Treatment differs according to the type of anaemia.
1. Iron-deficiency anaemia
The most important aspect of treatment is for the underlying cause to be identified and managed in order to halt the loss of iron.
Replacement iron is then given to allow for the production of more haemoglobin and to replenish depleted iron stores. Iron is normally given orally. However, in cases where there are problems with absorption of iron or intolerable side effects of oral iron, it can be given intravenously. Blood transfusions are given if there’s active bleeding or if the haematocrit (the percentage of red blood cells in a sample) is very low.
Oral iron is safe, inexpensive and effective, provided that the correct dosage is taken. There are several types of oral iron, all of which are equally effective. The difference between them is the amount of elemental or actual iron they each contain, which is different from the number of milligrams of the pill itself.
For example, ferrous sulphate 325mg tablets contain 65mg of elemental iron. In the past, it was recommended to take iron up to three times per day. Recent research has shown that taking the tablets once a day, or even every second day, might improve absorption and reduce side effects. It’s important to follow your doctor’s guidelines.
These pointers will help you to optimise the success of iron replacement and avoid side effects:
- Enteric-coated formulations are not recommended because iron is best absorbed from the first parts of the small intestine. Enteric preparations release iron further down the digestive tract, where it isn’t well absorbed. Check this with your doctor.
- Some foods and medications interfere with iron absorption. It’s preferable to avoid taking iron with food, antibiotics, tea, coffee, calcium tablets or milk. They should be taken 1 hour before or 2 hours after food; and 2 hours before or 4 hours after taking antacids.
- Iron is best absorbed in an acidic environment, so taking it with 250mg vitamin C or orange juice does help.
Oral iron commonly causes side effects, which include a metallic taste in the mouth, nausea, constipation, stomach upset, dark stools and vomiting. Up to 70% of individuals report gastrointestinal side effects.
These can be ameliorated by taking a smaller dose (such as taking the liquid form of ferrous sulphate and adjusting the dose until the symptoms are tolerable), taking it with food (this is still better than not taking it at all), and taking tablets with a lower elemental iron content. Note that iron tablets may turn stools black and that this is completely normal.
In children, the dose is dependent on the child’s weight. It’s best for a doctor or pharmacist to advise on the correct dose for your child.
Intravenous (IV) iron:
Iron can also be administered by intravenous injection in your doctor’s rooms. This is usually reserved for individuals in whom there is a poor response to oral iron – either because of insufficient absorption of iron due to problems with the digestive tract, or where iron supplements cause intolerable side effects.
The newer iron infusions, however, have a much improved safety profile compared to the older preparations, and IV iron is now sometimes offered as first-line treatment as it allows for the replacement of the iron quickly over one or two sessions of intravenous administration.
Intravenous iron is significantly more expensive than iron tablets and needs to be administered in a doctor’s rooms or hospital where there are facilities for monitoring of the infusion.
In the past, the older types of IV iron carried a significant risk of serious allergic reactions. Today’s preparations are much safer and carry a risk of one tenth of one percent. Infusion reactions are more common. These are less serious but uncomfortable, and include temporary flushing and joint and muscle pain, which resolve when the infusion is stopped.
These reactions can be minimised by:
- Avoiding antihistamines as premedication
- Treating back and joint pain with non-steroidal anti-inflammatories
- Giving the infusion slowly
- Giving steroids before the infusion (in severe cases)
The choice between oral and intravenous iron is now more about the severity of the anaemia and the cost and availability of IV iron. Your doctor can advise you on this.
Oral iron is still most certainly used as treatment in children and adolescents.
Response to iron supplementation:
If you’re taking supplemental iron, you may feel an improved sense of well-being within the first few days of starting treatment.
Blood tests will show a rising haemoglobin level from 1-2 weeks after starting treatment, and haemoglobin levels should return to normal by 6-8 weeks of treatment.
Checking for the response to iron can be done two weeks after starting iron (your haemoglobin should have started rising as well as the reticulocyte count) and your doctor can check for side effects if oral iron is being used. If IV iron is used, testing can only be performed 4-8 weeks after treatment.
Iron supplementation is needed for as long as it takes to restore the ferritin and transferrin saturation levels – usually about 6 months. Repeat blood testing of these levels is necessary.
Sometimes blood tests don’t improve after the prescribed period. A number of factors may play a role and should be considered:
- Is the iron being taken as directed?
- Is the correct type of iron being used (e.g. an enteric-coated pill may be poorly absorbed)
- Is there a condition affecting absorption (e.g. coeliac disease or H. Pylori infection)?
- Is there another cause of the anaemia present in addition to low iron?
- Is there ongoing bleeding that hasn’t been addressed?
Iron-containing cocktails of vitamins shouldn’t be used alone to treat iron deficiency as they contain insufficient amounts of iron. However they can be used as part of routine supplementation to prevent iron deficiency. Once iron deficiency occurs, specific iron supplements are required to provide sufficient iron for replacement.
Increasing dietary intake of iron also cannot be used to treat established iron deficiency. This is because a 2,000-calorie, balanced diet can only provide about 10mg of iron, compared to the 65mg in one 325mg ferrous sulphate tablet.
2. Aplastic anaemia
Treatment for aplastic anaemia includes blood transfusions and medication. These treatments can prevent or limit complications, relieve symptoms, and improve quality of life.
In some cases, a cure may be possible. Blood and marrow stem cell transplants may cure the disorder. Removing a known cause of aplastic anaemia, such as exposure to a toxin, may also cure the condition.
3. Haemolytic anaemia
Treatments for haemolytic anaemia include:
- Medications to suppress the immune system (such as prednisone, cyclophosphamide and rituximab) in cases of autoimmunity
- Blood transfusions if the anaemia is severe
- Plasmapheresis (filtration of the blood similar to dialysis, where auto-antibodies are removed)
- Surgical removal of the spleen (splenectomy) and bone marrow transplant.
Treatment of the underlying cause might also treat the anaemia.
- People who have mild haemolytic anaemia may not need treatment – as long as the condition doesn’t worsen.
- In turn, people with severe haemolytic anaemia usually need ongoing treatment.
Treatment for thalassaemias depends on the type and severity of the disorder. People who are carriers, or who have alpha or beta thalassaemia, may need little or no treatment.
Regular blood transfusions are the mainstay of treatment if treatment is required. Iron chelation therapy (removal of excess iron from the blood) may be needed if iron overload develops from repeated transfusions.
If severe enough, bone marrow transplantation can be performed, and the spleen is removed to prevent ongoing destruction of the red blood cells.
Sickle cell anaemia has no widely available cure. However, certain treatments can help to relieve symptoms and prevent and treat complications. Treatment should be overseen by a specialist with expertise in this field.
The goals of treating sickle cell anaemia are to:
- Relieve pain
- Prevent infections through preventative antibiotics and immunisations
- Protect against eye damage and stroke
- Control complications
Bone marrow transplants may offer a cure in a small number of individuals (mainly children and adolescents). Counselling should be provided to people who wish to conceive, as there’s a risk of passing on the genes.
6. Pernicious anaemia
This type of anaemia is treated by replacing the missing vitamin B12 in the body. Treatment usually involves injections of vitamin B12 once a week for four weeks, and then once a month for an indefinite amount of time.
Tablets can be taken if the oral route is preferred, but the dose needs to be high enough (1,000-2,000 micrograms per day) to overcome the problems with vitamin B12 absorption from the digestive tract. If you have this disease, you may need lifelong treatment.
7. Fanconi anaemia
Treatment for fanconi anaemia (FA) is based on a person’s age, and how well or poorly the bone marrow makes new blood cells.
The four main types of treatment for FA are:
- Blood and marrow stem cell transplant
- Androgen therapy
- Synthetic growth factors
- Gene therapy
8. Anaemia of chronic disease
The most important aspect of treatment is to correct the underlying disorder or to ensure that it’s optimally treated, for example ensuring that blood sugar levels are controlled in individuals with diabetes.
The treatment choice for the anaemia depends on how severe it is and may include:
- Erythropoietin (to stimulate increased red cell production)
- Iron supplementation
- Blood transfusions
The course and prognosis of anaemia
The course and prognosis of anaemia depends on:
- The underlying cause and available treatments
- How quickly it develops
- The presence of other illnesses
For example, mild iron deficiency anaemia that occurs as a result of pregnancy or insufficient dietary intake requires relatively simple treatment and has a good prognosis. More severe iron losses, e.g. from chronic blood loss into the digestive tract (especially in the elderly), may require more prolonged iron replacement or even a blood transfusion.
The success of iron replacement treatment also depends on:
- How well the iron tablets or syrup are tolerated
- Whether the individual takes the medication as prescribed
- How well the individual is monitored for an adequate response to the iron therapy
- Whether steps are taken to change to an intravenous form of iron if the response is inadequate. This will also depend on affordability and whether a facility is available for administration and monitoring of an IV infusion.
Anaemia due to a genetic disorder may require much more intensive treatment such as regular blood transfusions, medication to suppress the immune system, bone marrow transplants and splenectomy (surgery to remove the spleen). These treatments may have uncertain outcomes and potentially serious complications.
Underlying conditions associated with the anaemia may also affect its prognosis, such as cancer, kidney failure, or autoimmune inflammatory conditions such as lupus (SLE).
It’s important to note that, if left untreated, anaemia can cause complications, including:
- Growth impairment in infants and children
- Premature birth in pregnant women
- Heart failure and arrhythmias (a rapid or irregular heartbeat).
Some types of inherited anaemias (e.g. sickle cell anaemia and thalassaemia) can even be life-threatening due to the severity of the anaemia they cause and complications such as blood clots.
Talk to your doctor about how to manage a chronic disease or other health problem that is causing your anaemia.
Reviewed by Cape Town-based general practitioner, Dr Dalia Hack. October 2018.
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