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Drug-induced anemia
Other Resources UpToDate PubMed

Drug-induced anemia

Contributors: Nina Haghi MD, Eric Ingerowski MD, FAAP, Paritosh Prasad MD
Other Resources UpToDate PubMed


While not the most common cause of anemia, drugs may induce anemia by a variety of mechanisms. One of the more well-known mechanisms is through destruction (hemolytic anemia). Other mechanisms include suppression of bone marrow (aplastic anemia) or interference with DNA synthesis.

Drug-induced hemolytic anemia may be caused by immune-mediated hemolysis, oxidative injury, or thrombotic microangiopathy. It may present acutely (within 1 hour of administration) or within weeks of taking the drug. Symptoms include weakness, fatigue, pallor, dyspnea, headache, and cardiac irregularities.

Drug-induced hemolytic anemia occurs when the drug binds to the RBCs and is recognized as an antigen by a circulating antibody. Various types of "drug-dependent" reactions may occur; however, the overall result is destruction of an opsonized RBC through phagocytosis causing extravascular hemolysis. Drugs may also alter the RBC membrane, causing antibodies to recognize these alterations as foreign. This type of reaction is less common and can present weeks to months after drug initiation.

Oxidative hemolysis causes RBC injury by triggering the production of intracellular hydrogen peroxide. Glucose-6-phosphate dehydrogenase (G6PD) deficiency and hemoglobin H disease are examples of conditions in which oxidative hemolysis occurs in response to certain medications.

Drug-induced thrombotic microangiopathy (TMA) may be immune or nonimmune mediated. Immune-mediated cases involve antibodies that cause direct tissue toxicity, resulting in thrombus formation and injuring small arterioles / capillaries. RBCs then become fragmented as they pass through these thrombi. Nonimmune-mediated cases are caused by drugs that directly damage tissues.

Drugs such as chemotherapeutic agents cause anemia through the suppression of bone marrow.

Lastly, drugs that impair metabolism of folic acid and interfere with DNA synthesis may induce megaloblastic anemia. Hydroxyurea is one of the most common examples.


D64.81 – Antineoplastic chemotherapy induced anemia
D64.9 – Anemia, unspecified

428383000 – Anemia caused by medication

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Nutritional deficiency
  • Anemia of chronic disease
  • Iron deficiency anemia
  • Infection
  • Autoimmune Hemolytic anemia
  • Toxin or venom exposure
  • Hemoglobinopathy
  • RBC membranopathy
  • Disseminated intravascular coagulation
  • Thrombotic thrombocytopenic purpura
  • Hemolytic uremic syndrome
  • HELLP syndrome
  • Trauma
  • Paroxysmal hemoglobinuria (PNH)

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Reviewed:04/22/2021
Last Updated:04/26/2021
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Drug-induced anemia
A medical illustration showing key findings of Drug-induced anemia : Fatigue, Jaundice, Exertional dyspnea, Tachycardia, Anemia, Pallor
Copyright © 2024 VisualDx®. All rights reserved.