids 1.
Key Recommendations
- Treatment should be individualized based on the underlying cause and severity of hemolytic anemia.
- Supportive care, including folic acid supplementation and blood transfusions, is crucial in managing hemolytic anemia.
- Monitoring for potential complications, such as kidney damage and hemolytic transfusion reactions, is essential.
- A shared decision-making process between the patient and healthcare provider is critical in managing hemolytic anemia.
From the FDA Drug Label
- 2 Hemolytic Anemia Cases of hemolytic anemia in patients treated with hydroxyurea for myeloproliferative diseases have been reported [see Adverse Reactions (6.1)]. Patients who develop acute jaundice or hematuria in the presence of persistent or worsening of anemia should have laboratory tests evaluated for hemolysis (e.g., measurement of serum lactate dehydrogenase, haptoglobin, reticulocyte, unconjugated bilirubin levels, urinalysis, and direct and indirect antiglobulin [Coombs] tests). In the setting of confirmed diagnosis of hemolytic anemia and in the absence of other causes, discontinue hydroxyurea.
Hemolytic Anemia is a potential side effect of hydroxyurea, particularly in patients with myeloproliferative diseases.
- Key Points:
- Cases of hemolytic anemia have been reported in patients treated with hydroxyurea.
- Patients who develop acute jaundice or hematuria with persistent or worsening anemia should be evaluated for hemolysis.
- If hemolytic anemia is confirmed and no other causes are present, hydroxyurea should be discontinued. 2
From the Research
Definition and Causes of Hemolytic Anemia
- Hemolytic anemia is a disease caused by autoantibodies, resulting in various complaints and clinical symptoms 3.
- The cause of autoimmune hemolytic anemia can not be determined in about half of cases 3.
- Hemolytic anemia is defined by the premature destruction of red blood cells, and can be chronic or life-threatening 4.
Diagnosis of Hemolytic Anemia
- The direct antiglobulin test is the cornerstone of diagnosis, allowing the distinction into warm forms, cold agglutinin disease, and other more rare forms 5.
- Laboratory test results that confirm hemolysis include reticulocytosis, as well as increased lactate dehydrogenase, increased unconjugated bilirubin, and decreased haptoglobin levels 4.
- A peripheral blood smear should be performed when hemolysis is present to identify abnormal red blood cell morphologies 4.
Treatment Options for Hemolytic Anemia
- Corticosteroids are the first-line treatment option for warm autoantibody-related hemolytic anemia 3, 6, 5.
- Rituximab has become an option in refractory disease 6, 5, 7.
- Splenectomy is second-line therapy for warm autoimmune hemolytic anemia 6, 5.
- Plasma exchange (PE) may be utilised in severe and refractory anemia, especially in the case of cardiovascular imbalance in fulminant hemolysis 3.
- New drugs are under development, including B-cell directed therapies and inhibitors of complement, spleen tyrosine kinases, or neonatal Fc receptor 5.
Subtypes of Hemolytic Anemia
- Warm autoimmune hemolytic anemia (wAIHA) is frequently associated with chronic lymphocytic leukemia or autoimmune systemic disease 6.
- Cold agglutinin disease is a clonal lymphoproliferative bone marrow disease, usually refractory to corticosteroids 6, 5, 7.
- Primary chronic cold agglutinin disease is a subgroup of cold-antibody autoimmune hemolytic anemia, and the best documented therapy is infusions with rituximab 6.