What is the appropriate treatment for a patient with a red‑cell distribution width of 17.2 % and a mean corpuscular volume of 87.2 fL?

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Treatment for RDW 17.2% and MCV 87.2 fL

Your patient has an elevated RDW (17.2%) with a normal MCV (87.2 fL), which strongly suggests either early iron deficiency, combined nutritional deficiencies (iron plus B12/folate), or hemolysis—you must immediately order serum ferritin, transferrin saturation, vitamin B12, folate, reticulocyte count, and CRP to guide definitive treatment. 1

Diagnostic Workup Required Before Treatment

The combination of elevated RDW with normal MCV is diagnostically significant and requires immediate laboratory evaluation:

  • Serum ferritin is the single most powerful test and must be obtained immediately 2

    • Ferritin <30 μg/L confirms iron deficiency in the absence of inflammation 1, 2
    • Ferritin <100 μg/L may still indicate iron deficiency if concurrent inflammation is present 2

  • Transferrin saturation <16-20% supports iron deficiency 1, 2

  • Vitamin B12 and folate levels must be checked simultaneously because combined deficiencies can maintain a normal MCV despite significant nutrient deficits 1

  • Reticulocyte count distinguishes between deficiency states (low/normal reticulocytes) versus hemolysis or acute blood loss (elevated reticulocytes) 1

  • C-reactive protein (CRP) is essential to interpret ferritin correctly in the context of inflammation 1, 2

Most Likely Diagnosis and Treatment Algorithm

If Iron Deficiency is Confirmed (Ferritin <30 μg/L or <100 μg/L with inflammation):

  • Initiate oral iron supplementation immediately once iron deficiency is confirmed 2

  • Continue treatment for 3-6 months after hemoglobin normalizes to replete iron stores 2

  • Investigate gastrointestinal blood loss aggressively 1, 2:

    • All adult men and post-menopausal women with confirmed iron deficiency require complete gastrointestinal evaluation, regardless of symptom presence 2
    • Upper endoscopy with mandatory small bowel biopsies to exclude malignancy and detect coeliac disease (present in 2-3% of IDA patients) 2
    • Colonoscopy or CT colonography to exclude colonic cancer/polyps 2

  • Stop NSAIDs and anticoagulants whenever possible 2

If Combined Iron and B12/Folate Deficiency is Found:

  • The coexistence of iron deficiency with vitamin B12 or folate deficiency produces a normocytic anemia with elevated RDW, reflecting a heterogeneous mixture of microcytic and macrocytic red cells 1

  • Treat both deficiencies simultaneously:

    • Iron supplementation (oral or intravenous) 1
    • Appropriate vitamin supplementation (B12 or folate) 3

If Hemolysis is Suspected (Elevated Reticulocyte Count):

  • Confirm with decreased haptoglobin, elevated lactate dehydrogenase, and increased indirect bilirubin 3

  • Address the underlying hemolytic process rather than empiric supplementation 3

Critical Pitfalls to Avoid

  • Do not assume iron deficiency based solely on elevated RDW: Approximately 10% of patients with iron deficiency have a normal RDW, and 32% of patients with anemia of chronic disease exhibit an elevated RDW 3, 4

  • Do not overlook combined deficiencies: Combined iron and B12/folate deficiency can maintain a normal MCV despite significant nutrient deficits, making the elevated RDW your only clue 1

  • Do not fail to investigate for gastrointestinal malignancy: In adult men and post-menopausal women with iron deficiency anemia, both upper and lower gastrointestinal endoscopy should be performed to exclude malignancy 1, 2

  • Do not start treatment without confirming the diagnosis: Elevated RDW does not exclusively indicate nutritional deficiency; it may reflect underlying inflammation, malignancy, or medication effects requiring alternative management strategies 3

References

1
Guideline

Management of Abnormal Red Cell Distribution Width (RDW)

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Diagnosis and Management of Iron Deficiency Anemia

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Interpreting Red Cell Distribution Width (RDW) Values

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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