This handout is for acute hf — high-output from severe anemia (hb <7). Your care team identified this based on: hb <7 g/dl + hf symptoms (dyspnea, orthopnea, edema, s3 gallop) → high-output anemic hf pathway.
Other reasons your team may use this plan: new dyspnea or orthopnea in known severe anemia (ckd on dialysis, mds, chemotherapy, chronic gi bleed) — escalate to high-output hf workup; anginal chest pain at rest with hb <7 — supply-demand mismatch (type 2 mi risk) requires urgent transfusion + ischemia workup; acute hb drop ≥3 g/dl within 24-48 h (active hemorrhage, hemolysis) + new dyspnea/hypotension — emergent crossmatch + transfusion + source control.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| furosemide | 10-20 mg IV with each unit of pRBCs (NOT high-dose upfront — anemia + over-diuresis worsens hypotension) | IV | with each transfusion + q12h prn congestion | Mehta serial diuretic protocol Transfusion 2017 — 10-20 mg IV furosemide with each unit reduces TACO incidence; gentler than DOSE high-dose protocol because anemic patients tolerate volume loss poorly |
| iron_sucrose | 200 mg IV over 60 min weekly × 5 doses (total 1000 mg) | IV | weekly | AFFIRM-AHF PMID 33216035 — IV ferric carboxymaltose in HFrEF + iron deficiency reduces hospitalization (similar effect with sucrose); preferred over PO in HF (poor PO absorption in inflammation); KDIGO recommends IV iron in dialysis patients |
| ferric_carboxymaltose | 750 mg IV × 1-2 doses (max 1500 mg over 7 d) OR weight-based: <50 kg 15 mg/kg | IV | single or 2 doses 7 d apart | AFFIRM-AHF PMID 33216035 + IRONMAN PMID 36356631 — single-dose convenience; rapid total-dose repletion; HFA-ESC 2021 Class I |
| ferric_derisomaltose | 20 mg/kg IV (max 1000 mg) single dose | IV | single dose | IRONMAN PMID 36356631 — large single-dose; UK + EU first-line; emerging US use |
| epoetin_alfa | 50-100 U/kg SC TIW (titrate to Hb 11-11.5 NOT >12 per CHOIR/CREATE) | SC | three times weekly | KDIGO 2012 — Hb target 11.5 (NOT >13 — increases mortality + thrombosis per CHOIR PMID 17108346); REQUIRES iron sufficiency (TSAT >20, ferritin >100) for response |
| cyanocobalamin_b12 | 1000 µg IM daily × 7 then weekly × 4 then monthly OR 1000 µg PO daily (oral effective in non-pernicious deficiency) | IM/PO | per protocol | Standard repletion; IM avoids PO absorption issues in pernicious + post-gastrectomy; recheck B12 + MMA at 3 mo |
| folic_acid | 1-5 mg PO daily × 4 mo or until repleted | PO | daily | Standard repletion; ALSO prophylactic in chronic hemolysis to prevent megaloblastic crisis |
| prednisone | 1 mg/kg/d PO (60-80 mg) tapered over weeks-months | PO | daily | First-line for warm AIHA per BSH 2017 — taper based on Hb response; 70% respond |
| rituximab | 375 mg/m² IV weekly × 4 (or 1000 mg × 2 doses 2 wk apart) | IV | weekly × 4 | Second-line warm AIHA + first-line cold agglutinin disease per BSH 2017; ~50% durable response |
| pantoprazole | 40 mg IV q12h initial; 80 mg IV bolus + 8 mg/h infusion if active UGIB | IV | q12h or continuous | ACG 2021 UGIB — high-dose IV PPI for high-risk peptic ulcer stigmata per Lau NEJM 2007 |
Plan: High-output HF from severe anemia — judicious transfusion + IV diuretic during infusion + etiology-specific repletion (FOCUS PMID 22168590; AABB 2016 PMID 26684776; AFFIRM-AHF PMID 33216035; IRONMAN PMID 36356631)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Hematology referral for ongoing etiology workup if not resolved (MDS, hemoglobinopathy, AIHA); GI referral for endoscopy completion if iron-deficient; outpatient IV iron repletion in HF clinic per AFFIRM-AHF/IRONMAN; nephrology for CKD-related anemia + EPO management; PCP + cardiology follow-up at 1-2 weeks; recheck CBC + iron studies at 4-6 weeks; counsel on warning signs (recurrent bleeding, pallor, fatigue)
Guideline: FOCUS PMID 22168590 + AABB 2016 PMID 26684776 + 2022 ACC/AHA HF + AFFIRM-AHF (Ponikowski 2020) + KDIGO 2012 anemia in CKD