Patient handout

Anemia symptom-triage (outpatient ddx + ED escalation for severe)

PRODUCTION

1. Your condition

This handout is for anemia symptom-triage (outpatient ddx + ed escalation for severe). Your care team identified this based on: mcv <80 + low ferritin (<30) + low tsat + high tibc + high stfr — iron-deficiency anemia (ida); oral ferrous sulfate 325 mg qod (better tolerated) or iv iron if refractory/intolerant; men + post-menopausal women must get gi evaluation for occult bleeding/malignancy (camaschella nejm 2015 pmid 32513860 verify; bsh iron 2021 pmid 30303080 verify).

Other reasons your team may use this plan: mcv <80 + mentzer <13 + normal iron studies + family hx mediterranean/asian/african — thalassemia trait (alpha/beta); confirm hb electrophoresis; no iron unless concurrent ida; genetic counseling for partner screen; mcv <80-95 + chronic inflammation (ra, ibd, ckd, malignancy) + normal/high ferritin + low tsat + stfr/log(ferritin) <1 — anemia of chronic disease/inflammation (acd/ai); treat underlying; esa if ckd + hgb <10; mcv <80 + high ferritin + high tsat + ringed sideroblasts on bmbx — sideroblastic anemia (hereditary x-linked, acquired mds, lead, alcohol, inh); lead level if occupational/pediatric; pyridoxine trial if hereditary.

3. When to call your provider

Contact your care team if any of the following happen:

Hgb <7 + symptoms (chest pain, dyspnea, AMS, hypotension) → ED + transfusion
Hgb <8 + cardiac disease → ED + transfusion + cardiology consult
Brisk hemolysis with hemodynamic instability → ED + transfusion + ICU monitoring
TTP pentad (MAHA + thrombocytopenia + neuro/renal/fever) → STAT PLEX (route heme.ttp.core.v1)
DIC features (coag + thrombocytopenia + bleeding/thrombosis) → route heme.dic.v1
Pancytopenia + blasts on smear → STAT hematology + BMBx + route heme.acute-leukemia.core.v1
Acute GI bleed → ED + endoscopy (route gi.ugib.core.v1)
Severe AIHA (Hgb <6 + ongoing hemolysis) → admit + IV steroid + ?IVIG bridge
Refractory IDA to PO iron at 4 wk → IV iron OR GI workup
CKD anemia + Hgb >13 on ESA → reduce ESA + reassess target
IV iron anaphylaxis / severe hypersensitivity → stop infusion + epinephrine + supportive + report
IV iron hypophosphatemia (ferric carboxymaltose) symptomatic → phosphate repletion + monitoring
Sickle cell crisis confirmed → route heme.sickle-cell.core.v1

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Hgb <7 + symptoms (chest pain, dyspnea, AMS, hypotension) OR Hgb <8 + cardiac disease — ED + STAT pRBC transfusion (TRICC threshold PMID 9971864 verify) + cause workup(life-threatening)
Hgb low + retic high + LDH high + haptoglobin low + indirect bili high + DAT (Coombs) positive — autoimmune hemolytic anemia (AIHA); prednisone 1 mg/kg PO daily × 2-4 wk taper; IV methylpred if severe; rituximab if refractory; cold AIHA → keep WARM
Microangiopathic hemolytic anemia (schistocytes) + thrombocytopenia + neuro/renal/fever — TTP pentad; STAT plasma exchange (PLEX) — DO NOT delay for ADAMTS13; route heme.ttp.core.v1(life-threatening)
Pancytopenia (low Hgb + low WBC + low plt) + smear (blasts → leukemia; hypocellular → aplastic) + BMBx — emergent hematology; route heme.acute-leukemia.core.v1 if blasts; aplastic anemia → IST or HSCT; PRCA → IVIG / thymectomy
Megaloblastic anemia (MCV >100 + hypersegmented neut + macro-ovalocytes) — ALWAYS start B12 BEFORE folate (folate alone in B12 deficiency precipitates subacute combined degeneration of cord — irreversible neurologic); cyanocobalamin 1000 mcg IM weekly × 8 then monthly OR 1000-2000 mcg PO daily; check anti-IF + anti-parietal for pernicious anemia (Stabler NEJM 2013 PMID 22106456 verify)
IDA in adult male OR post-menopausal female — MANDATORY upper + lower endoscopy (occult GI bleed, colorectal cancer, celiac); capsule endoscopy if both negative; assume malignancy until proven otherwise (BSH 2021 PMID 30303080 verify)
Acute Hgb drop + tachycardia/hypotension + melena/hematochezia/hematemesis/trauma — acute blood loss; ED + IVF + STAT pRBC transfusion + endoscopy + identify source; route gi.ugib.core.v1 / gi.lgib.core.v1(life-threatening)

5. Follow-up

Hematology referral for refractory / hemolytic / pancytopenia / MDS / hemoglobinopathy. GI for IDA + occult blood loss workup (men + post-menopausal women → endoscopy + colonoscopy; capsule if negative). Dietitian for vegan / alcohol / malnutrition / pregnancy. Pregnancy nutrition + iron supplementation. Chronic CKD / RA / IBD optimization (route neph.ckd.core.v1). Genetic counseling for thalassemia / sickle / HS. Recurrence prevention (deprescribe NSAID/PPI if drug-induced); dietary counseling; partner thalassemia screen.

6. Sources

Guideline: 2015 Camaschella iron NEJM + 2013 Stabler B12 NEJM + 2021 BSH iron + KDIGO 2012 anemia of CKD + TRICC transfusion + ASH AIHA/PRCA/TTP guidelines