HOW I DO – Anemia – 20

HOW I DO – Anemia – PART – 20

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question: In last part, we switched to Anemia. And we covered 1. How to decide which patients need urgent evaluation and who can wait. Hear their symptoms mainly. More the symptoms, more the urgency. Next see signs like heart rate, blood pressure – if abnormal, urgent. Hb number alone is not sufficient to decide urgency. Drop rate of Hb, symptoms and signs, underlying heart disease etc are more critical. 2. If additional lab abnormalities are there e.g. very high ESR, even if mild high creatinine, changes in platelet or wbc count, or abnormal smear examination should suggest need for more evaluation. And not just treat with iron, vitamins. 3. If there is no improvement in approximately one month with oral iron, vitamin or there is a drop in Hb, more evaluation is must.

Thank you for this very simple algorithm of what to look for in history, examination, comorbidities, and what basic tests to order and what to look for. Actually this is basic medicine.

Answer: Yes, but like everything else in life, basic is the hardest to practice. With more and more new information, we tend to forget practicing basic steps. This is very important for younger doctors to understand. They focus too quickly on ordering tests. But without pretest probability sense of what to expect, which comes from history and examination, tests can confuse you. And lead to either over work up for simple things or missed serious diagnosis. Basic blood tests have become much cheaper and more widely available. This again has led to less focus on basics of medicine. For those who are interested, read the concept of PRETEST PROBABILITY. A very important part of medicine practice. Good clinicians do this intuitively anyways. But when you read how it matters so much in daily practice, it further strengthens need for history and examination. This was part of our exam questions for diagnosis of pulmonary embolism using VQ scan (an old test).

Que: Interesting. I will certainly read about this concept. Now let us go to the next level discussion about evaluation for anemia.

Ans:. Yes. So you start with basic tests, if there is no specific sign from history or examination. Or in a very classical case as in general practice, you may order no further tests and give iron, vitamins.

1. In general, I would recommend cbc, liver function profile (not just SGPT. So as to see albumin globulin ratio as well), creatinine, ESR for a completely new patient. Along with a urine routine. And if possible, USG abdomen. In addition, if MCV is low, iron profile or at least a ferritin. Serum iron alone is not very reliable as it has wider fluctuations. E.g. If patient had an iron rich diet recently, this may come normal. But ferritin is storage iron, which is most accurate test among all tests for iron deficiency. Transferrin saturation adds to information especially when ferritin is borderline. Since ferritin normal range is wide, about 10 to 100+ depending on lab. No one test is perfect however. A very recent paper in BLOOD Journal suggests that person may actually have iron deficiency even at ferritin of 2000, based on a large analysis. BLOOD is most reputed journal in hematology field. Earlier dictum was that below 10 is definite iron deficiency, 10-100 is grey zone, and over 100 is mostly no iron deficiency. So sometimes we have to go case by case, and consider iron replacement as a therapeutic test. Iron profile especially ferritin can be very inaccurate during acute infection, even viral or other.
2. LOW MCV is the most common first sign of iron def, when you see a CBC report. Especially if associated with low RBC count. If RBC count is normal or high, it could be thalassemia minor associated low MCV. In other hemoglobinopathies also MCV is frequently low.
3. Once iron deficiency is confirmed, than we can talk about either treatment or next set of tests.

Que: Wait, why do you say next set of tests if iron def is confirmed???

Ans: Interesting, or rather frustrating, right? That is what patients also think. All patients don’t need more tests, but some do. Typically, if I have a young woman, under approximately 40 with long standing history of anemia with history of improvements with better diet or iron supplements but keeps relapsing; or a student with poor dietary habits for whatever reason; or a young person with poor dietary habits related to job e.g. sales….Any such classical cases, with no other signs to suspect anything else, and of course age generally below 30-40, then I write treatment only after very basic blood tests. If there is heavy menstrual periods, I advise in parallel to see a gynecologist. And call them after a month or so for follow up with only CBC. After about 3 months, I check ferritin also to ensure their storage iron is also improving, to prevent quick relapse of iron def anemia. And then I advise about 6 monthly ferritin and cbc if they have achieved normal Hb. Pure iron deficiency patients mostly achieve normal or near normal Hb in about 3 months generally. If Hb is not improving within first month and if not normal in about 3 months, to evaluate for additional causes. Sometimes patients have dual etiology. Or other reasons which continue to cause iron def.

MORE IMPORTANTLY HOWEVER ARE THE OTHER PATIENTS IN WHOM WE MUST ADVISE NEXT SET OF TESTS. WHO ARE THESE OTHER PATIENTS AND WHAT NEXT SET OF TESTS?

February 14^th 2026 Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 9998084001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com   www.shyamhemoncclinic.com