Definition: Hb: Male <130g/l and female < 120g/l.
Hb falls with age
Asymptomatic patient with Hb>110 above 65 years or a patient with Hb>100 above 75 years of age often does not require investigation.
Urgent referral to haematology:
- Blood film abnormalities ( refer if suggested by the Haematologist).
- Assosiated cytopenias ( platelets <80 and / or neutrophils <1.0).
- Lymphadenopathy or splenomegaly with anaemia.
- Unexplained, progressive or severe anaemia.
Useful questions to ask to aid investigation:
Is the cause likely to be Iron deficiency/bleeding?
- Bleeding history
- GI / Gynae / urological symptoms
- Low MCV
- Fall in MCV within normal range – check Ferritin, refer based on history (e.g. red flag for GI referral) Iron Malabsorption – PPI therapy, atrophic gastritis, known or suspected Coeliac or Crohn’s
- 1. Ferritin is an acute phase protein – Transferrin saturation useful if inflammatory symptoms and Ferritin normal / high.
- 2. For patients with low MCV – have they had previous Hb electrophoresis? E.g. Alpha Thalassaemia trait is common and not clinically significant.
Is the cause likely NOT to be iron deficiency/bleeding?
MCV can help: Normocytic (80-100fl) Causes – CRF, chronic disease (inflammatory / cancer), myeloma, other haematological causes including myelodysplasia Macrocytic (>100fl)
Causes – B12 / Folate deficiency, alcohol / liver disease, hypothyroidism (rarely significant anaemia by itself) / myelodysplasia / haemolytic anaemia.
Note: B12 / Folate deficiency not usually referred – see B12 / Folate guidance.
Non-Urgent Referral to Haematology:
- Symptomatic patients with unexplained anaemia (e.g. Hb 20g/L below their normal).
- Failure of response to oral iron (following appropriate investigation for cause of iron deficiency).
- Investigations prior to referral – Ferritin / transferrin saturation, B12/ Folate, renal and liver biochemistry, serum electrophoresis.
Management of Microcytic Anaemia (MCV <80f/l);
Consider iron deficiency.
- Ferritin <15µg/L and / or transferrin saturation <20%.
- A cause needs to be established for any case of iron deficiency.
- Patients with established iron deficiency anaemia usually treated initially with elemental iron e.g. ferrous sulphate 200mg bd.
- Advise to optimise absorption helps: take iron with a source of Vitamin C; avoid dairy products / tea / chappati flour.
- If patients are not responding to iron treatment, consider compliance issues and changing to a different oral preparation.
- PPIs inhibit iron absorption.
- Refer to Haematology to consider parental iron in patients with confirmed iron deficiency, that fail to respond to oral iron or those who are intolerant to at least 2 different oral preparations.
Once Hb is within normal range, iron supplementation needs to be continued for three months to build iron stores.