Anaemia — Bleepd

Is the patient bleeding? Check observations and look for a source first.

Send haematinics before any transfusion; use the MCV to guide the work-up.

Act now

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Active bleeding or shock: major haemorrhage protocol; see the Upper GI bleed topic.

Symptoms, rate of fall, haemodynamic status.
Bleeding: melaena, haematemesis, surgical drains, retroperitoneal. Drug chart: anticoagulants, antiplatelets, NSAIDs.
Haemolysis clues: jaundice, dark urine.

FBC and film, reticulocytes, ferritin, iron studies, B12, folate, CRP, U&E, LFT, clotting, group and save.
Suspected haemolysis: LDH, bilirubin, haptoglobin, direct antiglobulin test.

Microcytic: iron deficiency — oral iron (IV if not tolerated or rapid repletion needed). New iron deficiency in men and post-menopausal women needs GI investigation.
Macrocytic: B12 or folate deficiency, alcohol, liver disease, hypothyroidism, drugs. Replace B12 before folate if both are low.
Normocytic: acute bleeding, chronic disease, CKD, haemolysis, marrow problems.
Transfuse using NICE NG24 thresholds — see the Blood transfusion topic.

Falling Hb with bleeding, haemolysis, pancytopenia or an abnormal film: senior and haematology.

Ferrous sulfate

200 mg oral once daily or on alternate days.

Hydroxocobalamin

1 mg IM 3 times a week for 2 weeks (no neurological involvement), then every 2–3 months.

Folic acid

5 mg oral daily for 4 months, once B12 deficiency is excluded or treated.

Check the BNF and your local formulary before prescribing.

Written to current guidance (NICE NG24) · sources checked 14 Nov 2026. We watch NICE for updates weekly.

Sources (3)

Reviewed by Aboodee Alhasso, MPharm MRCPharm IP on 14 Nov 2026

For healthcare professionals, as an aid to clinical judgement — not a substitute for it. Follow your local policy and ask a senior when in doubt.