Anaemia – ProductiveMedic

Anaemia

GP Anaemia

⇛ History, Examination and Urine dip

⇛ Fast-track as below if appropriate

⇛ Admit if severe symptomatic anaemia

Comprehensive medical history to include:

Ethnicity (thalassaemia)
Diet + lifestyle (weight loss, vegetarian/vegan, alcohol intake)
Gastrointestinal symptoms (malabsorption/dyspepsia/melaena)
Medications
Female patient: Obstetric/gynaecologic
Significant comorbidity (renal/inflammatory)

Clinical examination to include:

Reticuloendothelial
Gastrointestinal
Signs of hypothyroidism
Urine Dip

Signs and Symptoms – SEE NICE GUIDANCE FOR OTHER SCENARIOS		Action	NICE 2015 link
ANAEMIA (iron-deficiency)
+	60 and over	2ww referral	[1.3.1]^Colorectal
→	(unexplained) with rectal bleeding in adults under 50	Consider 2ww referral	[1.3.3]^Colorectal
→	without rectal bleeding, adults under 60	Offer testing with quantitative FIT	[1.3.4]^Colorectal
ANAEMIA (non-iron-deficiency)
→	without rectal bleeding, 60 and over	Offer testing with quantitative FIT	[1.3.4]^Colorectal
Haemoglobin levels low
+	visible haematuria in women 55 and over	Consider a direct access USS	[1.5.12]^Endometrial
+	upper abdominal pain, 55 and over	Consider non-urgent direct access upper gastrointestinal endoscopy	[1.2.3]^Oesophageal [1.2.9]^Stomach

Use CANCER MAPS for red flag NICE referral criteria

- Important instructions and notes - please click to read.
  
  Instructions: Click the links (blue text), icons () and drop-downs (▶) for further information. Select the appropriate clinical scenario to adjust the pathway.
  
  This is an adapted version of the source material referenced/linked below. Please see the original source for full details.
  
  Please read our medical disclaimer - this pathway may not be suitable for your particular patient or healthcare setting/system.
  If you would like to commission a more appropriate localised pathway please get in touch.
  Adapted from these sources
  
  Central Manchester Hospitals Anaemia Guide
  
  Camden CCG: Abnormal FBC results guidance
  
  Kernow CCG: Initial Investigation and Management of Anaemia
  
  MTW NHS Trust: Guidelines for investigation and referral for Normocytic or Macrocytic Anaemia
- ⇛ History, Examination and Urine dip
  
  ⇛ Fast-track as below if appropriate
  
  ⇛ Admit if severe symptomatic anaemia
- Select type of anaemia based on MCV
  - Microcytic Anaemia
  - Normocytic Anaemia
  - Macrocytic Anaemia
- BUKU: Low haemoglobin →
- Consider Iron deficiency anaemia | Thalassaemia | Anaemia of chronic diseaseUsually Normocytic picture
  
  Consider
  Iron Deficiency Anaemia | Thalassaemia | Anaemia of Chronic DiseaseUsually normocytic picture
  
  ⇛ Ferritin | Hb electrophoresis (if appropriate ethnic group)
  & consider: ESR/CRP + Serum Iron Profile (if ferritin normal/high) | Coeliac screen
- Select ⇒
- Microcytosis - Select options after above blood tests done
- Select ⇒
- Iron Deficiency Anaemia
  Select other clinical scenarios once red flags features have been excluded
  NOTE: Iron Deficiency Anaemia (IDA) is not a diagnosis
  Further assessment including a detailed history is required to establish the cause of the IDA:
  - Manchester Anaemia Guide IDA pathway [PDF]
- See Anaemia related NICE criteria and action at top of page
  Use CANCER MAPS for red flag NICE referral criteria
- Consider upper GI investigations including OGD
  Use CANCER MAPS for red flag NICE referral criteria
- See Anaemia related NICE criteria and action at top of page
  Use CANCER MAPS for red flag NICE referral criteria
  ??Seek advice from local pathways or secondary care if doesn't meet the above criteria??
- Follow haematuria investigation pathways
  
  Use CANCER MAPS for red flag NICE referral criteria
- Refer to confirm Coeliac disease with OGD and duodenal biopsy
- ⇛ Assuming other clinical scenarios above are not applicable:
  - In pre-menopausal women prescribe iron replacement.
  - Repeat FBC and Ferritin at 3 months.
  - If not iron replete (and not due to menstrual loss) consider referring to gastroenterology.
- BEWARE falsely raised ferritin in inflammatory disease. Consider CRP/ESR and iron studies to assess the likelihood of masked IDA
  Anaemia of Chronic Disease: Signs, Symptoms & Initial InvestigationsDirect link to PDF page 12 on desktops
  
  ⇛ FBC | Blood Film | Reticulocyte Count | Ferritin | Serum Iron Studies | U+E | CRP/ESR/PV | LDH | LFT
  
  Causes of Anaemia of Chronic Disease
  - Collagen vascular and autoimmune disorders (e.g., rheumatoid arthritis, SLE, dermatomyositis, giant cell arteritis, polymyalgia rheumatica, scleroderma, inflammatory bowel disease)
  - Chronic infection (e.g., tuberculosis, chronic fungal infections, hepatitis, osteomyelitis, HIV)
  - Acute infection (e.g., pneumonia, pyelonephritis, endocarditis, cellulitis, and soft tissue infections)
  - Chronic diseases (e.g., chronic kidney disease, diabetes mellitus, congestive heart failure, major recent thrombosis, chronic pulmonary disease)
  - Malignancy (e.g., lymphoma, renal cell carcinoma, multiple myeloma)
  - Critical illness and major trauma.
  [Further information & Source: Manchester Anaemia Guide]
  
  REFER TO APPROPRIATE SPECIALTY AS NECESSARY
  
  Renal Anaemia Management
- Inherited disorders of haemoglobin (haemoglobinopathy) should be considered in all individuals with microcytic anaemia, particularly if there is no evidence of iron deficiency or red cell changes persist after adequate iron replacement. Although these conditions are more frequently associated with individuals of non-northern European origin, they may be found in all ethnic groups.
  
  Conditions most frequently associated with microcytic hypochromic indices include:
  1. Alpha thalassaemia
  2. Beta thalassaemia
  3. Delta beta thalassaemia
  4. Haemoglobin E
  5. Other haemoglobin variants
  [Further information & Source: Manchester Anaemia Guide]
- BUKU: Low MCV →
- Consider: Acute bleeding | Anaemia of chronic disease | Renal anaemia | Mixed Iron deficiency anaemia + Macrocytosis | Multiple myeloma
 
 Consider
 Anaemia of Chronic Disease | Mixed deficiency A combined IDA and B12/Folate deficiency can present with a normal MCV. Please use the IDA options in the microcytosis section. | Recent blood loss | Multiple Myeloma
 
 ⇛ Blood Film | Reticulocyte Count If raised check Coomb's test (DAT/DCT), bilirubin, haptoglobin and LDH (to assess for haemolytic anaemia) <a href="http://www.lhp.leedsth.nhs.uk/lpdetail.aspx?id=62#24" target="_blank">[Source]</a> BEWARE: any recent blood loss also increases the reticulocyte count. Normal bilirubin suggests bleed, while raised bilirubin suggests haemolysis | Ferritin + B12 + Folate | U+E | CRP/ESR | LFT | TFT
 & consider Myeloma screen | Haemolysis screen
- BEWARE falsely raised ferritin in inflammatory disease. Consider iron studies to assess the likelihood of masked IDA in patients with raised ESR/CRP
- Select ⇒
- Normocytosis - Select options after above blood tests done
- Anaemia of Chronic Disease: Signs, Symptoms & Initial InvestigationsDirect link to PDF page 12 on desktops
  
  Causes of Anaemia of Chronic Disease
  - Collagen vascular and autoimmune disorders (e.g., rheumatoid arthritis, SLE, dermatomyositis, giant cell arteritis, polymyalgia rheumatica, scleroderma, inflammatory bowel disease)
  - Chronic infection (e.g., tuberculosis, chronic fungal infections, hepatitis, osteomyelitis, HIV)
  - Acute infection (e.g., pneumonia, pyelonephritis, endocarditis, cellulitis, and soft tissue infections)
  - Chronic diseases (e.g., chronic kidney disease, diabetes mellitus, congestive heart failure, major recent thrombosis, chronic pulmonary disease)
  - Malignancy (e.g., lymphoma, renal cell carcinoma, multiple myeloma)
  - Critical illness and major trauma.
  [Further information & Source: Manchester Anaemia Guide]
  
  REFER TO APPROPRIATE SPECIALTY AS NECESSARY
  
  Renal Anaemia Management
- B12 defiency: Management pathway and notesDirect link to PDF page 4 on desktops
  
  Causes of vitamin B12 deficiency
  - Pernicious anaemia
  - Gastric causes: Gastrectomy | Gastric resection
  - Inadequate dietary intake of B12 eg: vegan diet
  - Intestinal causes: Malabsorption | Ileal resection | Crohn’s disease
  - Medicines: eg: colchicine, metformin, anticonvulsants | long term use of PPIs and H2blockers
  Food based malabsorption associated with gastric atrophy, either age related or associated with long-term PPI use – likely cause for 30-50% of cases with sub-clinical B12 deficiency.
  
  [Further information & Source: Manchester Anaemia Guide]
- Folate defiency: Management pathway and notesDirect link to PDF page 6 on desktops
  
  Causes of Folate deficiency
  - Dietary deficiency eg: alcoholism, dietary fads
  - Malabsorption eg: coeliac disease
  - Excessive requirements: Physiological | Malignancy | Haemolytic anaemia
  - Medicines: colestyramine, sulfasalazine, methotrexate
  [Further information & Source: Manchester Anaemia Guide]
  
  NOTE: If the Bilirubin or Reticulocyte count is raised
  REFER TO HAEMATOLOGY for suspected HAEMOLYSIS
- IS THE BILIRUBIN RAISED?
  YES → suggests HAEMOLYSIS
  REFER URGENTLY TO HAEMATOLOGY
  
  NO → suggests Bleeding - Establish source of bleeding.
  Offer FIT ± refer for GI investigations if no apparent source.
  
  BUKU Haematology: Haemolysis
- REFER TO HAEMATOLOGYDirect link to PDF page 13 on desktops.
  BUKU Haematology: Myeloma screen → Paraprotein | MGUS | Myeloma
- REFER TO HAEMATOLOGYDirect link to PDF page 13 on desktops.
  BUKU Haematology: Blood film comments | Pancytopenia
- Consider: Vitamin B12 deficiency | Folate deficiency | Alcohol abuse | Liver disease/Liver cirrhosis | Hypothyroidism | Haemolytic anaemia | Myelodysplastic syndrome | Multiple myeloma
 
 Consider
 Vitamin B12 deficiency | Folate deficiency | Alcohol abuse | Liver disease | Hypothyroidism | Haemolytic anaemia | Myelodysplastic syndrome | Multiple Myeloma
 
 ⇛ Blood Film | Reticulocyte Count If raised check Coomb's test (DAT/DCT), bilirubin, haptoglobin and LDH (to assess for haemolytic anaemia) <a href="http://www.lhp.leedsth.nhs.uk/lpdetail.aspx?id=62#24" target="_blank">[Source]</a> BEWARE: any recent blood loss also increases the reticulocyte count. Normal bilirubin suggests bleed, while raised bilirubin suggests haemolysis | B12 + Folate | LFT (+ GGT) | TFT
 & consider Haemolysis screen | Myeloma screen
- Select ⇒
- Macrocytosis - Select options after above blood tests done
- B12 defiency Management pathway and notesDirect link to PDF page 4 on desktops
  
  Causes of vitamin B12 deficiency
  - Pernicious anaemia
  - Gastric causes: Gastrectomy | Gastric resection
  - Inadequate dietary intake of B12 eg: vegan diet
  - Intestinal causes: Malabsorption | Ileal resection | Crohn’s disease
  - Medicines: eg: colchicine, metformin, anticonvulsants | long term use of PPIs and H2blockers
  Food based malabsorption associated with gastric atrophy either age related or associated with long-term PPI use – likely cause for 30-50% of cases with sub-clinical B12 deficiency.
  
  [Further information & Source: Manchester Anaemia Guide]
- Folate defiency: Management pathway and notesDirect link to PDF page 6 on desktops
  
  Causes of Folate deficiency
  - Dietary deficiency eg: alcoholism, dietary fads
  - Malabsorption eg: coeliac disease
  - Excessive requirements: Physiological | – Malignancy | Haemolytic anaemia
  - Medicines: colestyramine, sulfasalazine, methotrexate
  [Further information & Source: Manchester Anaemia Guide]
  
  NOTE: If the Bilirubin or Reticulocyte count is raised
  REFER TO HAEMATOLOGY for suspected HAEMOLYSIS
- REFER TO HAEMATOLOGYDirect link to PDF page 13 on desktops.
  BUKU Haematology: Blood film comments | Pancytopenia
- REFER TO HAEMATOLOGYDirect link to PDF page 13 on desktops.
  BUKU Haematology: Myeloma screen → Paraprotein | MGUS | Myeloma
- IS THE BILIRUBIN RAISED?
  YES → suggests HAEMOLYSIS
  REFER URGENTLY TO HAEMATOLOGY
  
  NO → suggests Bleeding - Establish source of bleeding.
  Offer FIT ± refer for GI investigations if no apparent source.
  
  BUKU Haematology: Haemolysis
- Further information
  Toggle show/hide (one at a time)
  - Clinical Assessment
  - NICE 2WW referral guidelines
- Comprehensive medical history to include:
  - Ethnicity (thalassaemia)
  - Diet + lifestyle (weight loss, vegetarian/vegan, alcohol intake)
  - Gastrointestinal symptoms (malabsorption/dyspepsia/melaena)
  - Medications
  - Female patient: Obstetric/gynaecologic
  - Significant comorbidity (renal/inflammatory)
- Clinical examination to include:
  - Reticuloendothelial
  - Gastrointestinal
  - Signs of hypothyroidism
  - Urine Dip

NICE 2015 REFERRAL CRITERIA
- 2 WEEK WAIT - ANAEMIA RELATED NICE 2015 REFERRAL CRITERIA

Signs and Symptoms - SEE NICE GUIDANCE FOR OTHER SCENARIOS		Action	NICE 2015 link
ANAEMIA (iron-deficiency)
+	60 and over	2ww referral	[1.3.1]^Colorectal
→	(unexplained) with rectal bleeding in adults under 50	Consider 2ww referral	[1.3.3]^Colorectal
→	without rectal bleeding, adults under 60	Offer testing with quantitative FIT	[1.3.4]^Colorectal
ANAEMIA (non-iron-deficiency)
→	without rectal bleeding, 60 and over	Offer testing with quantitative FIT	[1.3.4]^Colorectal
Haemoglobin levels low
+	visible haematuria in women 55 and over	Consider a direct access USS	[1.5.12]^Endometrial
+	upper abdominal pain, 55 and over	Consider non-urgent direct access upper gastrointestinal endoscopy	[1.2.3]^Oesophageal [1.2.9]^Stomach

Use CANCER MAPS for red flag NICE referral criteria

- BUKU: High MCV →
- HAEMATOLOGY REFERRALSDirect link to PDF page 13 on desktops. In this document HSC205 = 2WW pathway
- Section Break

Reference

Anaemia DDx | BUKU Home

TEST SITE: ALL PAGES ARE A WORK IN PROGRESS - LIKELY TO CHANGE OR BREAK!

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