Anemia, ↑retic, ↑LDH, ↑indirect bili, ↓haptoglobin
Most accurate: Direct Coombs (DAT) + smear — spherocytes = warm IgG
Warm (IgG): Prednisone / methylprednisolone → rituximab (now often earlier second-line) / splenectomy if refractory
Cold (IgM, mycoplasma/EBV): avoid cold, treat underlying, rituximab
Order set
- FBC, film, reticulocytes
- DAT (Coombs)
- LDH, haptoglobin, bilirubin
- Cold agglutinins if suspected
Criteria
AdmitSymptomatic/rapidly falling Hb
ICUHaemodynamic compromise
TransfuseSymptomatic anaemia (least-incompatible)
DischargeHb stabilising on steroids, cause sought
Never
- Give steroids/splenectomy for cold IgM — they don't work
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Rapid Hb drop
- Hemodynamic compromise
Differentials
- Hereditary spherocytosis
- G6PD
- MAHA (TTP/HUS)
Common mistakes
- Steroids for cold IgM
- Transfusion delay in life-threatening anaemia
Disposition & follow-up
Warm → steroids; identify secondary cause; haematology follow-up.
Discharge package
MedicationsSteroid taper; folate
Follow-upHaematology; monitor Hb/steroid effects
Warning symptomsFatigue, dark urine, jaundice
💊 Treatment detail — doses & preparation
Prednisone (ITP/AIHA)corticosteroid
Dose1 mg/kg OD until platelets/Hb recover, then slow taper over weeks
PreparationTablets with food
MonitorGlucose, BP, mood; bone + gastric protection if prolonged
Rituximabanti-CD20
Dose375 mg/m² IV weekly ×4 (ITP/AIHA/cold agglutinin)
PreparationDilute in NS to 1–4 mg/mL; slow ramped infusion with premedication (paracetamol/antihistamine/steroid)
MonitorInfusion reactions (first dose), hepatitis B reactivation — screen first
Folic acidvitamin
Dose5 mg OD (deficiency/methotrexate cover — give on non-MTX days)
Preparation5 mg tablets
MonitorCorrect B12 deficiency FIRST if coexisting
Cold agglutininvariant
DoseKeep WARM; rituximab first-line; steroids/splenectomy less effective
PreparationWarm fluids + blankets
MonitorHaemolysis markers (LDH, haptoglobin, bili)
📖 BSH Autoimmune Haemolytic AnaemiaReviewed July 2026