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Anaemia (adults)


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. 1. Ferritin is an acute phase protein – Transferrin saturation useful if inflammatory symptoms and Ferritin normal / high.
  2. 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.


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