TOC  |  HEME   

Microcytic hypochromic Anemia

A. Iron deficiency anemia

  1. Blood loss: menstruation (10-20 mg of iron loss/month), GI bleeding, GU bleeding, trauma, etc., intravscular hemolysis.
  2. Insufficient iron intake: menstruating, pregnant, surgical pts, elderly & indigent pts, poor dietary iron intake
  3. Impaired absorption: malabsorption
  4. RX:  iron rich diet, iron supplement as ferrous sulfate or liquid iron (Fer-in-Sol); IM or IV iron-dextran complex (Imferon) 100-250 mg ,or INFed of 50mg/ml at no more than 2 ml IM/day (first test with 0.5 ml dose), or Dexferrum at 100 mg per dose IV.

*  See below about some points about iron deficiency anemia

B. Sideroblastic anemia

It is characterized by ineffective erythropoiesis anemia with ringed sideroblasts, saturation of serum iron binding capacity (usually approaching 80%), >LDH, & bizarre peripheral smear with hypochromia, distorted red cells, & basophilic stippling.

  1. Hereditary or congenital: x linked or autosomal recessive
  2. Acquired sideroblastic anemia
    a. Idiopathic refractory sideroblastic anemia
    b. Secondary to: neoplasm (Di Guglielmo's disease erythroleukemia), inflammatory, hematologic, metabolic diseases.
    c. Associated with drugs or toxins: (1) Alcohol. (2) Lead. (3) Chloramphenicol. (4) Anti TB meds: INH. (5) Anti neoplastic alkylating agents as cytophosphamide.

C. Thalassemia hemoglobinopathies / anemia  


Some points about iron deficiency:  
Liz Simmons, MD (Dept. of Hematology/Oncology) July 2003


· Ferritin

· Iron saturation (Helpful but not absolute):

· Indices: MCV usually reduced in proportion to the hemoglobin. Exceptions:


1. For uncomplicated iron deficiency anemia (menstruating female; patients with clear source of iron deficiency anemia):

Iron sulfate (ferrous sulfate) 325 mg three times a day: best tolerated with food. Work up to full dose over a week. Patients should be advised to use stool softener at first sign of constipation. Twice a day is often sufficient, but it may take longer to correct the anemia. Expect 6-8 weeks to normalize hemoglobin. To replace iron stores, continue iron at once daily dose for 6 months after correction of anemia. Do not expect ferritin levels to normalize until then (ferritin reflects iron stores; we don't store iron until we replete our red blood cells). Menstruating women with recurrent or severe iron deficiency should take continued iron supplementation until menopausal (with intermittent evaluation of CBC/ferritin to ensure compliance/maintenance of normal hemoglobin). Some women will do well long term with a multivitamin/iron supplement, but must make sure that above initial treatment is completed.

2. For iron deficiency anemia of unknown cause, same treatment applies, but patients should be evaluated for source of bleeding:

· GI workup mandatory for anyone over 50, consider for those over 40 without a good explanation for iron deficiency; most males at any age should be evaluated for GI blood loss; INCLUDES STOOL FOR OB.

3. Iron intolerance:
Most patients will be able to tolerate oral iron if they work up to a full dose over several days, take it with food and are prepared to deal with constipation.

If a patient does not tolerate ferrous sulfate, a trial of ferrous gluconate should be given (same dosing). It contains less iron (30 mg), so may take a little longer to work. Niferex tablets (nonformulary, prescription required) contain 50 mg elemental iron and may be tried when ferrous sulfate or gluconate are not tolerated.

4. Intravenous iron
should be reserved for patients who really do not tolerate oral iron after a reasonable trial period (working up to full dose, trying different preparations, as above) or for patients with excessive iron losses due to untreatable causes (huge hiatal hernias, etc.), very severe iron deficiency intolerant to oral iron, but IV iron does not work any faster than oral iron. It has to be broken down to a usable form of iron within the bone marrow and does not begin to work for about 2 weeks.  Expect 6-8 weeks to normalize the hemoglobin. Ferritin levels may abruptly rise and are not helpful in the short run. PDR has a table which gives the total dose of imferon to use based on hemoglobin and weight of patient.

5. When should patient be referred to Hematology?

We are happy to answer questions that will help with management of these patients via email or phone call.