Anemia Treatment
Hematological / Oncological
Context
- 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
Recommended Treatment
- 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.
- Patient tolerance should guide the choice of iron preparation

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: 1st dose 100 mg/hr; subsequent doses 150 mg/hr if no adverse reaction to 1st 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
- Iron sucrose (20 mg Fe/mL): 100-300 mg intermittent per session, given as a total cumulative dose of 1000 mg over 14 days
- 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
- IV iron should not be considered a routine treatment, but may be initiated when there is:
Criteria For Hospital Admission
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
Criteria For Transfer To Another Facility
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
Criteria For Close Observation And/or Consult
- 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
Criteria For Safe Discharge Home
Arrange discharge and follow-up for patients who are hemodynamically stable with no active bleeding.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
There is clear, high-quality evidence from numerous RCTs that support treatment recommendations.
Related Information
OTHER RELEVANT INFORMATION
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:
Reference List
Steinbicker AU, Muckenthaler MU. Out of Balance—Systemic Iron Homeostasis in Iron-Related Disorders. Nutrients. 2013 Aug;5(8):3034–61.
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
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
Long B, Koyfman A. Emergency Medicine Evaluation and Management of Anemia. Emergency Medicine Clinics. 2018 Aug 1;36(3):609-30
Zeller MP, Verhovsek M. Treating iron deficiency. CMAJ. 2017 Mar 13;189(10):E409
Turner J, Parsi M, Badireddy M. Anemia. StatPearls [Internet]. 2020 Apr 12.
Hayter J, Thomas A. Investigation and management of anaemia. Medicine. 2021 Feb 25.
Doyle GR, McCutcheon JA. Clinical procedures for safer patient care: Chapter 8 intravenous therapy. BCcampus. 2015.
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Sep 14, 2023
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