Treatment with erythropoietin can be successful if the serum levels of the hormone are under 500 mU/ml.

A 48-year-old Caucasian woman comes to the physician for a follow-up visit.  She was recently diagnosed of anemia.  She currently complains of chronic and frequent tiredness, and daytime sleepiness.  Her other medical problems include hypertension and rheumatoid arthritis.  She takes diclofenac, enalapril and ferrous sulfate.  She has no known drug allergies.  Her social history is not significant.  Her vital signs are within normal limits.  Examination shows no abnormalities.  Stool testing for occult blood is negative.  Two months ago, when she was started on oral iron therapy, her baseline hemoglobin and hematocrit values were 8 g/dL (n>12.0) and 26% (n>36), respectively.  Her most recent laboratory results are as follows: CBC Hb 8.2 g/dL Ht 27% MCV 88fl Platelet count 450,000/cmm Leukocyte count 6,000/cmm Segmented neutrophils 63% Lymphocytes 31% Monocytes 6% Hematology Iron, serum 80 μg/dL Iron binding capacity, serum 200 μg/dL (normal: 250-370 μg/dL) Ferritin 300 ng/mL Erythropoietin 1500 mU/mL (normal: 500-3600 mU/mL) ESR 40 mm/h Serum vitamin- B 12 level 440 pg/mL (normal: 200-800 pg/mL) Serum folic acid level 18 ng/mL (normal: 2.5-20 ng/mL) Bone marrow studies reveal decreased numbers of sideroblasts and normal amounts of storage iron. Which of the following is the most appropriate intervention in the management of this patient? Patients with chronic diseases may develop anemia (anemia of chronic disease, or ACD). Chronic conditions such as inflammation and malignancy gradually suppress red blood cell production in the bone marrow. Hematologic studies reveal a low serum iron (80 μg/dL) and elevated ferritin levels (300 ng/mL), and usually, normal transferrin saturation. (Approximately 25% of ACD patients can have low transferrin saturation.) Around 20% of ACD patients have a hemoglobin concentration lower than 8 g/dL. In those cases, the cause of the anemia may be mixed; thalassemia, sideroblastic and iron deficiency anemia, as well as myelodysplasia have to be ruled out. This patient has a definite diagnosis of ACD made by bone marrow studies. Bone marrow studies reveal normal or increased amounts of storage iron in the macrophages, and a decreased number of sideroblasts. Treatment of the underlying disease and frequent follow-up visits are essential in the management of patients with ACD. Apart from treating the underlying cause, the 2 major options for treating anemia in these individuals are, erythropoietin injections or periodic blood transfusion. However, patients of ACD with erythropoietin levels more than 500 mU/mL usually do not respond to treatment with erythropoietin or darbepoetin. When the anemia is severe, such as in this patient, blood transfusions are necessary. Iron supplementation may be useful in patients with rheumatoid arthritis with co-existing ACD and iron-deficiency anemia, which can result from gastrointestinal bleeding secondary to drug therapy. Otherwise, iron therapy does not significantly help in the management of patients with ACD. Treatment of the underlying disease (which is usually a chronic infection, autoimmune or inflammatory disease such as rheumatoid arthritis, lupus, and vasculitis) and frequent follow-up visits are essential in the management of patients with anemia of chronic disease. When the anemia is severe, blood transfusions are necessary. Treatment with erythropoietin can be successful if the serum levels of the hormone are under 500 mU/ml. If erythropoietin levels are normal and anemia is severe, periodic transfusions of packed red blood cells are indicated.