Shaping better health
REMEDY : BNSSG referral pathways & Joint Formulary

Anaemia DRAFT

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WHO Definition:

<130g/l Hb in an adult male <120g/l Hb in an adult female; age-dependant in childhood. Anaemia is the commonest haematological disorder seen in general medical practice. Risk factors are extremes of age, being female, pregnant or lactating and although anaemia itself may cause morbidity in the majority of cases it is secondary to an underlying disorder.

Generally, healthy individuals tolerate extreme anaemia well, with cardiovascular status being the major limiting factor. In haemodynamically stable patients without active bleeding, Hb levels between 70 g/L and 90 g/L were well tolerated with equivalent or lower mortality/morbidity outcomes compared with a liberal transfusion trigger of <100 g/L. It is generally recommended that determination of transfusion requirements be based upon severity of illness parameters rather than arbitrary Hb levels.

Who to refer

If clinically stable transfusion is rarely indicated if Hb is 70g/l or above (80-90g/l or above if cardiovascular disease).

Mild, stable anaemia with no reversible cause, especially in the elderly, can be managed in the community with monitoring every 3-6 months unless frail and/or near end of life, or less frequently if clinically stable and not progressive. 

Referral to Haematology clinic may not be suitable for:

Patients who are elderly or frail with mild unexplained anaemia (esp if Hb ≥100g/l). Consider monitoring in the community and discussion with a clinical haematology advice & guidance service.

  • If transfusion support for symptomatic care is considered appropriate direct arrangements with local Medical Day Care / Ambulatory Care facility may be made. Please see Blood Transfusions page of Remedy.

Referral to Haematology is not appropriate for:

Iron deficiency anaemia:

Refer to gastroenterology, gynaecology or urology as directed by the clinical assessment.

Except in premenopausal women, upper and lower GI investigations are likely to be an appropriate

Parenteral Iron: If oral iron replacement is poorly tolerated and patient remains anaemic, referral for parenteral iron can be made from primary care directly to Medical Day Care Southmead / Ambulatory Care (BRI) - where should this link to?. Ensure that the patient is counselled about benefits and risks of parenteral iron – information leaflet available in Medical Day Care / Ambulatory Care.

B12 or folate deficiency: can be managed according to BNF guidance in the community.

Anaemia of chronic disease: including renal failure consider referral to the relevant specialist team

Red Flag

 Refer via 2WW pathways as follows:

  • A blood film report that suggests acute leukaemia (often associated with other cytopenias)
  • A blood film suggestive of Chronic Myeloid Leukaemia (usually associated leukocytosis)
  • Suspected Myeloma.

Urgency of referral will vary depending on various factors including degree of anaemia, rapidity of progression and presence of associated features, as well as frailty of patient.

  • A blood film report that suggests a primary haematological disorder.
  • With thrombocytopenia or neutropenia.
  • Examination shows splenomegaly or lymphadenopathy.
  • Reticulocytosis (without obvious bleeding). Raised LDH, bilirubin and low haptoglobin is consistent with haemolysis. Blood film and direct antiglobulin test (Coomb’s test) complete the assessment for this.
  • Unexplained, progressive, symptomatic anaemia.
  • Amonocloncal protein (also known as paraprotein), abnormal serum free light chain assay or positive urine light chains (Bence Jones protein); usually the laboratory report guides further action.
  • Unexplained MCV>105 fl (see macrocytosis).

Before referral

Asessment in Primary Care

  • Anaemia may be multifactorial, especially in the elderly
  • Initial investigations should include ferritin, B12, folate, renal function, liver function, CRP.
  • Further assessment should include blood film, myeloma screen, reticulocyte count.
  • Any unexplained cytopenia should prompt consideration of HIV testing

Microcytosis/microcytic anaemia:



Normocytic anaemia:


Macrocytosis/macrocytic anaemia

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Management of Anaemia in Primary Care

  • If clinically stable transfusion is rarely indicated if Hb is 70g/l or above (80-90g/l or above if cardiovascular disease).
  • Mild stable anaemia with no reversible cause esp in the elderly can be managed in the community with monitoring every 3-6 months or less frequently if clinically stable and not progressive.  



URGENT ADVICE: 9am to 5pm via hospital switchboard for haematology SpR. ONLY for emergency advice. Out of hours and weekends – emergency advice may be obtained from the on call haematology clinician via hospital switchboard.

NON-URGENT ADVICE: Use Haematology advice and guidance service which can be accessed through the NHS e-referral system. Your query will be responded by a consultant haematologist within 3 working days.

REFERRAL: via e-RS or cancer fast track pathways as indicated

Minimal information: the referral letter should include abnormal clinical findings (location, size, any associated features) and any abnormal full blood count results or other relevant test results, particularly if these investigations were not done in laboratories of the hospital to which the referral is made.

Cancer fast track: ensure that the location and size of any lymphadenopathy is described. According to NICE guidance and previous section in this guidance.

Other haematology referrals: most new referrals should go to one of the general haematology clinics but may be triaged to a specialist clinic