FOSTER DEVELOPMENT HOMOEOPATHIC

MEDICAL COLLEGE,
AURANGABAD,
DEPARTMENT - PRACTICE OF MEDICINE
MD PART 2
ANAEMIA & IT’S HOMOEOPATHIC
MANAGEMENT

BY DR TUSHAR SUNIL MHASKE

GUIDED BY PRINCIPAL
DR. ANUPAMA PATHRIKAR DR. ANUPAMA
PATHRIKAR
ANAEMIA & IT’S - BY DR TUSHAR MHASKE

HOMOEOPATHIC - MD MEDICINE
- PART-2
MANAGEMENT - 2023-25
 INTRODUCTION
Anemia is described as a reduction in the proportion of the red blood cells. Anemia is
not a diagnosis, but a presentation of an underlying condition. Whether or not a
patient becomes symptomatic depends on the etiology of anemia, the acuity of
onset, and the presence of other comorbidities, especially the presence of
cardiovascular disease. Most patients experience some symptoms related to anemia
when the hemoglobin drops below 7.0 g/dL.
Erythropoietin (EPO), which is made in the kidney, is the major stimulator of red blood
cell (RBC) production. Tissue hypoxia is the major stimulator of EPO production, and
levels of EPO are generally inversely proportional to the hemoglobin concentration. In
other words, an individual who is anemic with low hemoglobin has elevated levels of
EPO. However, levels of EPO are lower than expected in anemic patients with renal
failure. In anemia of chronic disease (AOCD), EPO levels are generally elevated, but
not as high as they should be, demonstrating a relative deficiency of EPO.
Normal Hemoglobin (Hgb)-specific laboratory cut-offs will differ slightly, but in
general, the normal ranges are as follows:
•13.5 to 18.0 g/dL in men
•12.0 to 15.0 g/dL in women
•11.0 to 16.0 g/dL in children
•Varied in pregnancy depending on the trimester, but generally greater than 10.0 g/dL
ETIOLOGY
The etiology of anemia depends on whether the anemia is
hypoproliferative (i.e., corrected reticulocyte count <2%)
or hyperproliferative (i.e., corrected reticulocyte count >2%).
Hypoproliferative anemias are further divided by the mean
corpuscular volume into microcytic anemia (MCV<80 fl), normocytic
anemia (MCV 80-100 fl), and macrocytic anemia (MCV>100 fl).
1) Hypoproliferative Microcytic Anemia (MCV<80 fl)
•Iron deficiency anemia
•Anemia of chronic disease (AOCD)
•Sideroblastic anemia (may be associated with an elevated MCV as
well, resulting in a dimorphic cell population)
•Thalassemia
•Lead poisoning
2) Hypoproliferative Normocytic Anemia (MCV 80-100 fL)
•Anemia of chronic disease (AOCD)
•Renal failure
•Aplastic anemia
•Pure red cell aplasia
•Myelofibrosis or myelophthisic processes
•Multiple myeloma
Macrocytic anemia can be caused by either a hypoproliferative
disorder, hemolysis, or both. Thus, it is important to calculate the
corrected reticulocyte count when evaluating a patient with
macrocytic anemia. In hypoproliferative macrocytic anemia, the
corrected reticulocyte count is <2%, and the MCV is greater than 100
fl. But, if the reticulocyte count is > 2%, hemolytic anemia should be
considered.
3) Hypoproliferative Macrocytic Anemia (MCV>100 fL)
•Alcohol
•Liver disease
•Hypothyroidism
•Folate and Vitamin B12 deficiency
•Myelodysplastic syndrome (MDS)Refractory anemia (RA)
•Refractory anemia with ringed sideroblasts (RA-RS)
•Refractory anemia with excess blasts (RA-EB)
•Refractory anemia with excess blasts in transformation
•Chronic myelomonocytic leukemia (CMML)
•Drug-induced
•Diuretics
•Chemotherapeutic agents
4) Hemolytic anemiaHemolytic anemia (HA) is divided into
extravascular and intravascular causes.
•Extravascular hemolysis: red cells are prematurely removed from
the circulation by the liver and spleen. This accounts for a majority of
cases of HAHemoglobinopathies (sickle cell, thalassemias)
•Enzyemopathies (G6PD deficiency, pyruvate kinase deficiency)
•Membrane defects (hereditary spherocytosis, hereditary
elliptocytosis)
•Drug-induced
•Intravascular hemolysis: red cells lyse within the circulation, and
is less common. PNH
•AIHA
•Transfusion reactions
•MAHA
•DIC
•Infections
PATHOPHYSIOLOGY
The pathophysiology of anemia varies greatly depending on the primary
cause. For instance, in acute hemorrhagic anemia, it is the restoration of
blood volume with intracellular and extracellular fluid that dilutes the
remaining red blood cells (RBCs), which results in anemia. A proportionate
reduction in both plasma and red cells results in falsely normal hemoglobin
and hematocrit.
RBC are produced in the bone marrow and released into circulation.
Approximately 1% of RBC are removed from circulation per day. Imbalance
in production to removal or destruction of RBC leads to anemia.
The main mechanisms involved in anemia are listed below:
1. Increased RBC destruction
•Blood lossAcute- hemorrhage, surgery, trauma, menorrhagia
•Chronic- heavy menstrual bleeding, chronic gastrointestinal blood losses [6]
(in the setting of hookworm infestation, ulcers, etc.), urinary losses (BPH,
renal carcinoma, schistosomiasis)
•Hemolytic anemiaAcquired- immune-mediated, infection, microangiopathic,
blood transfusion-related, and secondary to hypersplenism
2. Deficient/defective erythropoiesis
•Microcytic
•Normocytic, normochromic
•Macrocytic
 HISTORY AND PHYSICAL EXAMINATION
A thorough history and physical must be performed.
Some important questions to obtain in a history:
•Obvious bleeding- per rectum or heavy menstrual bleeding, black
tarry stools, hemorrhoids
•Thorough dietary history
•Consumption of nonfood substances
•Bulky or fatty stools with foul odor to suggest malabsorption
•Thorough surgical history, with a concentration on abdominal and
gastric surgeries
•Family history of hemoglobinopathies, cancer, bleeding disorders
•Careful attention to the medications taken daily
1) Symptoms of anemia
Classically depends on the rate of blood loss. Symptoms usually
include the following:
•Weakness
•Tiredness
•Lethargy
•Restless legs
•Shortness of breath, especially on exertion, near syncope
•Chest pain and reduced exercise tolerance- with more severe
anemia
•Pica- desire to eat unusual and nondietary substances
•Mild anemia may otherwise be asymptomatic
2) Signs of anemia
•Skin may be cool to touch
•Tachypnea
•HINT:
•Pallor of conjunctiva

•“Boxcars” or “sausaging” of retinal veins: suggestive of hyperviscosity which can

be seen in myelofibrosis
•Jaundice- elevated bilirubin is seen in several hemoglobinopathies, liver diseases
and other forms of hemolysis
•Lymphadenopathy: suggestive of lymphoma or leukemia

•Glossitis (inflammation of the tongue) and cheilitis (swollen patches on the

corners of the mouth): iron/folate deficiency, alcoholism, pernicious anemia
•Abdominal exam:Splenomegaly: hemolysis, lymphoma, leukemia, myelofibrosis

•Hepatomegaly: alcohol, myelofibrosis

•Scar from gastrectomy: decreased absorptive surface with the loss of the terminal
ileum leads to vitamin B12 deficiency
•Cardiovascular:
•Tachycardia

•Systolic flow murmur

•Severe anemia may lead to high output heart failure

•Neurologic exam: Decreased proprioception/vibration: vitamin B12
deficiency
•Skin: Pallor of the mucous membranes/nail bed or palmar creases:
suggests hemoglobin < 9 mg/dL

•Petechiae: thrombocytopenia, vasculitis

•Dermatitis herpetiformis (in iron deficiency due to malabsorption-

Celiac disease)
 EVALUATION
Approach to anemia includes identification of the type of anemia:
1. Complete blood count (CBC) including differential
2. Calculate the corrected reticulocyte count = percent reticulocytes x
(patient's HCT/normal HCT)
For normal HCT, use 45% in men and 40% in women
If result > 2, this suggests hemolysis or acute blood loss, while results < 2
suggests hypoproliferation.
3. After calculating the reticulocyte count, check the MCV.
•MCV (<80 fl) Iron deficiency- decreased serum iron, percent saturation of
iron, with increased total iron-binding capacity (TIBC), transferrin levels,
and soluble transferrin receptor
•Lead poisoning- basophilic stippling on the peripheral blood smear, ringed
sideroblasts in bone marrow, elevated lead levels
•AOCD- may be normocytic
•Thalassemia- RBC count may be normal/high, low MCV, target cells, and
basophilic stippling are on peripheral smear. Alpha thalassemia is
differentiated from beta-thalassemia by a normal Hgb electrophoresis in
•MCV (90-100fl)Renal failure: BUN/Creatinine
•Aplastic anemia- ask for drug exposure, check for infections (EBV,
hepatitis, CMV, HIV), test for hematologic malignancies and paroxysmal
nocturnal hemoglobinuria (PNH)
•Myelofibrosis/myelophthisis- check bone marrow biopsy
•Multiple myeloma- serum and urine electrophoresis
•Pure red cell aplasia- test for Parvovirus B19, exclude thymoma
•MCV (>100 fl)B12/folate levels- B12 and folate deficiency can be
differentiated by an elevated methylmalonic and homocysteine level in
B12 deficiency and only an elevated homocysteine level in folate
deficiency. Methylmalonic levels are relatively normal.
•MDS- hyposegmented PMNs on peripheral smear, bone marrow biopsy
•Hypothyroidism- TSH, free T4
•Liver disease- check liver function
•Alcohol- assess alcohol intake
•Drugs
Steps to evaluate for hemolytic anemia
1) Confirm the presence of hemolysis- elevated LDH, corrected reticulocyte count
>2%, elevated indirect bilirubin and decreased/low haptoglobin
2) Determine extra vs. intravascular hemolysis-
•ExtravascularSpherocytes present
•Urine hemosiderin negative
•Urine hemoglobin negative
•IntravascularUrine hemosiderin elevated
•Urine hemoglobin elevated
3) Examine the peripheral blood smear
•Spherocytes: immune hemolytic anemia (Direct antiglobulin test DAT+) vs. hereditary
spherocytosis (DAT-)
•Bite cells: G6PD deficiency
•Target cells: hemoglobinopathy or liver disease
•Schistocytes: TTP/HUS, DIC, prosthetic valve, malignant HTN
•Acanthocytes: liver disease
•Parasitic inclusions: malaria, babesiosis, bartonellosis
4) If spherocytes +, check if DAT is +
•DAT(+): Immune hemolytic anemia (AIHA)
•DAT (-): Hereditary spherocytosis
Other investigations that might be warranted include
esophagogastroduodenoscopy for the determination of an upper GI
bleed, colonoscopy for the determination of a lower GI bleed, and
imaging studies if malignancy, or internal hemorrhage is suspected.
If a menstruating woman has heavy vaginal bleeding, evaluate the
presence of fibroids with a pelvic ultrasound.
 MANAGEMENT
Management depends primarily on treating the underlying cause of anemia.
1) Anemia due to acute blood loss- Treat with IV fluids, crossmatched packed red
blood cells, oxygen. Always remember to obtain at least two large-bore IV lines for
the administration of fluid and blood products. Maintain hemoglobin of > 7 g/dL in a
majority of patients. Those with cardiovascular disease require a higher hemoglobin
goal of > 8 g/dL.
2) Anemia due to nutritional deficiencies: Oral/IV iron, B12, and folate.
•Oral supplementation of iron is by far the most common method of iron repletion.
The dose of iron administered depends on the patient's age, calculated iron deficit,
the rate of correction required, and the ability to tolerate side effects. The most
common side effects include metallic taste and gastrointestinal side effects such as
constipation and black tarry stools. For such individuals, they are advised to take
oral iron every other day, in order to aid in improved GI absorption. The hemoglobin
will usually normalize in 6-8 weeks, with an increase in reticulocyte count in just 7-
10 days.
• IV iron may be beneficial in patients requiring a rapid increase in levels. Patients
with acute and ongoing blood loss or patients with intolerable side effects are
candidates for IV iron.
3) Anemia due to defects in the bone marrow and stem cells:
Conditions such as aplastic anemia require bone marrow
transplantation.
4) Anemia due to chronic disease: Anemia in the setting of renal
failure, responds to erythropoietin. Autoimmune and rheumatological
conditions causing anemia require treatment of the underlying
disease.
5) Anemia due to increased red blood cell destruction:
•Hemolytic anemia caused by faulty mechanical valves will need
replacement.
•Hemolytic anemia due to medications requires the removal of the
offending drug.
•Persistent hemolytic anemia requires splenectomy.
•Hemoglobinopathies such as sickle anemia require blood
transfusions, exchange transfusions, and even hydroxyurea to
decrease the incidence of sickling.
•DIC, which is characterized by uncontrolled coagulation and
thrombosis, requires the removal of the offending stimulus. Patients
DIFFERENTIAL DIAGNOSIS
Hemolysis during phlebotomy and significant hemodilution due to large volume
fluid resuscitation may lead to a falsely low red cell count.
In acute blood loss from trauma, anemia may not immediately be present on
laboratory testing, as the fluid shifts have not had time to occur to normalize the
circulating volume, thus diluting the number of red blood cells remaining
Anemia of chronic disease: consider renal failure, underlying malignancies, and
autoimmune conditions
Bone marrow infiltration: consider in a patient with weight loss, fatigue.
Macrocytic anemia with B12/folate deficiency: consider in a patient with
paresthesias, vegans/vegetarians or in patients with recent gastric bypass
surgeries
Hemolytic anemia: consider in all patients with jaundice, dark urine. Always
question the recent use of medications.
Acute upper or lower GI bleed: trauma, carcinoma, peptic ulcer disease, use of
NSAIDs.
PROGNOSIS
The prognosis for anemia depends on the cause of anemia.
Nutritional replacements of (iron, B12, folate) should begin
immediately. In iron deficiency, replacements must continue for at
least three months after the normalization of iron levels, in order to
restore iron stores. Usually, nutritional deficiencies have a good
prognosis if treated early and adequately.
Anemia, due to acute blood loss, if treated and stopped early, has a
good prognosis.
COMPLICATIONS
Anemia, if undiagnosed or left untreated for a prolonged period of
time can lead to multiorgan failure and can even death.
Pregnant women with anemia can go into premature labor and give
birth to babies with low birth weight . Anemia during pregnancy also
increases the risk of anemia in the baby and increased blood loss
during pregnancy.
Complications are more predominant in the older population due to
multiple comorbidities . The cardiovascular system is the most
commonly affected in chronic anemia. Myocardial infarction, angina,
and high output heart failure are common complications. Other
cardiac complications include the development of arrhythmias and
cardiac hypertrophy.
Severe iron deficiency is associated with restless leg syndrome and
esophageal webs.
Severe anemia from a young age may lead to impaired neurological
development in the form of cognitive, mental, and developmental
HOMOEOPATHIC MANAGEMENT
Homoeopathic Management If anemia is caused by loss of blood or other
fluids : calcariacarbonica, carbo vegetabilis, hydrangea, Ferrum
metallicum, phosphoric acid, Sulphur, Staphysagria, Nux vomica,
If anemia is caused by violent acute disease: calcariacarbonica, carbo
vegetabilis, Natrum Muraticum, veratrum alb.
Alumina: Best suited remedy for anemia caused due to nutritional
disturbances. chlorosis in young girls at puberty, scanty menses and pale.
Craving for indigestible things .
Argentum nitricum: shortness of breath, heart burn, irritative gastralgia,
violent and irregular palpitations, irregular menses, rapid and excessive
albuminuria, desire for sugar or candy.
Kali carbonicum: blood lacks red blood corpuscles. Young ladies at time of
puberty have menstrual trouble on account of great weakness. Dropsy,
lower backache, vertigo when turning head rapidly, frequent chilliness,
every time patient goes out of doors .
Pulsatilla nigricans: chloro-anemia women, always complains of feeling
chilly, and still better fresh air, feels exhausted, all tissues relaxed,
peevish, slow, phlegmatic temperament, after failure of iron and China.
Natrum carbonium: pallid anemia with great debility, milky-white
skin, emaciation, skin rash, nervousness and anxiety .
Natrum Sulphuricum: Hydrogenoid constitution, depending upon
dampness of weather or dwelling in damp
houses; sycosis and hydraemia .
Hydrastis: Atony, weakness, faintness and prostration from dyscrasic
disorders injuring normal blood-formation; carcinoma etc., marasmus;
expression dull; skin sallow, yellowish-white; bad effects from Merc .
China officinalis: Complaints from loss of animal fluids, be it blood, semen,
diarrhea, leucorrhea or over lactation; great debility, trembling, aversion to
exercise; palpitations with rush of blood to head, and redness of face with
cold hands; heaviness of head, with loss of sight, fainting and ringing in
ears; sleeplessness; intolerance of fruits .
Ferrum metallicum: Pure anemia with appearance of false plethora; face
ashy Pale or greenish, becomes bright red in flushes; great paleness of
mucous membranes; bellow’s sound of the heart and anemic murmurs of
the arteries and veins; vomiting as soon as food is taken, with relief of
gastralgic pains, prostration with lethargic dullness; animal food not
desired .