• Anemia treatment approach is based on:
  • acuity of the anemia,
  • level of anemia and
  • underlying cause if known (decreased RBC production, increased destruction and blood loss)
• Iron deficiency anemia comprises an estimated 50% of cases of chronic anemia:
  • inadequate dietary iron intake or absorption
  • chronic blood loss that depletes iron stores
  • increased iron requirements during periods of rapid growth

• RBC Transfusion
  • Used more with acute or subacute anemia but have a role in chronic anemia.
  • Treat the patient not the hemoglobin level
  • In a patient with acute blood loss, maintain Hgb > 70 g/L. If pre-existing cardiovascular disease, maintain Hgb greater than 80g/L
  • Patients with severe/symptomatic chronic anemia can be treated with RBC transfusion to stabilize their condition.
    • Hgb < 70 g/L: consider transfusion.
    • Hgb < 71-90 g/L: consider transfusion in patients with pre-existing cardiovascular disease, evidence of impaired tissue oxygenation or expected ongoing losses.
    • Hb > 90 g/L: likely inappropriate.
  • In patients at risk for transfusion-associated circulatory overload, consider furosemide – it can be given pre, post or in between transfusions in addition to slowing the rate of transfusion
• Iron Supplementation
  • Only given in stable patients.
  • Oral iron replacement is almost always preferred to intravenous (IV) therapy
    • Patient tolerance should guide the choice of iron preparation
      • no formulation has proven superior to another.
    • Iron should be taken every second day with orange juice to increase absorption.
    • Inform patients of side effects: constipation and black stools.

Source: Adapted from the BC Guidelines on iron deficiency (ref. 7)

• • IV iron should not be considered a routine treatment, but may be initiated when there is:
    • Complete or partial failure of oral iron therapy trial (in compliant patients)
    • Intolerance to oral iron therapy
    • Inadequate iron absorption
    • Continued blood loss
    • Urgent surgery in an iron-deficient patient/pre-operative indication
    • Chronic kidney disease
  • Typical IV adult dosing:
    • Iron sucrose (20 mg Fe/mL): 100-300 mg intermittent per session, given as a total cumulative dose of 1000 mg over 14 days
      • Maximum daily dose = 300 mg
      • Maximum rate: 1^st dose 100 mg/hr; subsequent doses 150 mg/hr if no adverse reaction to 1^st dose
    • Iron dextran complex (50 mg Fe/mL): IV intermittent based on body weight and hemoglobin with a maximum 1000 mg/day
    • Ferric gluconate complex (12.5 mg Fe/mL): 125 mg (10 mL) IV per dose; up to 1000 mg over 8 sessions
  • B12 deficiency:
    • Intramuscular hydroxycobalamin – initial loading dose followed by 3-monthly maintenance doses.
  • Folate deficiency:
    • Oral folic acid (1-5mg)
    • Rule out B12 deficiency prior to initiating folate replacement → can worsen neurological symptoms of B12 deficiency
  • Bone marrow or stem cell failure: will require bone marrow transplant
  • Anemia of chronic disease:
    • In the presence of renal failure → responds to erythropoietin
  • RBC destruction due to:
    • Faulty mechanical valves →valve replacement
    • Medications → stop offending agent
    • Hemoglobinopathies (ie. Sickle cell anemia) → blood transfusions, exchange transfusions, hydroxyurea
    • Immune mediated hemolytic anemias →high dose corticosteroids (prednisone 1mg/kg) and folic acid supplementation
    • Persistent hemolytic anemia → splenectomy

Hospital admission should be considered for patients with:

• Severe anemia; particularly if cause is unknown
• Shock
• The inability to follow-up for further testing or treatment
• Underlying reason for transfusion requires admission
• Relative indications
• Comorbidities: renal disease, congestive heart failure, or older age

Consider transferring patients to another facility if: 

• The patient has severe anemia with life-threatening complications or symptoms that cannot be adequately managed at the current facility 
• The patient may benefit from additional resources or expertise 

• All patients with severe anemia, or moderate risk factors with pre-existing comorbid medical conditions should be closely monitored due to the increased risk of complications
• Undiagnosed anemias alongside recurring/chronic anemia prompts consultation with a hematologist or general internal medicine physician

Arrange discharge and follow-up for patients who are hemodynamically stable with no active bleeding.

1. BC Guidelines for Iron Deficiency – Diagnosis and Management: https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/iron-deficiency.pdf

   Iron sucrose dosing and implications: http://pdtm.vch.ca/Documents/iron%20sucrose%20NEW.pdf

   Choosing wisely Canada video on blood transfusion:

   
   

1. Steinbicker AU, Muckenthaler MU. Out of Balance—Systemic Iron Homeostasis in Iron-Related Disorders. Nutrients. 2013 Aug;5(8):3034–61.

   
   

2. Why Give Two When One Will Do? A toolkit for reducing unnecessary red blood cell

   transfusions in hospitals. Choosing Wisely Canada. 2019 [cited 2023 May 16]. Available from: https://choosingwiselycanada.org/wp-content/uploads/2017/07/CWC_Transfusion_Toolkit_v1.2_2017-07-12.pdf

   
   

3. Janz TG, Johnson RL, Rubenstein, SD. Anemia In The Emergency Department: Evaluation And

   Treatment. EB Medicine. 2013 [cited 2023 May 16]. Available from: https://scghed.com/wp-content/uploads/2017/07/Anaemia.pdf

   
   

4. Long B, Koyfman A. Emergency Medicine Evaluation and Management of Anemia. Emergency Medicine Clinics. 2018 Aug 1;36(3):609-30

   
   

5. Zeller MP, Verhovsek M. Treating iron deficiency. CMAJ. 2017 Mar 13;189(10):E409

   
   

6. Turner J, Parsi M, Badireddy M. Anemia. StatPearls [Internet]. 2020 Apr 12.

   
   

7. Hayter J, Thomas A. Investigation and management of anaemia. Medicine. 2021 Feb 25.

   
   

8. Doyle GR, McCutcheon JA. Clinical procedures for safer patient care: Chapter 8 intravenous therapy. BCcampus. 2015.