Clinical Manual for Management of the HIV-Infected ... - myCME.com

Check the testosterone level in individuals (both
men and women) with anemia of uncertain cause,
particularly if they have other signs or symptoms of
hypogonadism. Perform further testing if indicated by
the clinical presentation and results of the initial workup
(eg, evaluation for parvovirus B19 or other infection,
vitamin B12 deficiency, G6PD deficiency, malignancy,
or gastrointestinal blood loss).
Consider bone marrow biopsy if the diagnosis is
unclear, if the anemia is chronic or severe, if the initial
evaluation does not determine the cause, or if the
anemia is accompanied by pancytopenia. Bone marrow
biopsy may also be performed to confirm a diagnosis.
Review the patient’s medication list for drugs that may
cause anemia. Some common medications that may
cause anemia are the following:
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ZDV
Ganciclovir, valganciclovir
Sulfonamides
Pyrimethamine
Dapsone
Ribavirin
Interferon-alfa
Antineoplastic agents
Refer the patient to hematology or oncology specialists
as appropriate.
Treatment
Section 5—Complaint-Specific Workups | 5-3
The appropriate treatment depends on the cause and
severity of the anemia. Refer to pertinent chapters in
Section 6: Disease-Specific Treatment or primary care
management guidelines as appropriate.
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Patients with severe anemia may require transfusion
(unless hemolysis is suspected) with or without
hospitalization for evaluation and treatment.
Consider treating anemia of chronic disease with
ART, if it is otherwise indicated, while avoiding
medications associated with bone marrow toxicity.
Mild anemia often resolves without intervention
after the start of ART as the immune system is
reconstituted.
If drug-induced anemia is suspected, discontinue
the offending medication, if possible. For example,
for patients taking ZDV in whom other causes of
anemia have been excluded, consider substituting
another nucleoside/nucleotide analogue in place of
ZDV. If it is not possible to alter therapy, consider
using erythropoietin (EPO) or red blood cell
transfusion to increase the hematocrit.
EPO may be used to stimulate red blood cell
production. A typical dosage of recombinant human
EPO is 40,000 units weekly by subcutaneous
injection. Note that EPO replacement is ineffective
if the erythropoietin level is >500 international units
per liter (check serum EPO levels before treatment)
or if iron levels are low. For patients in whom EPO
is started, monitor the hemoglobin and hematocrit
regularly (eg, every week until stabilized, then every
4 weeks) and adjust the dosage as required.
Treat hypogonadal patients with testosterone.
Treat iron deficiency with ferrous sulfate 325 mg
orally 3 times daily.
Treat nutritional deficiencies as indicated. For
folate deficiency, give folic acid 1-5 mg daily for 1-
4 months; for vitamin B12 deficiency: administer
cobalamin 1 g intramuscularly once daily for 7 days,
then once weekly for 4 weeks, then once monthly, or
1-2 g orally once daily.