eMedicine Specialties > Emergency Medicine > Hematology & Oncology

Anemia, Chronic: Treatment & Medication

Author: Fredrick Melik Abrahamian, DO, FACEP, Associate Professor of Medicine, University of California at Los Angeles School of Medicine; Director of Education for Emergency Medicine Residency Program, Consulting Staff, Department of Emergency Medicine, Olive View-University of California at Los Angeles Medical Center
Coauthor(s): Eric Wilke, MD, Medical Director, Traditions Emergency Medicine, College Station Medical Center
Contributor Information and Disclosures

Updated: Jan 14, 2008

Treatment

Prehospital Care

  • Prehospital care most often is initiated for patients in extremis. Attention to ABCs is most appropriate. All such patients should have IV placement, fluid resuscitation, and airway management as necessary.
  • Initial status and appearance of the patient may hold useful information and should be elicited from prehospital personnel.
  • Most patients presenting with chronic anemia are not in distress.

Emergency Department Care

  • Patients with chronic anemia usually do not require intervention in the ED. Ultimate treatment requires investigation into the etiology of the anemia and correction of the underlying cause.
  • Records of previous hospitalization or ED visits are invaluable in many aspects. Such patients frequently have undergone previous workup, and trends of previous Hgb or hematocrit indicate the time course of the illness.
  • EDs rarely treat anemia beyond the emergent needs. Discharging the patient on iron, vitamin B-12, or folate may mask other problems and cloud the correct diagnosis.
  • Transfusions
    • One conspicuous exception in the treatment of chronic anemia is the use of transfusion therapy. Unless cardiopulmonary or cerebrovascular disease is present, transfusion is rarely needed in patients who have chronic anemia with an Hgb greater than 7 g/dL. Multiple situations that may require transfusion include angina, CHF, transient ischemic attack (TIA), and signs of tissue hypoxia.
    • It is important to weigh the risks and benefits of blood transfusion.
    • Many adverse reactions are associated with transfusion therapy. Most frequently encountered is a febrile nonhemolytic reaction. Patients who have had previous transfusion or patients who are pregnant are at greatest risk. Treatment is supportive with antipyretics. The clinician should maintain a high level of suspicion for a hemolytic reaction because fever may the first symptom.
    • Many patients fear infection. Hepatitis C occurs in 1 of 103,000 transfusions, hepatitis B occurs in 1 of 200,000 transfusions, and human immunodeficiency virus (HIV) occurs in 1 of 490,000 transfusions.
    • The graft versus host reaction is rare but is especially dangerous in patients who are immunocompromised. It carries a mortality rate higher than 90%. Pathogenesis in this reaction involves donor T lymphocytes attacking host human leukocyte antigens (HLA). High fever, erythematous rash, diarrhea, and abnormal LFTs associated with recent or concurrent transfusion may herald the severe reaction. Symptoms may not appear until 8 days after transfusion, and death occurs in 3-4 weeks. Using irradiated blood can decrease the incidence of graft versus host reaction and should be considered in all patients deemed immunocompromised, as well as in fetuses receiving intrauterine transfusions, patients receiving units from a blood relative, and patients transplanted with marrow. Care should be taken when transfusing patients with CHF. Preferably, transfusion should occur over 3-4 hours in the sitting position.

Consultations

  • Generally, patients with chronic anemia can be treated on an outpatient basis, and referral to a primary care provider is appropriate.
  • Consultation with the patient's primary care provider or an available internist should begin in the ED.
  • Symptomatic patients with an underlying medical condition that requires surgical consultation, such as chronic GI bleeding from colon cancer, should be evaluated by a surgeon in the ED.

More on Anemia, Chronic

Overview: Anemia, Chronic
Differential Diagnoses & Workup: Anemia, Chronic
Treatment & Medication: Anemia, Chronic
Follow-up: Anemia, Chronic
References
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References

  1. Binder LS. Anemia. In: Harwood-Nuss AL, Linen CH, eds. The Clinical Practice of Emergency Medicine. Philadelphia, Pa: Williams & Wilkins; 1996:915-7.

  2. Chandrasoma P, Taylor CR. The blood and lymphoid system. In: Concise Pathology. New York, NY: McGraw-Hill; 1991:374-406.

  3. Dzieczkowski JS, Anderson KC. Transfusion biology and therapy. In: Harrison TR, ed. Harrison's Principles of Internal Medicine. Vol 1. New York, NY: McGraw-Hill; 1998:718-24.

  4. Fischbach FT. Blood studies. In: A Manual of Laboratory Diagnostic Tests. Philadelphia, Pa: Williams & Wilkins; 1984:25-8, 867-8.

  5. Hamilton GC. Anemia, polycythemia, and white blood cell disorders. In: Rosen P, Barkin RM, eds. Emergency Medicine Concepts and Clinical Practice. Vol 3. 4th ed. St. Louis: Mosby; 1998:2053-2076.

  6. Lux SE, Fruchtman SM, Berk PD. Introduction to anemias: Polycythemia vera and agnogenic myeloid metaplasia. In: Handin RI, Lux SE, Stossel TD, eds. Blood: Principles and Practice of Hematology. Philadelphia, Pa: Williams & Wilkins; 1995:430-5, 1391-2.

  7. Rapaport SI. Diagnosis of anemia. In: Introduction to Hematology. Philadelphia, Pa: Williams & Wilkins; 1987:10-38.

  8. Rhule RL. Anemia. In: Schwarz GR, ed. Principles and Practice of Emergency Medicine. Vol 2. Philadelphia, Pa: Williams & Wilkins; 1992:1966-77.

  9. Tarasiuk A, Abdul-Hai A, Moser A, et al. Sleep disruption and objective sleepiness in children with beta-thalassemia and congenital dyserythropoietic anemia. Arch Pediatr Adolesc Med. May 2003;157(5):463-8. [Medline].

  10. Williams MD, Wheby MS. Anemia in pregnancy. Med Clin North Am. May 1992;76(3):631-47. [Medline].

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Further Reading

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Keywords

anemia, chronic anemia, malaise, fatigue, dyspnea, GI bleed, hemolysis, hemorrhage, sickle cell anemia, thalassemia, hemoglobin, Hgb, red blood cell, RBC, decreased production of RBCs, destruction of RBCs, hypochromic microcytic anemia, macrocytic anemia, normocytic anemia, aplastic anemia, myelophthisic anemia, myeloid metaplasia, agnogenic myeloid metaplasia, hemolytic anemia, iron deficiency

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Contributor Information and Disclosures

Author

Fredrick Melik Abrahamian, DO, FACEP, Associate Professor of Medicine, University of California at Los Angeles School of Medicine; Director of Education for Emergency Medicine Residency Program, Consulting Staff, Department of Emergency Medicine, Olive View-University of California at Los Angeles Medical Center
Fredrick Melik Abrahamian, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Eric Wilke, MD, Medical Director, Traditions Emergency Medicine, College Station Medical Center
Eric Wilke, MD is a member of the following medical societies: American College of Emergency Physicians and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Roy Alson, MD, PhD, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Deputy Medical Advisor, North Carolina Office of EMS; Associate Medical Director, North Carolina Baptist AirCare
Roy Alson, MD, PhD, FACEP, FAAEM is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, North Carolina Medical Society, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey L Arnold, MD, FACEP, Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center
Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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