## Warm Autoimmune Hemolytic Anemia (AIHA) — First-Line Management **Key Point:** Corticosteroids are the first-line pharmacological treatment for warm AIHA, achieving remission in 60–80% of patients. ### Mechanism of Action Corticosteroids (prednisolone or methylprednisolone) work by: 1. Suppressing T-cell-mediated antibody production against RBC antigens 2. Reducing complement-mediated hemolysis 3. Decreasing macrophage Fc-receptor expression in the spleen, reducing RBC destruction ### Dosing & Response - **Initial dose:** Prednisolone 1 mg/kg/day (typically 40–60 mg/day) - **Timeline:** Response seen within 3–7 days; hemoglobin stabilization within 2–4 weeks - **Taper:** Gradual reduction over 2–3 months once remission achieved ### Peripheral Blood Smear Findings in Warm AIHA | Finding | Significance | |---------|-------------| | Spherocytes | Partial RBC membrane loss from splenic macrophage attack | | Polychromasia | Reticulocytosis (bone marrow response) | | Nucleated RBCs | Immature RBC release due to hemolytic stress | | Agglutination (cold AIHA) | NOT seen in warm AIHA | **Clinical Pearl:** DAT positivity (IgG ± C3) confirms immune-mediated hemolysis and guides therapy selection. **High-Yield:** Corticosteroids are ALWAYS first-line; splenectomy is reserved for steroid-refractory or steroid-dependent cases (requires 3+ months of therapy first). ### When to Consider Alternative Agents - **Rituximab (anti-CD20):** Second-line for steroid-refractory disease or steroid-dependent relapse - **Splenectomy:** Considered after 3 months of steroid therapy if inadequate response (60–70% remission rate) - **Folic acid:** Supportive only; does NOT treat hemolysis [cite:Harrison 21e Ch 335]
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