How to Treat Anemia in a Patient Who Refuses Transfusions for Religious Reasons

Here’s how readers responded to a You Make the Call question about a Jehovah’s Witness patient with stage IV uterine cancer, a uterine abscess, and low hemoglobin, who is receiving epoetin alfa and intravenous iron.

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I have taken care of many Jehovah’s Witness patients. They can tolerate a very low hemoglobin concentration. I would treat the patient like any other patient at this stage. I would continue the IV iron and the epoetin alfa.

Steven Sandler, MD
Advocate Illinois Masonic Medical Center
Skokie, IL

I have run into similar situations quite a few times. Artificial blood was found to have several unacceptable side effects, so it was not approved by the FDA. I tend to give IV iron and folic acid, subcutaneous or oral B12, and erythropoietin. Also, reduce blood draws to a minimum and use a pediatric collection tube.

If the patient is also bleeding, I may add aminocaproic acid, desmopressin, and coagulation factor VII-a (recombinant) as determined by the situation. I sometimes add cryoprecipitate, if acceptable to the patient.

Archana Maini, MD
Broward General Medical Center
Fort Lauderdale, FL

I would guess not due to pulmonary hypertension consequences.

Ian Giles, MD
Sysmex America, Inc.
Lincolnshire, IL

There are no licensed blood substitutes. Hemopure (HBOC-201), a polymerized cow hemoglobin, is available by emergency investigational new drug application. I would contact the manufacturer, HbO2 Therapeutics, to assess availability prospectively for the proposed application of getting a patient through chemotherapy.

Jed Gorlin, MD, MBA
Memorial Blood Centers
Saint Paul, MN

This patient might benefit from a comprehensive approach to minimizing anemia and minimizing transfusion. Often called “patient blood management,” this is an approach pioneered for the care of Jehovah’s Witness patients. Though particularly difficult for inpatients, blood draws should be kept to an absolute minimum. Ask the lab to use neonatal-size samples. Find a surgeon, if you need one, who agrees to prioritize minimization of bleeding over other concerns. Transfuse only for life-threatening bleeding or anemia after all other efforts at hemodynamic stabilization have been exhausted, and only if the patient allows you to. Make sure other causes of anemia (low folate, B12 levels, etc.) are ruled out.

Artificial oxygen-carrying red cell substitutes are not proven efficacious or safe, and I would explore this possibility only as a last-ditch compassionate-use approach, rather than prophylaxis. They are not FDAlicensed for use in humans to my knowledge.

Neil Blumberg, MD
University of Rochester Medical Center
Rochester, NY