Anaemia in Adults


Anaemia can be caused by:

  • Iron, folate, and B12 deficiencies
  • Chronic Kidney Disease (CKD)
  • Anaemia of chronic inflammation (ACI)
  • Bone marrow malignancy
  • 10% of people aged over 65 years living in the community have anaemia. After age 50, the prevalence rises rapidly
  • Most anaemia is mild. Only 3% of women and 1.5% of men have haemoglobin levels less than 110 g/L
  • In older people with anaemia, one third have nutrient deficiency, one third have ACI or CKD (or both)


History and Examination

  • Weight loss
  • Bone pain
  • Night sweats
  • Jaundice
  • Lymphadenopathy
  • Hepatosplenomegaly


Determine the most likely cause by arranging or assessing all of the following:

  • Full Blood Count (FBC) (indicates severity and whether other cell lines are involved)
  • Blood film (gives blood cell morphology which helps indicate the likely cause). This needs to be specifically requested on the laboratory form
  • Reticulocyte count (indicates whether bone marrow is active). This needs to be specifically requested on the laboratory form. If reticulocyte count is:
    • low i.e. decreased production - indicates nutritional anaemias, anaemia of chronic inflammation, renal failure, or bone marrow failure or infiltration
    • normal, assess in relation to the mean cell volume (MCV)
    • high i.e. increased destruction - indicates haemolysis or acute blood loss
  • MCV identifies whether macrocytic (MCV more than 98), normocytic (MCV 82 to 98), or microcytic (less than 82)

Further investigations will depend on these results:

  • Increased reticulocytes
    • Look for haemolysis or acute blood loss
    • Haemolysis:
      • Determine whether it is congenital or acquired:
      • Ask about family history e.g. hereditary spherocytosis, thalassaemias, sickle cell anaemia
      • Ask about medications
      • May be auto-immune
  • Macrocytic anaemia
    • Consider alcohol excess, B12 deficiency or folate deficiency, hypothyroidism, primary bone marrow failure or bone marrow malignancy including multiple myeloma and secondary cancers
  • Microytic anaemia
    • Consider iron deficiency or anaemia of chronic inflammation. If neither of these, consider haemoglobinopathy such as thalassemia, and request haemoglobinopathy screen
    • Anaemia of chronic inflammation
      • Previously known as anaemia of chronic disease
      • Can be caused by any systemic inflammatory condition e.g. malignancy, infection, autoimmune conditions
      • May have normal or elevated ferritin and reduced serum iron
      • May have an elevated C-reactive protein (CRP) and other inflammatory markers
      • Can present as either microcytic or normocytic anaemia
  • Normocytic anaemia
    • Consider recent haemorrhage, renal failure, thyroid or other endocrine abnormality, anaemia of chronic inflammation or bone marrow malignancy including multiple myeloma and secondary cancers
  • Cause is not obvious
    • Measure:
      • Ferritin, B12, folate
      • Urea and electrolytes (U&Es) and liver function tests (LFTs)
      • Thyroid-stimulating hormone (TSH)
      • Serum protein electrophoresis plus urine Bence-Jones protein

Note: When iron deficiency coexists with inflammatory disease, ferritin may be spuriously normal - it is an acute phase protein. Requesting additional iron studies may assist in these situations.


Most anaemia is managed in general practice.

  • Identify the cause and treat the underlying problem e.g. blood loss, chronic inflammation, folate, or B12 deficiency.
  • If no identifiable cause, it may be appropriate to monitor until symptomatic or until a treatable cause is found. In the elderly, about one third of anaemias are unexplained.
  • If severe symptomatic anaemia, consider whether the patient may benefit from red cell transfusion.


Referral Criteria

Most anaemia is managed in general practice, request haematology assessment if anaemia is associated with:

  • Blood film or other findings which are indicative of haematological disease, such as leukaemia, myelodysplasia, myeloma
  • Abnormalities of other blood cell lines, such as thrombocytopenia, neutropenia
  • Investigations suggest haemolysis, such as reticulocytosis, hyperbilirubinaemia, elevated Lactate dehydrogenase (LDH), positive direct antiglobulin test
  • Include FBC, blood film, reticulocytes result, and any other relevant tests, in your referral
  • Urgent or written advice is available

Referral Instructions

e-Referral Service Selection

  • Specialty: Haematology
  • Clinic Type: Not otherwise specified
  • Service: DRSS-Eastern-Haematology-Devon CCG- 15N

Referral Forms

DRSS Referral Form

Supporting Information

Pathway Group

This guideline has been signed off by NEW Devon CCG.

Publication date: July 2016


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