A 28-year-old woman presents with fatigue, dyspnea, and jaundice. Laboratory investigations reveal hemoglobin 7.2 g/dL, reticulocyte count 12%, indirect hyperbilirubinemia, and a positive direct antiglobulin test (DAT). She has no prior transfusions or pregnancy. What is the drug of choice for her condition?

Question

Accepted Answer

B. Corticosteroids (Prednisolone). ## Diagnosis: Warm Autoimmune Hemolytic Anemia (AIHA)

### Clinical Presentation
The patient presents with hemolytic anemia (low Hb, elevated reticulocyte count, indirect hyperbilirubinemia) and a positive DAT, confirming immune-mediated hemolysis. The absence of transfusion or pregnancy history excludes secondary causes.

### Drug of Choice: Corticosteroids

**Key Point:** Corticosteroids (Prednisolone 1 mg/kg/day) are the first-line pharmacological treatment for warm AIHA. They suppress antibody production and reduce complement-mediated destruction of RBCs.

**High-Yield:** Response rates to corticosteroids in warm AIHA are 70–80%, with most patients achieving remission within 2–4 weeks.

### Treatment Algorithm

```mermaid
flowchart TD
  A[Warm AIHA diagnosed] --> B[Corticosteroids first-line]
  B --> C{Response at 2-4 weeks?}
  C -->|Yes| D[Taper and maintain]
  C -->|No| E[Add second-line agent]
  E --> F[Rituximab or Azathioprine]
  G[Splenectomy] --> H[Reserved for steroid-dependent/refractory cases]
```

### Comparison of Treatment Options

| Agent | Role | Timing | Efficacy |
|-------|------|--------|----------|
| **Corticosteroids** | First-line | Immediate | 70–80% response |
| Rituximab | Second-line (refractory) | Weeks 2–4 | 50–60% response |
| Azathioprine | Steroid-sparing agent | Weeks 4–8 | Adjunctive |
| Splenectomy | Refractory/steroid-dependent | After medical failure | 50–60% durable remission |

**Clinical Pearl:** Splenectomy is NOT first-line; it is reserved for patients who fail corticosteroids or become steroid-dependent. Rituximab is increasingly used as second-line therapy in refractory cases.

**Tip:** In NEET PG, when a warm AIHA patient is presented without mention of steroid failure or refractoriness, always choose corticosteroids as the answer.

Answer

A. Immunosuppressive therapy with azathioprine

Answer

C. Rituximab

Answer

D. Splenectomy

Explanation

Diagnosis: Warm Autoimmune Hemolytic Anemia (AIHA)

Clinical Presentation

Drug of Choice: Corticosteroids

Treatment Algorithm

Comparison of Treatment Options

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Agent	Role	Timing	Efficacy
Corticosteroids	First-line	Immediate	70–80% response
Rituximab	Second-line (refractory)	Weeks 2–4	50–60% response
Azathioprine	Steroid-sparing agent	Weeks 4–8	Adjunctive
Splenectomy	Refractory/steroid-dependent	After medical failure	50–60% durable remission