What medications should be initiated for the different types of anemia after completing the work‑up?

Medication Initiation for Different Types of Anemia After Work-Up

After completing the anemia work-up, initiate oral iron supplementation (100–200 mg elemental iron daily) for confirmed iron deficiency, hydroxocobalamin 1 mg intramuscularly for vitamin B12 deficiency (dosing frequency depends on neurological involvement), and oral folic acid 5 mg daily for folate deficiency—but always treat B12 deficiency before giving folate to prevent subacute combined degeneration of the spinal cord. 1, 2

Iron Deficiency Anemia

Oral Iron Therapy (First-Line)

• Start with 100–200 mg elemental iron daily (e.g., ferrous sulfate 325 mg once to three times daily) for adults and pregnant women over 12 years old. 2, 3, 4
• Continue oral iron for 3–6 months to normalize hemoglobin and replenish iron stores. 3
• If side effects occur, reduce to a lower dose rather than discontinuing therapy. 3

Intravenous Iron Therapy (Second-Line)

• Reserve parenteral iron for patients who:
  • Cannot tolerate oral preparations due to side effects 3, 4
  • Have intestinal malabsorption (celiac disease, inflammatory bowel disease, bariatric surgery) 3
  • Fail to respond to oral therapy 3, 4
  • Have prolonged inflammation or chronic kidney disease 3
• For chronic kidney disease patients not on dialysis with transferrin saturation ≤ 30% and ferritin ≤ 500 ng/mL, consider a 1–3 month trial of oral iron OR intravenous iron. 2

Critical Pitfall

• Always investigate and exclude sources of blood loss (gastrointestinal, genitourinary) before starting iron therapy, especially in men and postmenopausal women. 1, 3

Vitamin B12 Deficiency

With Neurological Involvement

• Administer hydroxocobalamin 1 mg intramuscularly on alternate days until no further improvement occurs. 1
• Then provide maintenance therapy with 1 mg intramuscularly every 2 months lifelong. 1
• Seek urgent specialist advice from neurology and hematology if unexplained sensory, motor, or gait symptoms are present. 1

Without Neurological Involvement

• Give hydroxocobalamin 1 mg intramuscularly three times weekly for 2 weeks. 1
• Follow with maintenance therapy of 1 mg intramuscularly every 2–3 months lifelong. 1

Essential Warning

• Never give folic acid first when B12 deficiency is suspected, as it may mask underlying B12 deficiency and precipitate subacute combined degeneration of the spinal cord. 1, 2

Folic Acid Deficiency

Treatment Protocol

• Always check and treat vitamin B12 deficiency before initiating folic acid to avoid neurological complications. 1, 2
• Prescribe oral folic acid 5 mg daily for a minimum of 4 months. 1
• If malabsorption is suspected, conduct further investigations while continuing therapy. 1

Anemia of Chronic Disease / Inflammation

Primary Management

• Treat the underlying inflammatory condition, autoimmune disease, infection, or malignancy as the first priority. 5, 6
• Address functional iron deficiency when ferritin > 100 ng/mL but transferrin saturation < 20% in the presence of elevated CRP. 2

Iron Supplementation in Inflammation

• For patients with transferrin saturation < 20% and serum ferritin < 100 ng/mL, give intravenous iron before or during erythropoiesis-stimulating agent (ESA) therapy. 1
• Oral iron is less effective during active inflammation due to hepcidin-mediated blockade of intestinal absorption. 6

Erythropoiesis-Stimulating Agents (ESAs)

• Consider ESA therapy only in patients receiving chemotherapy after correcting iron deficiency and other underlying causes. 1
• ESA treatment is not recommended in patients who are not on chemotherapy. 1
• Initiate ESAs when hemoglobin < 10 g/dL with symptomatic anemia, or < 8 g/dL with asymptomatic anemia during chemotherapy. 1
• Target hemoglobin is 12 g/dL without red blood cell transfusions. 1
• Dosing: approximately 450 IU/week/kg body weight for epoetins alpha, beta, and zeta; 6.75 mg/kg every 3 weeks or 2.25 mg/kg weekly for darbepoetin alpha. 1
• Stop ESA therapy if no initial hemoglobin response occurs within 4–8 weeks. 1

Anemia in Chronic Kidney Disease

Iron Repletion

• For patients with serum creatinine ≥ 2 mg/dL and transferrin saturation ≤ 30% with ferritin ≤ 500 ng/mL, initiate oral or intravenous iron for 1–3 months. 2
• Intravenous iron is preferred when rapid repletion is needed or oral absorption is impaired. 2

Erythropoietin Therapy

• Routine measurement of serum erythropoietin levels is not indicated in chronic kidney disease–related anemia. 2
• Erythropoietin deficiency is the most likely primary etiology when normocytic, normochromic anemia occurs without another identifiable cause. 2

Protein Malnutrition / Protein Energy Malnutrition

• If signs or symptoms of protein malnutrition or edema are present, investigate potential causes and refer back to the bariatric center for specialized management. 1

Monitoring Treatment Response

Iron Deficiency Anemia

• An increase in hemoglobin after therapeutic iron supplementation confirms the diagnosis of iron-deficiency anemia. 2
• Recheck iron studies in 2–4 weeks after acute bleeding episodes, as iron deficiency may develop once stores are depleted. 2

Vitamin Deficiencies

• Monitor clinical improvement and recheck levels at 3 months for vitamin A and vitamin E deficiencies. 1
• For vitamin K deficiency, recheck levels after 3 months of oral supplementation. 1

ESA Therapy

• Assess hemoglobin response within 4–8 weeks; discontinue if no response occurs. 1
• Do not escalate ESA doses or switch preparations in non-responders (except epoetin theta). 1