Anemia of chronic disease medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2]

The primary goal in the treatment of anemia of chronic disease is to treat the underlying disease itself. Supplemental iron is recommended, as needed, to keep the transferrin saturation of above 20 percent and a serum ferritin level of above 100 ng/mL. Intravenous iron is more effective than oral supplementaion. Stable patients can be administered synthetically prepared erythropoiesis-stimulating agent such as erythropoietin or darbepoietin. It is important to give oral iron supplementation to all the patients receiving erythropoietin or darbepoetin, in order to maintain a transferrin saturation more than 20 percent and a serum ferritin more than 100 ng/mL. In case of severe disease, blood transfusion is recommended. If the case is underlying malignancy, chemotherapy or radiotherapy may transiently exacerbate anemia due to myelosuppressive effects, but in the long term, it leads to improvement. If the cause is inflammatory disorder, such as rheumatoid arthritis the management of the disease with a disease-modifying antirheumatic drug (DMARD) improves the anemia significantly.

The primary goal in the treatment of anemia of chronic disease is to treat the underlying disease itself.^[1]

• If the cause is underlying malignancy, chemotherapy or radiotherapy may transiently exacerbate anemia due to mylesuppressive effects, however in the long term, it leads to improvement.
• If the cause is inflammatory disorder, such as rheumatoid arthritis the management of the disease with a disease-modifying antirheumatic drug (DMARD) improves the anemia significantly.^[2]
• If the root cause of anemia is not found, a detailed search for inflammatory disorders such as inflammatory bowel disease and malignancy should be carried.

• Supplemental iron is recommended, as needed, to keep the transferrin saturation of above 20 percent and a serum ferritin level of above 100 ng/mL.^[3]
• A variety of oral iron formulations can be used, such as ferrous sulfate.

• Intravenous iron is more effective than oral supplementation.
• Intestinal absorption of iron is greatly reduced due to hepcidin activity at intestinal lining.
• Hepcidin-induced entrapment of iron can be managed with parenteral iron infusions.
• A variety of IV iron formulations can be used, such as iron sucrose, iron dextran, or ferric carboxymaltose.

In the case of a patient who does not respond to oral iron, parenteral iron infusions erythropoietin should be considered.^[4]

• Stable patients can be administered synthetically prepared erythropoiesis-stimulating agent such as erythropoietin.^[5]
• Erythropoietin can be given once per week, while darbepoetin should be administered once every two or three weeks.
• It is important to give oral iron supplementation to all the patients receiving erythropoietin or darbepoetin, in order to maintain a transferrin saturation more than 20 percent and a serum ferritin more than 100 ng/mL.

• In case of severe disease, blood transfusion is recommended.
• Blood transfusions, if performed frequently, can result in iron overload and circulatory overload.

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