What is the appropriate management of anemia in a 69-year-old man with a red blood cell count of 3.67 ×10⁶/µL, hemoglobin 10.5 g/dL, hematocrit 33.9%, and red cell distribution width 16.2%?

Management of Moderate Anemia in a 69-Year-Old Male

This 69-year-old man requires immediate investigation for gastrointestinal blood loss while simultaneously starting oral iron supplementation, as his hemoglobin of 10.5 g/dL with elevated RDW of 16.2% strongly indicates iron deficiency anemia that mandates urgent evaluation for occult GI malignancy. 1

Diagnostic Confirmation

The laboratory pattern confirms iron deficiency anemia:

• Hemoglobin 10.5 g/dL represents moderate anemia requiring investigation in an adult male (normal >13 g/dL) 1
• RDW of 16.2% is elevated (normal <14.5%), which combined with microcytosis strongly suggests iron deficiency rather than thalassemia trait 2, 3
• The elevated RDW inversely correlates with hemoglobin level and reflects severity of iron deficiency 3

Critical next steps before treatment:

• Measure serum ferritin and transferrin saturation immediately 1, 2
• Ferritin <30 μg/L confirms iron deficiency; ferritin <45 μg/L provides optimal sensitivity/specificity in practice 1, 2
• If ferritin appears falsely normal (30-100 μg/L) due to inflammation, transferrin saturation <16-20% confirms true iron deficiency 2

Urgent Gastrointestinal Investigation

In men with hemoglobin <110 g/L (11 g/dL), fast-track GI referral is warranted to exclude colorectal cancer, though investigation should be considered at any level of anemia with confirmed iron deficiency 1

Required endoscopic evaluation:

Upper endoscopy with duodenal biopsies:

• Identifies underlying cause in 30-50% of elderly patients with iron deficiency 2
• Duodenal biopsies screen for celiac disease (present in 2-3% of iron deficiency cases) 1, 2
• Evaluates for gastric malignancy, NSAID gastropathy, peptic ulcer disease, and angiodysplasia 2

Colonoscopy:

• Essential in elderly males to detect colonic carcinoma, polyps, and angiodysplasia 2
• Particularly high-yield in patients over 65 years 2

Immediate Treatment Protocol

Start oral iron supplementation immediately while diagnostic workup proceeds:

• Ferrous sulfate 200 mg three times daily (provides approximately 195 mg elemental iron daily) 2
• Continue for at least 3 months after hemoglobin correction to replenish iron stores 2
• Alternative formulations (ferrous gluconate or ferrous fumarate) if ferrous sulfate not tolerated 2
• Adding ascorbic acid enhances absorption 2

Expected response and monitoring:

• Hemoglobin should rise ≥10 g/L (≥1 g/dL) within 2 weeks if iron deficiency is the cause 2
• Monitor hemoglobin and red cell indices at 3-month intervals for one year 2
• If hemoglobin increases <1 g/dL after 4 weeks, consider non-compliance, ongoing blood loss, malabsorption, or rare genetic disorders 2

Alternative Treatment Considerations

Intravenous iron should be considered if:

• Malabsorption is documented (celiac disease, inflammatory bowel disease) 2
• Patient fails to respond to oral iron within 2-4 weeks 2
• Expected hemoglobin increase of at least 2 g/dL within 4 weeks of IV iron 2

Erythropoiesis-stimulating agents (ESAs) are NOT indicated in this setting, as they are reserved for:

• Chronic kidney disease with hemoglobin <10 g/dL 4
• Cancer-related anemia from chemotherapy 4
• This patient requires investigation and iron repletion, not ESA therapy 1, 2

Critical Pitfalls to Avoid

Do not attribute iron deficiency in elderly men to dietary insufficiency alone – occult GI blood loss, especially from malignancy, must be excluded 2

Do not delay GI investigation even if patient is asymptomatic – colorectal cancer can present with isolated iron deficiency anemia 1

Do not rely on ferritin alone in elderly patients – chronic inflammation, malignancy, or hepatic disease can falsely elevate ferritin above 30 μg/L despite true iron deficiency; add transferrin saturation to confirm 2

Do not overlook combined deficiencies – iron deficiency can coexist with B12 or folate deficiency, recognizable by elevated RDW 2

Consider hemoglobin electrophoresis only if microcytosis persists with normal iron studies and appropriate ethnic background, to exclude thalassemia trait 1, 2

Rare Genetic Considerations

If patient fails both oral and IV iron therapy, consider genetic disorders:

• IRIDA (iron-refractory iron deficiency anemia): remarkably low transferrin saturation with low-normal ferritin, autosomal recessive TMPRSS6 mutations 2
• X-linked sideroblastic anemia (ALAS2 defects): trial of pyridoxine 50-200 mg daily 2

These are unlikely in a 69-year-old with new-onset anemia but should be considered if standard therapy fails 2